Impact on sales of adding a smaller serving size of beer and cider in licensed premises: an A-B-A reversal design.

BACKGROUND: Smaller serving sizes of alcoholic drinks could reduce alcohol consumption across populations thereby lowering the risk of many diseases. The effect of modifying the available range of serving sizes of beer and cider in a real-world setting has yet to be studied. The current study assessed the impact on beer and cider sales of adding a serving size of draught beer and cider (2/3 pint) that was between the current smallest (1/2 pint) and largest (1 pint) standard serving sizes. METHODS: Twenty-two licensed premises in England consented to taking part in the study. The study used an ABA reversal design, set over three 4-weekly periods, with A representing the non-intervention periods, during which standard serving sizes were served and B the intervention period when a 2/3 pint serving size of draught beer and cider was added to the existing range, along with smaller 1/2 pint and larger 1 pint serving sizes. The primary outcome was the daily volume of beer and cider sold, extracted from sales data. RESULTS: Fourteen premises started the study, of which thirteen completed it. Twelve of those did so per protocol and were included in the primary analysis. After adjusting for pre-specified covariates, the intervention did not have a significant effect on the volume of beer and cider sold per day (3.14 ml; 95%CIs -2.29 to 8.58; p = 0.257). CONCLUSIONS: In licensed premises, there was no evidence that adding a smaller serving size for draught beer and cider (2/3 pint) when the smallest (1/2 pint) and largest (1 pint) sizes were still available, affected the volume of beer and cider sold. Studies are warranted to assess the impact of removing the largest serving size. TRIAL REGISTRATION: ISRCTN: https://doi.org/10.1186/ISRCTN33169631 (08/09/2021), OSF: https://osf.io/xkgdb/ (08/09/2021).

Increasing uptake of FIT colorectal screening: protocol for the TEMPO randomised controlled trial testing a suggested deadline and a planning tool.

INTRODUCTION: Screening can reduce deaths from colorectal cancer (CRC). Despite high levels of public enthusiasm, participation rates in population CRC screening programmes internationally remain persistently below target levels. Simple behavioural interventions such as completion goals and planning tools may support participation among those inclined to be screened but who fail to act on their intentions. This study aims to evaluate the impact of: (a) a suggested deadline for return of the test; (b) a planning tool and (c) the combination of a deadline and planning tool on return of faecal immunochemical tests (FITs) for CRC screening. METHODS AND ANALYSIS: A randomised controlled trial of 40 000 adults invited to participate in the Scottish Bowel Screening Programme will assess the individual and combined impact of the interventions. Trial delivery will be integrated into the existing CRC screening process. The Scottish Bowel Screening Programme mails FITs to people aged 50-74 with brief instructions for completion and return. Participants will be randomised to one of eight groups: (1) no intervention; (2) suggested deadline (1 week); (3) suggested deadline (2 weeks); (4) suggested deadline (4 weeks); (5) planning tool; (6) planning tool plus suggested deadline (1 week); (7) planning tool plus suggested deadline (2 weeks); (8) planning tool plus suggested deadline (4 weeks). The primary outcome is return of the correctly completed FIT at 3 months. To understand the cognitive and behavioural mechanisms and to explore the acceptability of both interventions, we will survey (n=2000) and interview (n=40) a subgroup of trial participants. ETHICS AND DISSEMINATION: The study has been approved by the National Health Service South Central-Hampshire B Research Ethics Committee (ref. 19/SC/0369). The findings will be disseminated through conference presentations and publication in peer-reviewed journals. Participants can request a summary of the results. TRIAL REGISTRATION NUMBER: clinicaltrials.govNCT05408169.

Cigarette pack size and consumption: a randomized cross-over trial.

