Open science communication: The first year of the UK's Independent Scientific Advisory Group for Emergencies.

The COVID-19 pandemic has shone a light on the complex relationship between science and policy. Policymakers have had to make decisions at speed in conditions of uncertainty, implementing policies that have had profound consequences for people's lives. Yet this process has sometimes been characterised by fragmentation, opacity and a disconnect between evidence and policy. In the United Kingdom, concerns about the secrecy that initially surrounded this process led to the creation of Independent SAGE, an unofficial group of scientists from different disciplines that came together to ask policy-relevant questions, review the evolving evidence, and make evidence-based recommendations. The group took a public health approach with a population perspective, worked in a holistic transdisciplinary way, and were committed to public engagement. In this paper, we review the lessons learned during its first year. These include the importance of learning from local expertise, the value of learning from other countries, the role of civil society as a critical friend to government, finding appropriate relationships between science and policy, and recognising the necessity of viewing issues through an equity lens.

Moderators of real-world effectiveness of smoking cessation aids: a population study.

BACKGROUND AND AIMS: Understanding whether and how far smokers' characteristics influence the effectiveness of treatment may be important for tailoring recommendations on cessation aids to those most likely to help the user achieve abstinence. This study aimed to estimate the effectiveness of commonly used smoking cessation aids and test whether their effectiveness differs according to cigarette addiction, socio-economic status, age or sex. DESIGN: Correlational design using cross-sectional survey data collected monthly between 2006 and 2018. SETTING: England. PARTICIPANTS: A total of 18 929 adults (aged ≥ 16 years, 52.0% female) who had smoked within the previous 12 months and had made at least one quit attempt during that period. MEASUREMENTS: The outcome was self-reported abstinence from quit date to survey. Independent variables were self-reported use during the most recent quit attempt of: prescription nicotine replacement therapy (NRT), NRT over-the-counter, varenicline, bupropion, e-cigarettes, face-to-face behavioural support, telephone support, written self-help materials, websites and hypnotherapy. Moderators were cigarette addiction, social grade, age and sex. FINDINGS: After adjustment for covariates and use of other cessation aids, users of e-cigarettes [odds ratio (OR) = 1.95, 95% confidence interval (CI) = 1.69-2.24] and varenicline (OR = 1.82, 95% CI = 1.51-2.21) had significantly higher odds of reporting abstinence than those who did not report use of these cessation aids. Use of prescription NRT was associated with increased abstinence in older (≥ 45 years) (OR = 1.58, 95% CI = 1.25-2.00) but not younger (< 45 years) smokers (OR = 1.09, 95% CI = 0.85-1.42). Use of websites was associated with increased abstinence in smokers from lower (OR = 2.20, 95% CI = 1.22-3.98) but not higher social grades (OR = 0.74, 95% CI = 0.40-1.38). There was little evidence of benefits of using other cessation aids. CONCLUSIONS: Use of e-cigarettes and varenicline are associated with higher abstinence rates following a quit attempt in England. Use of prescription of nicotine replacement therapy is also associated with higher abstinence rates, but only in older smokers, and use of websites only in smokers from lower socio-economic status.

Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study.

