A comparative study of industry responses to government consultations about alcohol and gambling in the UK.

BACKGROUND: There is growing evidence that common strategies are used across unhealthy commodity industries (UCIs) to influence policy decisions in line with their commercial interests. To date, there have been relatively few studies comparing corporate political activity (CPA) across UCIs, especially comparing the alcohol and gambling industries. METHODS: A comparative and inductive thematic analysis of alcohol and gambling industry submissions to two House of Lords (HoL) inquiries in the UK was conducted. Themes in the framing, arguments and strategies used by the alcohol and gambling industries in CPA were compared. RESULTS: Alcohol and gambling industry responses largely used the same framings, both in terms of the problems and solutions. This included arguing that harms are only experienced by a 'minority' of people, emphasising individual responsibility and shifting blame for harms to other industry actors. They promoted targeted or localised solutions to these harms, in place of more effective population level solutions, and emphasised the perceived harms of introducing regulation not in the industries' interests. CONCLUSIONS: These findings are consistent with previous literature suggesting that UCIs use the same framing and arguments to shape the narrative around their harms and solutions to those harms. This study also identified novel strategies such as shifting blame of harms to other industry actors. Policy makers should be aware of these strategies to avoid undue industry influence on policy decisions and understanding commonalities in strategies may help to inform more effective public health responses across all UCIs.

Factors Associated with Adolescents' Support for Product Information and Health Messaging on Alcohol Packaging: A Cross-Sectional Study in the United Kingdom.

AIMS: Adolescents in the UK are among the heaviest drinkers in Europe. The World Health Organization recommends alcohol product labelling to inform consumers about product information and health risks associated with alcohol use. This study investigates support for product information and health messaging on alcohol packaging among UK adolescents. METHODS: The 2019 UK Youth Alcohol Policy Survey was an online cross-sectional survey among 3388 adolescents aged 11-19. Participants indicated their support for seven forms of messaging on packaging (e.g. number of alcohol units, links to health conditions). Logistic regression models investigated associations between support for each of the seven forms and alcohol use, perceived risks of alcohol use, and previous exposure to messaging. RESULTS: Between 60 and 79% of adolescents were supportive of different aspects of product labelling. Compared to lower-risk drinkers, higher-risk drinkers (AUDIT-C 5+) had higher odds of supporting including the number of alcohol units (OR: 1.82, 95% CI: 1.31-2.54), calories (OR: 1.52, 95% CI: 1.04-1.68), and strength of the product (OR: 1.73, 95% CI: 1.19-2.52) but lower odds of supporting including information on alcohol-related health conditions (OR: 0.68, 95% CI: 0.53-0.87). Adolescents who perceived risks of alcohol use more strongly were more likely to support all forms of product information and messaging. CONCLUSIONS: The majority of adolescents supported improved alcohol labelling. Higher-risk drinkers were supportive of improved product information but less supportive of health-related messaging. Adolescents who believe alcohol carries health risks were more likely to support messaging.

Independent Associations Between Different Measures of Socioeconomic Position and Smoking Status: A Cross-Sectional Study of Adults in England.

INTRODUCTION: To gain a better understanding of the complex and independent associations between different measures of socioeconomic position (SEP) and smoking in England. AIMS AND METHODS: Between March 2013 and January 2019 data were collected from 120 496 adults aged 16+ in England taking part in the Smoking Toolkit Study. Of these, 18.04% (n = 21 720) were current smokers. Six indicators of SEP were measured: social grade, employment status, educational qualifications, home and car ownership and income. Models were constructed using ridge regression to assess the contribution of each measure of SEP, taking account of high collinearity. RESULTS: The strongest predictor of smoking status was housing tenure. Those who did not own their own home had twice the odds of smoking compared with homeowners (odds ratio [OR] = 2.01). Social grade, educational qualification, and income were also good predictors. Those in social grades C1 (OR = 1.04), C2 (OR = 1.29), D (OR = 1.39), and E (OR = 1.78) had higher odds of smoking than those in social grade AB. Similarly, those with A-level/equivalent (OR = 1.15), GCSE/vocational (OR = 1.48), other/still studying (OR = 1.12), and no post-16 qualifications (OR = 1.48) had higher odds of smoking than those with university qualifications, as did those who earned in the lowest (OR = 1.23), third (OR = 1.18), and second quartiles (OR = 1.06) compared with those earning in the highest. Associations between smoking and employment (OR = 1.03) and car ownership (OR = 1.05) were much smaller. CONCLUSIONS: Of a variety of socioeconomic measures, housing tenure appears to be the strongest independent predictor of smoking in England, followed by social grade, educational qualifications, and income. Employment status and car ownership have the lowest predictive power. IMPLICATIONS: This study used ridge regression, a technique which takes into account high collinearity between variables, to gain a better understanding of the independent associations between different measures of SEP and smoking in England. The findings provide guidance as to which SEP measures one could use when trying to identifying individuals most at risk from smoking, with housing tenure identified as the strongest independent predictor.