BACKGROUND AND AIMS: Smoking fewer cigarettes per day may increase the chances of stopping smoking. Capping the number of cigarettes per pack is a promising policy option, but the causal impact of such a change is unknown. This study aimed to test the hypothesis that lowering cigarette pack sizes from 25 to 20 reduces the number of cigarettes smoked. DESIGN: This randomized controlled cross-over trial had two 14-day intervention periods with an intervening 7-day period of usual behaviour. Participants purchased their own cigarettes. They were instructed to smoke their usual brand from either one of two sizes of pack in each of two 14-day intervention periods: (a) 25 cigarettes and (b) 20 cigarettes. Participants were randomized to the order in which they smoked from the two pack sizes (a-b; b-a). SETTING: Canada. PARTICIPANTS: Participants were adult smokers who smoked from pack sizes of 25, recruited between July 2020 and June 2021. Of 252 randomized, 240 (95%) completed the study and 236 (94%) provided sufficient data for the primary analysis. MEASUREMENTS: Cigarettes smoked per participant per day. FINDINGS: Participants smoked fewer cigarettes per day from packs of 20 cigarettes [n = 234, mean = 15.7 standard deviation (SD) = 7.1] than from packs of 25 (n = 235, mean = 16.9, SD = 7.1). After adjusting for pre-specified covariates (baseline consumption and heaviness of smoking), modelling estimated that participants smoked 1.3 fewer cigarettes per day [95% confidence interval (CI) = -1.7 to -0.9], equivalent to 7.6% fewer (95% CI = -10.1 to -5.2%) from packs of 20 cigarettes. CONCLUSIONS: Smoking from packs of 20 compared with 25 cigarettes reduced the number of cigarettes smoked per day.

Evaluation of physical activity calorie equivalent (PACE) labels' impact on energy purchased in cafeterias: A stepped-wedge randomised controlled trial.

BACKGROUND: A recent meta-analysis suggested that using physical activity calorie equivalent (PACE) labels results in people selecting and consuming less energy. However, the meta-analysis included only 1 study in a naturalistic setting, conducted in 4 convenience stores. We therefore aimed to estimate the effect of PACE labels on energy purchased in worksite cafeterias in the context of a randomised study design. METHODS AND FINDINGS: A stepped-wedge randomised controlled trial (RCT) was conducted to investigate the effect of PACE labels (which include kcal content and minutes of walking required to expend the energy content of the labelled food) on energy purchased. The setting was 10 worksite cafeterias in England, which were randomised to the order in which they introduced PACE labels on selected food and drinks following a baseline period. There were approximately 19,000 workers employed at the sites, 72% male, with an average age of 40. The study ran for 12 weeks (06 April 2021 to 28 June 2021) with over 250,000 transactions recorded on electronic tills. The primary outcome was total energy (kcal) purchased from intervention items per day. The secondary outcomes were: energy purchased from non-intervention items per day, total energy purchased per day, and revenue. Regression models showed no evidence of an overall effect on energy purchased from intervention items, -1,934 kcals per site per day (95% CI -5,131 to 1,262), p = 0.236, during the intervention relative to baseline, equivalent to -5 kcals per transaction (95% CI -14 to 4). There was also no evidence for an effect on energy purchased from non-intervention items, -5 kcals per site per day (95% CI -513 to 504), p = 0.986, equivalent to 0 kcals per transaction (95% CI -1 to 1), and no clear evidence for total energy purchased -2,899 kcals per site (95% CI -5,810 to 11), p = 0.051, equivalent to -8 kcals per transaction (95% CI -16 to 0). Study limitations include using energy purchased and not energy consumed as the primary outcome and access only to transaction-level sales, rather than individual-level data. CONCLUSION: Overall, the evidence was consistent with PACE labels not changing energy purchased in worksite cafeterias. There was considerable variation in effects between cafeterias, suggesting important unmeasured moderators. TRIAL REGISTRATION: The study was prospectively registered on ISRCTN (date: 30.03.21; ISRCTN31315776).

Impact of wine bottle and glass sizes on wine consumption at home: a within- and between- households randomized controlled trial.