BACKGROUND: Given the rapid increase in the popularity of e-cigarettes and the paucity of associated longitudinal health-related data, the need to assess the potential risks of long-term use is essential. OBJECTIVE: To compare exposure to nicotine, tobacco-related carcinogens, and toxins among smokers of combustible cigarettes only, former smokers with long-term e-cigarette use only, former smokers with long-term nicotine replacement therapy (NRT) use only, long-term dual users of both combustible cigarettes and e-cigarettes, and long-term users of both combustible cigarettes and NRT. DESIGN: Cross-sectional study. SETTING: United Kingdom. PARTICIPANTS: The following 5 groups were purposively recruited: combustible cigarette-only users, former smokers with long-term (≥6 months) e-cigarette-only or NRT-only use, and long-term dual combustible cigarette-e-cigarette or combustible cigarette-NRT users (n = 36 to 37 per group; total n = 181). MEASUREMENTS: Sociodemographic and smoking characteristics were assessed. Participants provided urine and saliva samples and were analyzed for biomarkers of nicotine, tobacco-specific N-nitrosamines (TSNAs), and volatile organic compounds (VOCs). RESULTS: After confounders were controlled for, no clear between-group differences in salivary or urinary biomarkers of nicotine intake were found. The e-cigarette-only and NRT-only users had significantly lower metabolite levels for TSNAs (including the carcinogenic metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) and VOCs (including metabolites of the toxins acrolein; acrylamide; acrylonitrile; 1,3-butadiene; and ethylene oxide) than combustible cigarette-only, dual combustible cigarette-e-cigarette, or dual combustible cigarette-NRT users. The e-cigarette-only users had significantly lower NNAL levels than all other groups. Combustible cigarette-only, dual combustible cigarette-NRT, and dual combustible cigarette-e-cigarette users had largely similar levels of TSNA and VOC metabolites. LIMITATION: Cross-sectional design with self-selected sample. CONCLUSION: Former smokers with long-term e-cigarette-only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette-only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes. PRIMARY FUNDING SOURCE: Cancer Research UK.

Effectiveness of a brief community outreach tobacco cessation intervention in India: a cluster-randomised controlled trial (the BABEX Trial).

BACKGROUND: Tobacco use kills half a million people every month, most in low-middle income countries (LMICs). There is an urgent need to identify potentially low-cost, scalable tobacco cessation interventions for these countries. OBJECTIVE: To evaluate a brief community outreach intervention delivered by health workers to promote tobacco cessation in India. DESIGN: Cluster-randomised controlled trial. SETTING: 32 low-income administrative blocks in Delhi, half government authorised ('resettlement colony') and half unauthorised ('J.J. cluster') communities. PARTICIPANTS: 1213 adult tobacco users. INTERVENTIONS: Administrative blocks were computer randomised in a 1:1 ratio, to the intervention (16 clusters; n=611) or control treatment (16 clusters; n=602), delivered and assessed at individual level between 07/2012 and 11/2013. The intervention was single session quit advice (15 min) plus a single training session in yogic breathing exercises; the control condition comprised very brief quit advice (1 min) alone. Both were delivered via outreach, with contact made though household visits. MEASUREMENTS: The primary outcome was 6-month sustained abstinence from all tobacco, assessed 7 months post intervention delivery, biochemically verified with salivary cotinine. RESULTS: The smoking cessation rate was higher in the intervention group (2.6% (16/611)) than in the control group (0.5% (3/602)) (relative risk=5.32, 95% CI 1.43 to 19.74, p=0.013). There was no interaction with type of tobacco use (smoked vs smokeless). Results did not change materially in adjusted analyses, controlling for participant characteristics. CONCLUSIONS: A single session community outreach intervention can increase tobacco cessation in LMIC. The effect size, while small, could impact public health if scaled up with high coverage. TRIAL REGISTRATION NUMBER: ISRCTCN23362894.

Use of aids for smoking cessation and alcohol reduction: A population survey of adults in England.