Opportunistic screening for alcohol use problems in adolescents attending emergency departments: an evaluation of screening tools.

OBJECTIVE: To estimate and compare the optimal cut-off score of Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C in identifying at-risk alcohol consumption, heavy episodic alcohol use, ICD-10 alcohol abuse and alcohol dependence in adolescents attending ED in England. DESIGN: Opportunistic cross-sectional survey. SETTING: 10 emergency departments across England. PARTICIPANTS: Adolescents (n = 5377) aged between their 10th and 18th birthday who attended emergency departments between December 2012 and May 2013. MEASURES: Scores on the AUDIT and AUDIT-C. At-risk alcohol consumption and monthly episodic alcohol consumption in the past 3 months were derived using the time-line follow back method. Alcohol abuse and alcohol dependence was assessed in accordance with ICD-10 criteria using the MINI-KID. FINDINGS: AUDIT-C with a score of 3 was more effective for at-risk alcohol use (AUC 0.81; sensitivity 87%, specificity 97%), heavy episodic use (0.84; 76%, 98%) and alcohol abuse (0.98; 91%, 90%). AUDIT with a score of 7 was more effective in identifying alcohol dependence (0.92; 96%, 94%). CONCLUSIONS: The 3-item AUDIT-C is more effective than AUDIT in screening adolescents for at-risk alcohol use, heavy episodic alcohol use and alcohol abuse. AUDIT is more effective than AUDIT-C for the identification of alcohol dependence.

The Effect of Brief Interventions for Alcohol Among People with Comorbid Mental Health Conditions: A Systematic Review of Randomized Trials and Narrative Synthesis.

AIMS: To review the evidence on the effect of brief interventions (BIs) for alcohol among adults with risky alcohol consumption and comorbid mental health conditions. METHODS: A systematic review of randomized controlled trials (RCTs) published before May 2016 was undertaken and reported according to PRISMA guidelines. The findings were combined in a narrative synthesis. The risk of bias was assessed for included trials. RESULTS: Seventeen RCTs were included in the review and narrative synthesis: 11 in common mental health problems, and 6 in severe mental illness. There was considerable heterogeneity in study populations, BI delivery mode and intensity, outcome measures and risk of bias. Where BI was compared with a minimally active control, BI was associated with a significant reduction in alcohol consumption in four out of nine RCTs in common mental disorders and two out of five RCTs in severe mental illness. Where BI was compared with active comparator groups (such as motivational interviewing or cognitive behavioural therapy), findings were also mixed. Differences in the findings may be partly due to differences in study design, such as the intensity of BI and possibly the risk of bias. CONCLUSIONS: Overall, the evidence is mixed regarding the effects of alcohol BI in participants with comorbid mental health conditions. Future well-designed research is required to answer this question more definitively.

Variance in the Efficacy of Brief Interventions to Reduce Hazardous and Harmful Alcohol Consumption Between Injury and Noninjury Patients in Emergency Departments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

STUDY OBJECTIVE: We adopt a comparative framework to measure the extent to which variance in the efficacy of alcohol brief interventions to reduce hazardous and harmful drinking at less than or equal to 5-, 6-, and 12-month follow-up in emergency department settings can be determined by differences between study populations (targeted injury and noninjury specific). METHODS: A systematic review and meta-analysis of randomized controlled trials published before September 2016 was undertaken. Twenty-three high-quality and methodologically similar randomized controlled trials were eligible, with a total number of 15,173 participants included. Primary outcome measure was efficacy of brief intervention compared with a control group in reducing quantity of alcohol consumed. An inverse variance model was applied to measure the effect of treatment in standard mean differences for brief intervention and control groups. RESULTS: At 6-month follow-up, an effect in favor of brief intervention over control was identified for targeted injury studies (standardized mean difference=-0.10; 95% confidence interval [CI] -0.17 to -0.02; I2=0%). For pooled noninjury-specific studies, small benefits of brief intervention were evident at less than or equal to 5-month follow-up (standardized mean difference=-0.15; 95% CI -0.24 to -0.07; I2=0%), at 6-month follow-up (standardized mean difference=-0.08; 95% CI -0.14 to -0.01; I2=1%), and at 12-month follow-up (standardized mean difference=-0.08; 95% CI -0.15 to -0.01; I2=0%). CONCLUSION: Meta-analysis identified noninjury-specific studies as associated with better response to brief intervention than targeted injury studies. However, the inclusion of injured patients with noninjured ones in the experimental and control groups of noninjury-specific studies limited the interpretation of this finding.