BACKGROUND AND AIMS: Reducing alcohol consumption across populations would decrease the risk of a range of diseases, including many cancers, cardiovascular disease and Type 2 diabetes. The aim of the current study was to estimate the impact of using smaller bottles (37.5- versus 75-cl) and glasses (290 versus 370 ml) on consuming wine at home. DESIGN: Randomized controlled trial of households with cross-over randomization to bottle size and parallel randomization to glass size. SETTING: UK households. PARTICIPANTS: A total of 260 households consuming at least two 75-cl bottles of wine each week, recruited from the general population through a research agency. The majority consisted of adults who were white and of higher socio-economic position. INTERVENTION: Households were randomized to the order in which they purchased wine in 37.5- or 75-cl bottles, to consume during two 14-day intervention periods, and further randomized to receive smaller (290 ml) or larger (350 ml) glasses to use during both intervention periods. MEASUREMENTS: Volume (ml) of study wine consumed at the end of each 14-day intervention period, measured using photographs of purchased bottles, weighed on study scales. FINDINGS: Of the randomized households, 217 of 260 (83%) completed the study as per protocol and were included in the primary analysis. There was weak evidence that smaller bottles reduced consumption: after accounting for pre-specified covariates, households consumed on average 145.7 ml (3.6%) less wine when drinking from smaller bottles than from larger bottles [95% confidence intervals (CI) = -335.5 to 43. ml; -8.3 to 1.1%; P = 0.137; Bayes factor (BF) = 2.00]. The evidence for the effect of smaller glasses was stronger: households consumed on average 253.3 ml (6.5%) less wine when drinking from smaller glasses than from larger glasses (95% CI = -517 to 10 ml; -13.2 to 0.3%; P = 0.065; BF = 2.96). CONCLUSIONS: Using smaller glasses to drink wine at home may reduce consumption. Greater uncertainty remains around the possible effect of drinking from smaller bottles.

Visualising health risks with medical imaging for changing recipients' health behaviours and risk factors: Systematic review with meta-analysis.

BACKGROUND: There is ongoing clinical and research interest in determining whether providing personalised risk information could motivate risk-reducing health behaviours. We aimed to assess the impact on behaviours and risk factors of feeding back to individuals' images of their bodies generated via medical imaging technologies in assessing their current disease status or risk. METHODS AND FINDINGS: A systematic review with meta-analysis was conducted using Cochrane methods. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to July 28, 2021, with backward and forward citation searches up to July 29, 2021. Eligible studies were randomised controlled trials including adults who underwent medical imaging procedures assessing current health status or risk of disease, for which personal risk may be reduced by modifying behaviour. Trials included an intervention group that received the imaging procedure plus feedback of visualised results and assessed subsequent risk-reducing health behaviour. We examined 12,620 abstracts and included 21 studies, involving 9,248 randomised participants. Studies reported on 10 risk-reducing behaviours, with most data for smoking (8 studies; n = 4,308), medication use (6 studies; n = 4,539), and physical activity (4 studies; n = 1,877). Meta-analysis revealed beneficial effects of feedback of visualised medical imaging results on reduced smoking (risk ratio 1.11, 95% confidence interval [CI] 1.01 to 1.23, p = 0.04), healthier diet (standardised mean difference [SMD] 0.30, 95% CI 0.11 to 0.50, p = 0.003), increased physical activity (SMD 0.11, 95% CI 0.003 to 0.21, p = 0.04), and increased oral hygiene behaviours (SMD 0.35, 95% CI 0.13 to 0.57, p = 0.002). In addition, single studies reported increased skin self-examination and increased foot care. For other behavioural outcomes (medication use, sun protection, tanning booth use, and blood glucose testing) estimates favoured the intervention but were not statistically significant. Regarding secondary risk factor outcomes, there was clear evidence for reduced systolic blood pressure, waist circumference, and improved oral health, and some indication of reduced Framingham risk score. There was no evidence of any adverse effects, including anxiety, depression, or stress, although these were rarely assessed. A key limitation is that there were some concerns about risk of bias for all studies, with evidence for most outcomes being of low certainty. In particular, valid and precise measures of behaviour were rarely used, and there were few instances of preregistered protocols and analysis plans, increasing the likelihood of selective outcome reporting. CONCLUSIONS: In this study, we observed that feedback of medical images to individuals has the potential to motivate risk-reducing behaviours and reduce risk factors. Should this promise be corroborated through further adequately powered trials that better mitigate against risk of bias, such interventions could usefully capitalise upon the widespread and growing use of medical imaging technologies in healthcare.

The effect of nicotine dependence and withdrawal symptoms on use of nicotine replacement therapy: Secondary analysis of a randomized controlled trial in primary care.