BACKGROUND: It is important for policy planning to chart the methods smokers and high-risk drinkers use to help them change their behaviour. This study assessed prevalence of use, and characteristics of users, of support for smoking cessation and alcohol reduction in England. METHODS: Data were used from the Smoking and Alcohol Toolkit Studies, which involve monthly face-to-face computer-assisted interviews of adults aged 16+ in England. We included data collected between June 2014 and July 2015 on 1600 smokers who had made at least one quit attempt and 911 high-risk drinkers (defined as scores >8+ on the full AUDIT or 5+ on questions 1-3 of the AUDIT-C) who had made an attempt to cut down in the past 12 months. Participants provided information on their socio-demographic characteristics and use of aids during their most recent quit attempt including pharmacotherapy, face-to-face counselling, telephone support, self-help materials (digital and printed), and complementary medicine. RESULTS: A total of 60.3% of smokers used aids in the past year, compared with just 14.9% of high-risk drinkers. Use of pharmacotherapy was high among smokers and very low among drinkers (56.0%versus1.2%). Use of other aids was low for both behaviours: face-to-face counselling (2.6%versus4.8%), self-help materials (1.4%versus4.1%) and complementary medicine (1.0%versus0.5%). Use of aids was more common among smokers aged 25-54 compared with 16-24 year olds (25-34,ORadj1.49,p = 0.012; 35-44,ORadj1.93,p < 0.001; 35-44,ORadj1.93,p < 0.001; 45-54,ORadj1.66,p = 0.008), with cigarette consumption >10 relative to <1 (10-20,ORadj2.47,p = 0.011; >20,ORadj4.23,p = 0.001), and less common among ethnic minorities (ORadj0.69,p = 0.026). For alcohol reduction, use of aids was higher among ethnic minority groups (ORadj2.41;p = 0.015), and those of social-grade D/E relative to AB (ORadj2.29,p = 0.012&ORadj3.13,p < 0.001). CONCLUSION: In England, the use of pharmacotherapy is prevalent for smoking cessation but not alcohol reduction. Other aids are used at a low rate, with face-to-face counselling being more common for alcohol reduction than smoking cessation.

Bacteraemia during Transurethral Resection of the Prostate: What Are the Risk Factors and Is It More Common than We Think?

The aim of this work was to investigate the microbial causes, incidence, duration, risk factors and clinical implications of bacteraemia occurring during transurethral resection of the prostate (TURP) surgery to better inform prophylaxis strategies. An ethically approved, prospective, cohort study of patients undergoing TURP was conducted. Clinical information and follow-up details were collected using standardized data collection sheets. Blood was obtained for culture at 6 different time points peri-procedure. Standard of care antibiotic prophylaxis was given prior to surgery. Bacteriuria was assessed in a pre-procedure urine sample. Histopathology from all prostate chips was assessed for inflammation and malignancy. 73 patients were consented and 276 blood samples obtained. No patients developed symptomatic bacteraemia during the procedure, 17 patients developed asymptomatic bacteraemia (23.2%). Enterococcus faecalis and Pseudomonas aeruginosa were the most common organisms cultured. 10 minutes after the start of the TURP, the odds ratio (OR) of developing bacteraemia was 5.38 (CI 0.97-29.87 p = 0.05), and 20 minutes after the start of the procedure, the OR was 6.46 (CI 1.12-37.24, p = 0.03), compared to before the procedure. We also found an association between the development of intra-operative bacteraemia and recent antibiotic use (OR 4.34, CI 1.14-16.62, p = 0.032), the presence of a urinary catheter (OR 4.92, CI 1.13-21.51, p = 0.034) and a malignant histology (OR 4.90, CI 1.30-18.46, p = 0.019). There was no statistical relationship between pre-operative urine culture results and blood culture results. This study shows that asymptomatic bacteraemia is commonly caused by TURP and occurs in spite of antibiotic prophylaxis. Our findings challenge the commonly held view that urine is the primary source of bacteraemia in TURP-associated sepsis and raise the possibility of occult prostatic infection as a cause of bacteraemia. More work will be needed to determine the significance of transient bacteraemia in relation to more serious complications like infective endocarditis and malignancy.

DNA-mediated adjuvant immunotherapy extends survival in two different mouse models of myeloid malignancies.

We have previously shown that a specific promyelocytic leukemia-retinoic acid receptor alpha (PML-RARA) DNA vaccine combined with all-trans retinoic acid (ATRA) increases the number of long term survivors with enhanced immune responses in a mouse model of acute promyelocytic leukemia (APL). This study reports the efficacy of a non-specific DNA vaccine, pVAX14Flipper (pVAX14), in both APL and high risk myelodysplastic syndrome (HR-MDS) models. PVAX14 is comprised of novel immunogenic DNA sequences inserted into the pVAX1 therapeutic plasmid. APL mice treated with pVAX14 combined with ATRA had increased survival comparable to that obtained with a specific PML-RARA vaccine. Moreover, the survival advantage correlated with decreased PML-RARA transcript levels and increase in anti-RARA antibody production. In HR-MDS mice, pVAX14 significantly improved survival and reduced biomarkers of leukemic transformation such as phosphorylated mitogen-activated protein/extracellular signal-regulated kinase kinase (MEK) 1. In both preclinical models, pVAX14 vaccine significantly increased interferon gamma (IFNγ) production, memory T-cells (memT), reduced the number of colony forming units (CFU) and increased expression of the adapter molecule signalling to NF-κB, MyD88. These results demonstrate the adjuvant properties of pVAX14 providing thus new approaches to improve clinical outcome in two different models of myeloid malignancies, which may have potential for a broader applicability in other cancers.