INTRODUCTION: Nicotine replacement therapy (NRT) is effective for smoking cessation, but the optimal method of using NRT to maximize benefit is unclear. We examined whether nicotine dependence was associated with consumption of NRT, whether this was mediated by withdrawal symptoms, and the impact of these factors on cessation, in a population advised to use as much NRT as needed. METHODS: Secondary analysis of data from an open label, parallel group randomized controlled trial. Participants (n = 539) attended a smoking cessation clinic in primary care and remained engaged with treatment for at least one week following a quit attempt. Baseline dependence was measured by the Fagerström Test for Cigarette Dependence (FTCD), with tobacco exposure assessed via an exhaled carbon monoxide test. At one week after quit day, mean daily consumption of NRT was measured for all participants; withdrawal (Mood and Physical Symptoms Scale (MPSS)) was also assessed in the subsample who reported being completely abstinent to that point (n = 279). Abstinence was biochemically assessed at four weeks for all participants as the principal smoking cessation outcome. RESULTS: Each point higher on the FTCD was associated with 0.83 mg/day more NRT consumption, controlling for tobacco exposure. This relationship was diminished when withdrawal was controlled for, and withdrawal was associated with NRT consumption, with each point higher on the MPSS associated with a 0.12 mg/day increase. Increased consumption of NRT directly predicted subsequent smoking cessation. CONCLUSIONS: Higher dependence appears to lead to greater withdrawal, which appears to drive greater use of NRT. This effect may partly offset lower abstinence rates in people with higher dependence. Advice to use sufficient NRT to suppress withdrawal may increase abstinence rates.

Size and shape of plates and size of wine glasses and bottles: impact on self-serving of food and alcohol.

BACKGROUND: The physical properties of tableware could influence selection and consumption of food and alcohol. There is considerable uncertainty, however, around the potential effects of different sizes and shapes of tableware on how much food and alcohol people self-serve. These studies aimed to estimate the impact of: 1. Plate size and shape on amount of food self-served; 2.Wine glass and bottle size on amount of wine self-poured. METHODS: 140 adults participated in two laboratory studies-each using randomised within-subjects factorial designs-where they self-served food (Study 1) and wine (Study 2): Study 1: 3 plate sizes (small; medium; large) × 2 plate shapes (circular; square). Study 2: 3 wine glass sizes (small; medium; large) × 2 wine bottle sizes (75 cl; 50 cl). RESULTS: Study 1: There was a main effect of plate size: less was self-served on small (76 g less, p < 0.001) and medium (41 g less, p < 0.001) plates, compared to large plates. There was no evidence for a main effect of plate shape (p = 0.46) or a size and shape interaction (p = 0.47). Study 2: There was a main effect of glass size: less was self-served in small (34 ml less, p < 0.001) and medium (17 ml less, p < 0.001) glasses, compared to large glasses. There was no evidence of a main effect of bottle size (p = 0.20) or a glass and bottle size interaction (p = 0.18). CONCLUSIONS: Smaller tableware (i.e. plates and wine glasses) decreases the amount of food and wine self-served in an initial serving. Future studies are required to generate estimates on selection and consumption in real world settings when numerous servings are possible. Protocol registration information: OSF ( https://osf.io/dj3c6/ ) and ISRCTN ( https://doi.org/10.1186/ISRCTN66774780 ).

Cigarette pack size and consumption: an adaptive randomised controlled trial.

BACKGROUND: Observational evidence suggests that cigarette pack size - the number of cigarettes in a single pack - is associated with consumption but experimental evidence of a causal relationship is lacking. The tobacco industry is introducing increasingly large packs, in the absence of maximum cigarette pack size regulation. In Australia, the minimum pack size is 20 but packs of up to 50 cigarettes are available. We aimed to estimate the impact on smoking of reducing cigarette pack sizes from ≥25 to 20 cigarettes per pack. METHOD: A two-stage adaptive parallel group RCT in which Australian smokers who usually purchase packs containing ≥25 cigarettes were randomised to use only packs containing either 20 (intervention) or their usual packs (control) for four weeks. The primary outcome, the average number of cigarettes smoked per day, was measured through collecting all finished cigarette packs, labelled with the number of cigarettes participants smoked. An interim sample size re-estimation was used to evaluate the possibility of detecting a meaningful difference in the primary outcome. RESULTS: The interim analysis, conducted when 124 participants had been randomised, suggested 1122 additional participants needed to be randomised for sufficient power to detect a meaningful effect. This exceeded pre-specified criteria for feasible recruitment, and data collection was terminated accordingly. Analysis of complete data (n = 79) indicated that the mean cigarettes smoked per day was 15.9 (SD = 8.5) in the intervention arm and 16.8 (SD = 6.7) among controls (difference - 0.9: 95%CI = - 4.3, 2.6). CONCLUSION: It remains unclear whether reducing cigarette pack sizes from ≥25 to 20 cigarettes reduces cigarette consumption. Importantly, the results of this study provide no evidence that capping cigarette pack sizes would be ineffective at reducing smoking. The limitations identified in this study can inform a more efficient RCT, which is urgently required to address the dearth of experimental evidence on the impact of large cigarette pack sizes on smoking. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN34202533.

Health warning labels and alcohol selection: a randomised controlled experiment in a naturalistic shopping laboratory.

BACKGROUND AND AIMS: Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial-standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption. DESIGN: A between-subjects randomised experiment with three groups was conducted: group 1: image-and-text HWL; group 2: text-only HWL; group 3: no HWL. SETTING: A commercial-standard naturalistic shopping laboratory in the United Kingdom. PARTICIPANTS: Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home. INTERVENTIONS: Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image-and-text HWL (n = 135); (ii) text-only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non-alcoholic drinks, and snacks. MEASUREMENT: The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability. FINDINGS: There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text-only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image-and-text HWL group, compared to the text-only HWL group. CONCLUSIONS: In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour.

Impact of health warning labels communicating the risk of cancer on alcohol selection: an online experimental study.

AIMS: Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image-and-text (also known as 'pictorial' or 'graphic') HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (i) image-and-text, (ii) text-only, and (iii) image-only HWLs on selection of alcoholic versus non-alcoholic drinks. DESIGN: A between-subjects randomised experiment with a 2 (image: present versus absent) × 2 (text: present versus absent) factorial design. SETTING: The study was conducted on the online survey platform Qualtrics. PARTICIPANTS: Participants (n = 6024) were adults over the age of 18 who consumed beer or wine regularly (i.e. at least once a week), recruited through a market research agency. INTERVENTIONS: Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: (i) image-and-text HWL; (ii) text-only HWL; (iii) image-only HWL; and (iv) no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non-alcoholic drinks and selected one drink that they would like to consume. MEASUREMENTS: The primary outcome was the proportion of participants selecting an alcoholic versus a non-alcoholic drink. FINDINGS: Alcoholic drink selection was lower for all HWL types compared with no HWL (image-and-text: 56%; image-only: 49%; text-only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image-and-text HWLs reduced the odds of selecting an alcoholic drink compared with text-only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image-only HWLs (OR = 1.34, 95% CI = 1.16, 1.55). CONCLUSIONS: Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non-alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real-world field settings using physical products awaits investigation.

Altering the availability of products within physical micro-environments: a conceptual framework.

Altering the availability of products (e.g. food, alcohol or tobacco products) is one potential intervention to change behaviours to help reduce preventable premature deaths worldwide. However, research on these interventions lacks consistent conceptualisation, hindering clear reporting and cumulative synthesis. This paper proposes a conceptual framework - categorising intervention types and summarising constituent components - with which interventions can be reliably described and evidence synthesised. Three principal distinctions are proposed: interventions altering: (i) Absolute Availability (changing the overall number of options, while keeping the proportions comprised by any subsets of options constant); (ii) Relative Availability (changing the proportion comprised by a subset of options, yet keeping the overall number of options constant); (iii) Absolute and Relative Availability (changing both the overall number of options and the proportions comprised by subsets of options). These are subdivided into those targeting (a) a product or (b) a category of products. Mechanisms that might underlie each of these intervention types are discussed, and implications for future research highlighted. The proposed framework aims to facilitate study of a set of interventions that could contribute significantly to healthier behaviour across populations.

Impact of health warning labels on snack selection: An online experimental study.