Methotrexate Promotes Platelet Apoptosis via JNK-Mediated Mitochondrial Damage: Alleviation by N-Acetylcysteine and N-Acetylcysteine Amide.

Thrombocytopenia in methotrexate (MTX)-treated cancer and rheumatoid arthritis (RA) patients connotes the interference of MTX with platelets. Hence, it seemed appealing to appraise the effect of MTX on platelets. Thereby, the mechanism of action of MTX on platelets was dissected. MTX (10 µM) induced activation of pro-apoptotic proteins Bid, Bax and Bad through JNK phosphorylation leading to ΔΨm dissipation, cytochrome c release and caspase activation, culminating in apoptosis. The use of specific inhibitor for JNK abrogates the MTX-induced activation of pro-apoptotic proteins and downstream events confirming JNK phosphorylation by MTX as a key event. We also demonstrate that platelet mitochondria as prime sources of ROS which plays a central role in MTX-induced apoptosis. Further, MTX induces oxidative stress by altering the levels of ROS and glutathione cycle. In parallel, the clinically approved thiol antioxidant N-acetylcysteine (NAC) and its derivative N-acetylcysteine amide (NACA) proficiently alleviate MTX-induced platelet apoptosis and oxidative damage. These findings underpin the dearth of research on interference of therapeutic drugs with platelets, despite their importance in human health and disease. Therefore, the use of antioxidants as supplementary therapy seems to be a safe bet in pathologies associated with altered platelet functions.

A cluster randomized controlled trial of a brief tobacco cessation intervention for low-income communities in India: study protocol.

BACKGROUND: India has 275 million adult tobacco users and tobacco use is estimated to contribute to more than a million deaths in the country each year. There is an urgent need to develop and evaluate affordable, practicable and scalable interventions to promote cessation of tobacco use. Because tobacco use is so harmful, an increase of as little as 1 percentage point in long-term quit success rates can have an important public health impact. This protocol paper describes the rationale and methods of a large randomized controlled trial which aims to evaluate the effectiveness of a brief scalable smoking cessation intervention delivered by trained health professionals as an outreach programme in poor urban communities in India. METHODS/DESIGN: This is a pragmatic, two-arm, community-based cluster randomized controlled trial focused on tobacco users in low-income communities. The treatment arm is a brief intervention comprising brief advice including training in craving control using simple yogic breathing exercises (BA-YBA) and the control arm is very brief advice (VBA). Of a total of 32 clusters, 16 will be allocated to the intervention arm and 16 to the control arm. Each cluster will have 31 participants, making a total of 992 participants. The primary outcome measure will follow the Russell Standard: self-report of sustained abstinence for at least 6 months following the intervention confirmed at the final follow-up by salivary cotinine. DISCUSSION: This trial will inform national and international policy on delivery of scalable and affordable brief outreach interventions to promote tobacco use cessation in low resource settings where tobacco users have limited access to physicians and medications.

A new methodology for atrial flutter ablation by direct visualization of cavotricuspid conduction with voltage gradient mapping: a comparison to standard techniques.

AIMS: To demonstrate that critical conduction within the cavotricuspid isthmus (CTI) can be directly visualized by voltage gradient mapping and facilitate efficient ablation compared to standard techniques. METHODS AND RESULTS: Group 1 (1 operator, n = 11) ablated based upon contact voltage measurements and voltage gradient mapping. Ablation targeted low-voltage bridges (LVBs) within the CTI. Repeat maps were obtained following ablation. Group 2 (operators 2, 3, and 4 n = 35) utilized electroanatomic navigation and ablated by the creation of linear lesions from the tricuspid valve to the inferior vena cava. Demonstration of bidirectional block (BDB) was required in both groups. LVB were associated with CTI conduction in all Group A patients. LVB ablation terminated flutter, or created BDB. Following ablation, CTI voltage connections were absent in all patients. Compared with Group B, Group A had less radiofrequency (RF) lesions to atrial flutter (AFL) termination (P = 0.001), less total RF lesions (P = 0.0001), and less total RF time (P = 0.001). Group 1 had no recurrent AFL whereas Group 2 had three recurrences. (follow-up median of 231 ± 181 days). CONCLUSION: (i) Voltage gradient mapping visualized regions of critical CTI conduction, (ii) ablation of LVB terminated AFL and resulted in BDB, (iii) repeat mapping confirmed the absence of trans-isthmus voltage, and (iv) Compared with standard ablation, voltage gradient mapping decreases total RF lesions, lesions to AFL termination, and total RF time. Use of voltage gradient mapping can facilitate successful AFL ablation.

The acute effects of yogic breathing exercises on craving and withdrawal symptoms in abstaining smokers.

RATIONALE: Breathing exercises have been proposed as a way of combating cigarette cravings, potentially presenting a low-cost, easily scalable smoking cessation aid. OBJECTIVE: The aim of this study is to evaluate the acute impact of breathing exercises based on yogic pranayama on cravings in abstaining smokers. METHODS: Participants visited the laboratory on two occasions 24 h apart and were asked to abstain from smoking 12 h prior to the first visit until the end of the second visit. Smokers (N = 96) were randomly allocated to a yogic breathing exercise (YBG) or video control (VCG) group. The former was instructed on breathing exercises, practised these for 10 min and asked to use these when experiencing cravings until the next visit. The latter was shown a breathing exercise video for 10 min and asked to concentrate on their breathing. Strength of urges to smoke, other craving measures and mood and physical symptoms associated with cigarette withdrawal were assessed at the beginning and end of the first visit, and again at the second visit. RESULTS: At immediate follow-up, in the laboratory, all craving measures were reduced in YBG compared with VCG (strength of urges: F(1, 96) = 16.1, p < 0.001; cigarette craving: F(1, 96) = 11.3, p = 0.001; desire to smoke: F(1, 96) = 6.6, p = 0.012). There was no effect on mood or physical symptoms. Adherence to the breathing exercise regimen in the following 24 h was low, and at 24 h follow-up, there was no evidence of reduced cravings in YBG compared with VCG. CONCLUSIONS: Simple yogic-style breathing exercises can reduce cigarette craving acutely in the laboratory. Further research is needed to determine how far this translates into field settings.

Identification of behaviour change techniques to reduce excessive alcohol consumption.

BACKGROUND: Interventions to reduce excessive alcohol consumption have a small but important effect, but a better understanding is needed of their 'active ingredients'. AIMS: This study aimed to (i) develop a reliable taxonomy of behaviour change techniques (BCTs) used in interventions to reduce excessive alcohol consumption (not to treat alcohol dependence) and (ii) to assess whether use of specific BCTs in brief interventions might be associated with improved effectiveness. METHODS: A selection of guidance documents and treatment manuals, identified via expert consultation, were analysed into BCTs by two coders. The resulting taxonomy of BCTs was applied to the Cochrane Review of brief alcohol interventions, and the associations between the BCTs and effectiveness were investigated using meta-regression. FINDINGS: Forty-two BCTs were identified, 34 from guidance documents and an additional eight from treatment manuals, with average inter-rater agreement of 80%. Analyses revealed that brief interventions that included the BCT 'prompt self-recording' (P = 0.002) were associated with larger effect sizes. CONCLUSIONS: It is possible to identify specific behaviour change techniques reliably in manuals and guidelines for interventions to reduce excessive alcohol consumption. In brief interventions, promoting self-monitoring is associated with improved outcomes. More research is needed to identify other behaviour change techniques or groupings of behaviour change techniques that can produce optimal results in brief interventions and to extend the method to more intensive interventions and treatment of alcohol dependence.