Excessive consumption of energy-dense food increases the risk of obesity, which in turn increases the risk of non-communicable diseases, including heart disease, type 2 diabetes and most non-smoking-related cancers. Health warning labels (HWLs) that communicate the adverse health consequences of excess energy consumption could reduce intake of energy-dense foods. The aim of the current study was to estimate the impact on selection of energy-dense snacks of (a) image-and-text HWLs (b) text-only HWLs and (c) calorie information. In a between-subjects, 3 (HWL: image-and-text, text-only, no label) x 2 (calorie information: present, absent), factorial experimental design, participants (N = 4134) were randomised to view a selection of energy-dense and non-energy-dense snacks with one of five label types or no label. The primary outcome was the proportion of participants selecting an energy-dense snack in a hypothetical vending machine task. The proportion of participants selecting an energy-dense snack was reduced in all label groups, relative to the no label group (no label: 59%; calories only: 54%; text-only HWL: 48%; text-only HWL with calories: 44%; image-and-text HWL: 37%; image-and-text HWL with calories: 38%). Compared to the no label group, participants were least likely to select an energy-dense snack in the image-and-text HWL group (OR = 0.46, 95%CI = 0.40, 0.54, p < 0.001). Health warning labels - particularly those including an image and text - have the potential to reduce selection of energy-dense snacks in an online setting. Their impact on selection and consumption in real-world settings awaits testing.

Impact of bottle size on in-home consumption of wine: a randomized controlled cross-over trial.

AIM: To assess the impact of purchasing wine in 50 cl bottles compared with 75 cl bottles on the amount of wine consumed at home. DESIGN: Cross-over randomized controlled trial with a 'usual behaviour' period of a maximum of 3 weeks between conditions. SETTING: Households in the United Kingdom. PARTICIPANTS: One hundred and eighty-six households that consumed between two and eight 75 cl bottles of wine each week. INTERVENTION: Households were randomized to the order in which they purchased wine in two bottle sizes. During two 14-day intervention periods, households purchased a pre-set volume of wine-based on their baseline self-reported weekly consumption-in either 75 cl bottles or 50 cl bottles. On days 7 and 14 of each study period, participating households sent photographs of each purchased wine bottle. MEASUREMENTS: The primary outcome was the volume of study wine in millilitres (ml) consumed during each study period estimated through returned photographs. The secondary outcome was the rate of consumption measured by the mean number of days taken to drink 1.5 litres from each bottle size. FINDINGS: One hundred and sixty-six of 186 enrolled households satisfactorily completed the study. After accounting for pre-specified covariates, 191.1 ml [95% confidence interval (CI) = 42.03-339.2] or 4.5% (95% CI = 1.0-7.9%) more wine was consumed per 14-day period from 75-cl bottles than from 50-cl bottles. Consumption was 5.8% faster (95% CI = -10.9 to -0.4%) from 75 cl bottles than from 50 cl bottles. CONCLUSIONS: Consuming wine at home from 50 cl bottles, compared with 75 cl bottles, may reduce both amount consumed and rate of consumption.

Image-and-text health warning labels on alcohol and food: potential effectiveness and acceptability.

BACKGROUND: Health warning labels (HWLs) using images and text to depict the negative health consequences of tobacco consumption are effective and acceptable for changing smoking-related outcomes. There is currently limited evidence concerning their potential use for reducing consumption of alcoholic drinks and energy-dense foods. The aim of this research was to describe the potential effectiveness and acceptability of image-and-text (also known as pictorial or graphic) HWLs applied to: i. alcoholic drinks and ii. energy-dense snack foods. METHODS: Two online studies were conducted using between-subjects designs with general population samples. Participants rated one of 21 image-and-text HWLs on alcoholic drinks (n = 5528), or one of 18 image-and-text HWLs on energy-dense snacks (n = 4618). HWLs comprised a graphic image with explanatory text, depicting, respectively, seven diseases linked to excess alcohol consumption, and six diseases linked to excess energy intake. Diseases included heart disease and various cancers. Outcomes were negative emotional arousal, desire to consume the labelled product, and acceptability of the label. Free-text comments relating to HWLs were content analysed. RESULTS: For both alcoholic drinks and energy-dense snacks, HWLs depicting bowel cancer generated the highest levels of negative emotional arousal and lowest desire to consume the product, but were the least acceptable. Acceptability was generally low for HWLs applied to alcohol, with 3 of 21 rated as acceptable, and was generally high for snacks, with 13 of 18 rated as acceptable. The majority of free-text comments expressed negative reactions to HWLs on alcohol or energy-dense snacks. CONCLUSIONS: Image-and-text health warning labels depicting bowel cancer showed greatest potential for reducing selection and consumption of alcoholic drinks and energy-dense snacks, although they were the least acceptable. Laboratory and field studies are needed to assess their impact on selection and consumption.

The effect of wine glass size on volume of wine sold: a mega-analysis of studies in bars and restaurants.