Beliefs of stop smoking practitioners in United Kingdom on the use of nicotine replacement therapy for smoking reduction.

BACKGROUND: This paper aimed to assess the current beliefs of stop smoking practitioners and managers about using nicotine replacement therapy (NRT) for smoking reduction (SR) and the factors related to these beliefs. METHODS: An online survey was conducted of practitioners and managers working in the 152 English stop smoking services (SSSs). Questions were asked about their beliefs concerning the safety of using NRT for SR. RESULTS: Sixteen percent and 30% of the sample, respectively, believed that NRT use for a year or more and the concurrent use of NRT and cigarettes was harmful to health. The most commonly reported potential harms of the long-term use of NRT and the concurrent use of NRT and cigarettes were addiction, overdose and mouth cancer. Seventeen percent of the sample also believed that the use of NRT for SR could hinder smoking cessation. Reports differed as a function of the managers' relationship with their commissioner and influence on the commissioning process, while among practitioners as a function of the number of months worked, gender, frequency of update training and whether they advised reduction as a treatment option. CONCLUSIONS: A significant minority of stop smoking practitioners and stop smoking managers believe that NRT use for SR can be harmful to health and undermine smoking cessation. These beliefs should be addressed, especially if the use of NRT in these ways is provided as a route to quitting in SSSs.

The discovery of potent and long-acting oral factor Xa inhibitors with tetrahydroisoquinoline and benzazepine P4 motifs.

The discovery and evaluation of potent and long-acting oral sulfonamidopyrrolidin-2-one factor Xa inhibitors with tetrahydroisoquinoline and benzazepine P4 motifs are described. Unexpected selectivity issues versus tissue plasminogen activator in the former series were addressed in the later, delivering a robust candidate for progression towards clinical studies.

Effect of isometric exercise and body scanning on cigarette cravings and withdrawal symptoms.

AIMS: To examine the acute effects of a guided relaxation routine (body scan) and isometric exercise on desire to smoke and tobacco withdrawal symptoms. DESIGN: Experimental comparison of three conditions. PARTICIPANTS: Forty-eight individuals reporting smoking > or =10 cigarettes daily. INTERVENTION: Random assignment to one of three interventions delivered via a 10-minute audio: isometric exercise (IE, n = 14), body scanning (BS, n = 18) or a reading about natural history (control group, n = 16). Interventions were delivered twice on the same day: in the laboratory, then in their 'normal' environment. MEASUREMENTS: Desire to smoke (primary outcome) and withdrawal symptoms were rated at pre-intervention and up to 30 minutes post-intervention. FINDINGS: Controlling for baseline scores, post-intervention desire to smoke and withdrawal symptoms were significantly lower for IE and BS groups, compared with the controls, in both environments. There were no significant differences for IE versus BS. For desire to smoke, controlling for baseline values, ratings in the laboratory were significantly lower for IE and BS versus the control up to 30 minutes post-intervention. In the normal environment, these ratings were significantly lower only up to 5 minutes post-intervention. CONCLUSIONS: Brief IE and BS interventions are effective for reducing desire to smoke and withdrawal symptoms in temporarily abstaining smokers. These interventions were found to be more effective in the laboratory than in the smoker's normal environment, but this may be an artefact of there not being a sufficient 'wash-out' period between interventions. These techniques may be beneficial for managing desire to smoke and tobacco withdrawal.

Factors associated with the use of aids to cessation in English smokers.