AIM: To estimate the effects of wine glass size on volume of wine sold in bars and restaurants. DESIGN: A mega-analysis combining raw (as opposed to aggregate-level) data from eight studies conducted in five establishments. A multiple treatment reversal design was used for each data set, with wine glass size changed fortnightly while serving sizes were unaffected, in studies lasting between 14 and 26 weeks. SETTING AND PARTICIPANTS: Five bars and restaurants in England participated in studies between 2015 and 2018, using wine glasses of five sizes: 250, 300, 370, 450 and 510 ml, with the largest size only used in bars. MEASUREMENTS: Daily volume of wine sold by the glass, bottle or carafe for non-sparkling wine were recorded at bars (594 days) and restaurants (427 days), averaging 4 months per study. FINDINGS: Mega-analysis combining data from bars did not find a significant effect of glass size on volume of wine sold compared with 300-ml glasses: the volume of wine sold using 370-ml glasses was 0.5% lower [95% confidence interval (CI) = -8.1% to 6.1%], using 450-ml glasses was 1.0% higher (95% CI = -9.1 to 12.2) and using 510-ml glasses was 0.4% lower (95% CI = -9.4 to 9.4). For restaurants, compared with 300-ml glasses, the volume of wine sold using 250-ml glasses did not show a significant difference: 9.6% lower (95% CI = -19.0 to 0.7). Using 370-ml glasses the volume of wine sold was 7.3% higher (95% CI = 1.5% to 13.5%); no significant effect was found using 450-ml glasses: 0.9% higher (95% CI = -5.5 to 7.7). CONCLUSIONS: The volume of wine sold in restaurants in England may be greater when 370-ml glasses are used compared with 300-ml wine glasses, but may not be in bars. This might be related to restaurants compared with bars selling more wine in bottles and carafes, which require free-pouring.

Tobacco and electronic cigarette cues for smoking and vaping: an online experimental study.

OBJECTIVE: This study examined whether exposure to smoking and vaping cues the urge to smoke or vape. It extends previous studies on first-generation cigalikes (visually similar to cigarettes) and second-generation devices (visually similar to pens) by including third-generation tank system devices (larger bulky units). In an online experiment, participants were randomly assigned to view one of four videos, which included smoking, vaping (cigalike or tank system), or neutral cues. The primary outcome was urge to smoke. Secondary outcomes were urge to vape, desire to smoke and vape, and intention to quit or remain abstinent from smoking. RESULTS: UK adults varying in smoking (current or former) and vaping (user or non-user) status (n = 1120) completed the study: 184 (16%) failed study attention checks meaning 936 were included in the final analysis. Urges to smoke were similar across cue groups. Urges to vape were higher following exposure to vaping compared to neutral cues. There was no clear evidence of an interaction between cue group and smoking or vaping status. The lack of cueing effects on smoking urges is inconsistent with previous research, raising questions about the ability to assess craving in online settings.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption.

BACKGROUND: Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. OBJECTIVES: 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. SELECTION CRITERIA: We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. DATA COLLECTION AND ANALYSIS: We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. MAIN RESULTS: We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. AUTHORS' CONCLUSIONS: The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption.

BACKGROUND: Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers. OBJECTIVES: 1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches. SELECTION CRITERIA: We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product. DATA COLLECTION AND ANALYSIS: We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE. MAIN RESULTS: We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias. AUTHORS' CONCLUSIONS: The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Interventions to increase adherence to medications for tobacco dependence.

BACKGROUND: Pharmacological treatments for tobacco dependence, such as nicotine replacement therapy (NRT), have been shown to be safe and effective interventions for smoking cessation. Higher levels of adherence to these medications increase the likelihood of sustained smoking cessation, but many smokers use them at a lower dose and for less time than is optimal. It is important to determine the effectiveness of interventions designed specifically to increase medication adherence. Such interventions may address motivation to use medication, such as influencing beliefs about the value of taking medications, or provide support to overcome problems with maintaining adherence. OBJECTIVES: To assess the effectiveness of interventions aiming to increase adherence to medications for smoking cessation on medication adherence and smoking abstinence compared with a control group typically receiving standard care. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register, and clinical trial registries (ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform) to the 3 September 2018. We also conducted forward and backward citation searches. SELECTION CRITERIA: Randomised, cluster-randomised or quasi-randomised studies in which adults using active pharmacological treatment for smoking cessation were allocated to an intervention arm where there was a principal focus on increasing adherence to medications for tobacco dependence, or a control arm providing standard care. Dependent on setting, standard care may have comprised minimal support or varying degrees of behavioural support. Included studies used a measure that allowed assessment of the degree of medication adherence. DATA COLLECTION AND ANALYSIS: Two authors independently screened studies for eligibility, extracted data for included studies and assessed risk of bias. For continuous outcome measures, we calculated effect sizes as standardised mean differences (SMDs). For dichotomous outcome measures, we calculated effect sizes as risk ratios (RRs). In meta-analyses for adherence outcomes, we combined dichotomous and continuous data using the generic inverse variance method and reported pooled effect sizes as SMDs; for abstinence outcomes, we reported and pooled dichotomous outcomes. We obtained pooled effect sizes with 95% confidence intervals (CIs) using random-effects models. We conducted subgroup analyses to assess whether the primary focus of the adherence treatment ('practicalities' versus 'perceptions' versus both), the delivery approach (participant versus clinician-centred) or the medication type were associated with effectiveness. MAIN RESULTS: We identified two new studies, giving a total of 10 studies, involving 3655 participants. The medication adherence interventions studied were all provided in addition to standard behavioural support.They typically provided further information on the rationale for, and emphasised the importance of, adherence to medication or supported the development of strategies to overcome problems with maintaining adherence (or both). Seven studies targeted adherence to NRT, two to bupropion and one to varenicline. Most studies were judged to be at high or unclear risk of bias, with four of these studies judged at high risk of attrition or detection bias. Only one study was judged to be at low risk of bias.Meta-analysis of all 10 included studies (12 comparisons) provided moderate-certainty evidence that adherence interventions led to small improvements in adherence (i.e. the mean amount of medication consumed; SMD 0.10, 95% CI 0.03 to 0.18; I² = 6%; n = 3655), limited by risk of bias. Subgroup analyses for the primary outcome identified no significant subgroup effects, with effect sizes for subgroups imprecisely estimated. However, there was a very weak indication that interventions focused on the 'practicalities' of adhering to treatment (i.e. capabilities, resources, levels of support or skills) may be effective (SMD 0.21, 95% CI 0.03 to 0.38; I² = 39%; n = 1752), whereas interventions focused on treatment 'perceptions' (i.e. beliefs, cognitions, concerns and preferences; SMD 0.10, 95% CI -0.03 to 0.24; I² = 0%; n = 839) or on both (SMD 0.04, 95% CI -0.08 to 0.16; I² = 0%; n = 1064), may not be effective. Participant-centred interventions may be effective (SMD 0.12, 95% CI 0.02 to 0.23; I² = 20%; n = 2791), whereas those that are clinician-centred may not (SMD 0.09, 95% CI -0.05 to 0.23; I² = 0%; n = 864).Five studies assessed short-term smoking abstinence (five comparisons), while an overlapping set of five studies (seven comparisons) assessed long-term smoking abstinence of six months or more. Meta-analyses resulted in low-certainty evidence that adherence interventions may slightly increase short-term smoking cessation rates (RR 1.08, 95% CI 0.96 to 1.21; I² = 0%; n = 1795) and long-term smoking cessation rates (RR 1.16, 95% CI 0.96 to 1.40; I² = 48%; n = 3593). In both cases, the evidence was limited by risk of bias and imprecision, with CIs encompassing minimal harm as well as moderate benefit, and a high likelihood that further evidence will change the estimate of the effect. There was no evidence that interventions to increase adherence to medication led to any adverse events. Studies did not report on factors plausibly associated with increases in adherence, such as self-efficacy, understanding of and attitudes toward treatment, and motivation and intentions to quit. AUTHORS' CONCLUSIONS: In people who are stopping smoking and receiving behavioural support, there is moderate-certainty evidence that enhanced behavioural support focusing on adherence to smoking cessation medications can modestly improve adherence. There is only low-certainty evidence that this may slightly improve the likelihood of cessation in the shorter or longer-term. Interventions to increase adherence can aim to address the practicalities of taking medication, change perceptions about medication, such as reasons to take it or concerns about doing so, or both. However, there is currently insufficient evidence to confirm which approach is more effective. There is no evidence on whether such interventions are effective for people who are stopping smoking without standard behavioural support.