AIMS: To assess factors associated with the use of smoking cessation aids among smokers trying to quit in a country where these aids are widely available and free or cheap to access. DESIGN: Cross-sectional household survey, the 'Smoking Toolkit Study'. SETTING: England. PARTICIPANTS: A total of 3767 respondents who smoked and made at least one serious quit attempt in the past 12 months were interviewed from November 2006 to April 2008. MEASUREMENTS: We analysed differences across socio-demographic and smoking characteristics in the use of nicotine replacement therapy (NRT) over the counter or on prescription, bupropion, varenicline, telephone support and the National Health Service Stop Smoking Service (NHS-SSS) which combines behavioural support with medication. FINDINGS: More than half of smokers trying to quit (51.2%) had used any kind of treatment; 48.4% had used some form of medication but only 6.2% had used the NHS-SSS. The use of some form of smoking cessation treatment was higher in female than in male smokers [odds ratio (OR): 1.24, 95% confidence interval (CI): 1.08, 1.43] and increased with age (OR: 1.19, 95% CI: 1.14,1.25) and cigarettes smoked per day (OR = 1.05, 95% CI = 1.04,1.06). There was no association with social grade. Smokers who planned their quit attempt were more likely to have used all types of smoking cessation treatments, except for telephone support. CONCLUSIONS: In England, half of all attempts to quit smoking are aided by some form of pharmacological or behavioural treatment. However, the use of the most effective treatment option (the NHS-SSS) is low, despite it being free of charge. Factors associated with an increased use of aids to cessation were female sex, older age, more cigarettes smoked per day and planning a quit attempt. Research is needed into how to increase utilization rates, particularly among males and younger smokers.

Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial.

BACKGROUND: An integrated breathing and relaxation technique known as the Papworth method has been implemented by physiotherapists since the 1960s for patients with asthma and dysfunctional breathing, but no controlled trials have been reported. This study evaluated the effectiveness of the Papworth method in a randomised controlled trial. METHODS: Eighty-five patients (36 men) were individually randomised to the control group (n = 46) or to the intervention group receiving five sessions of treatment by the Papworth method (n = 39). Both groups received usual medical care. Assessments were undertaken at baseline, post-treatment (6 months after baseline) and at 12 months. The primary outcome measure was the St George's Respiratory Symptoms Questionnaire (SGRQ). Secondary outcome measures included the Hospital Anxiety and Depression Scale (HADS), the Nijmegen dysfunctional breathing questionnaire and objective measures of respiratory function. RESULTS: Post-treatment and 12 month data were available for 78 and 72 patients, respectively. At the post-treatment assessment the mean (SD) score on the SGRQ Symptom subscale was 21.8 (18.1) in the intervention group and 32.8 (20.1) in the control group (p = 0.001 for the difference). At the 12 month follow-up the corresponding figures were 24.9 (17.9) and 33.5 (15.9) (p = 0.007 for the difference). SGRQ Total scores and HADS and Nijmegen scores were similarly significantly lower in the intervention group than in the control group. The groups did not differ significantly following the treatment on objective measures of respiratory function except for relaxed breathing rate. CONCLUSIONS: The Papworth method appears to ameliorate respiratory symptoms, dysfunctional breathing and adverse mood compared with usual care. Further controlled trials are warranted to confirm this finding, assess the effect in other patient groups and determine whether there is some effect on objective measures of respiratory function.

Networks and governance: the case of intermediate care.

The present paper describes a novel approach to the study of services conceptualised as networks. It uses data collected as part of a case study evaluation of intermediate care, a 'joined-up government' policy that was explicitly intended to dissolve the boundaries between health and social care services. The evaluation was undertaken in five localities in England. Routine service use data were collated and standardised for the 12-month period from November 2002 to October 2003. A cohort of 258 service users was recruited during a census month (June 2003), and more detailed data on their personal characteristics and experiences prior to and during their intermediate care episode were collected. Information was obtained for 153 of these people, covering their experience during the 6 months following discharge. A graphical method of depicting individuals' movements between services was devised and a number of measures were used to investigate the network-like features of the data. User outcomes were explored by examining the relationship of characteristics of service users to their location at 6 months after discharge. The results of the analyses show that the five sites were developing service configurations that facilitated transitions between health, social care and other services, and that individual needs were taken into account in the decisions made about which people transferred into which services. While the results cannot be said to show that joined-up government works, they are consistent with the argument that joined-up government goes beyond partnership-type concepts, and in practice, involves the creation of what might be termed integrated service networks.