Evaluating and establishing national norms for mental wellbeing using the short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS): findings from the Health Survey for England.

PURPOSE: The Warwick-Edinburgh Mental Well-being Scale (WEMWBS), 14 positively worded statements, is a validated instrument to measure mental wellbeing on a population level. Less is known about the population distribution of the shorter seven-item version (SWEMWBS) or its performance as an instrument to measure wellbeing. METHODS: Using the Health Survey for England 2010-2013 (n = 27,169 adults aged 16+, nationally representative of the population), age- and sex-specific norms were estimated using means and percentiles. Criterion validity was examined using: (1) Spearman correlations (ρ) for SWEMWBS with General Health Questionnaire (GHQ-12), happiness index, EQ-VAS (2) a multinomial logit model with SWEMWBS (low, medium and high wellbeing) as the outcome and demographic, social and health behaviours as explanatory variables. Relative validity was examined by comparing SWEMWBS with WEMWBS using: (1) Spearman correlations (continuous data), and (2) the weighted kappa statistic (categorical), within population subgroups. RESULTS: Mean (median) SWEMWBS was 23.7 (23.2) for men and 23.2 (23.2) for women (p = 0.100). Spearman correlations were moderately sized for the happiness index (ρ = 0.53, P < 0.001), GHQ-12 (ρ = -0.52, p < 0.001) and EQ-VAS (ρ = 0.40, p < 0.001). Participants consuming <1 portion of fruit and vegetables a day versus ≥5 (odds ratio = 1.43 95% Confidence Interval = (1.22-1.66)) and current smokers versus non-smokers (1.28 (1.15-1.41)) were more likely to have low vs medium wellbeing. Participants who binge drank versus non-drinkers were less likely to have high versus medium wellbeing (0.81 (0.71-0.92)). Spearman correlations between SWEMWBS and WEMWBS were above 0.95; weighted kappa statistics showed almost perfect agreement (0.79-0.85). CONCLUSION: SWEMWBS distinguishes mental wellbeing between subgroups, similarly to WEMWBS, but is less sensitive to gender differences.

Pragmatic randomised controlled trial to evaluate the effectiveness and cost effectiveness of a multi-component intervention to reduce substance use and risk-taking behaviour in adolescents involved in the criminal justice system: A trial protocol (RISKIT-CJS).

BACKGROUND: Adolescence is a critical developmental stage when young people make lifestyle choices that have the potential to impact on their current and future health and social wellbeing. The relationship between substance use and criminal activity is complex but there is clear evidence that the prevalence of problematic substance use is far higher among adolescent offenders than the general adolescent population. Adolescent offenders are a marginalized and vulnerable population who are significantly more likely to experience health and social inequalities in later life than their non-offending peers. There is a paucity of evidence on effective interventions to address substance use and risk-taking behaviours in adolescent offender populations but it is clear that preventative or abstinence orientated interventions are not effective. RISKIT-CJS is an intervention developed in collaboration with young people taking account of the current best evidence. Feasibility and pilot studies have found the intervention addresses the needs of adolescents, is acceptable and has demonstrated potential in reducing substance use and risk-taking behavior. METHODS: The study is a mixed method, two-armed, prospective, pragmatic randomized controlled trial with individual randomisation to either treatment as usual alone or the RISKIT-CJS intervention in addition to treatment as usual. Adolescents, aged 13 to 17 years inclusive, engaged with the criminal justice system who are identified as having problematic substance use are eligible to participate. The study will be conducted across three geographical areas; South and South East England, London and North East England between March 2017 and February 2019. DISCUSSION: The study represents an ambitious programme of work to address an area of need for a marginalized and vulnerable population. TRIAL REGISTRATION: ISRCTN77037777 registered 15/09/2016.

Prevalence of Hazardous Drinking Among UK 18-35 Year Olds; the Impact of a Revision to the AUDIT Cut Score.

AIM: Most published research utilizes an AUDIT score of >8 as the threshold for hazardous drinking. Recent research suggests that this limit should be amended for younger drinkers (aged 18-35 years). This study aimed to explore the effect of a revision to AUDIT cut scores. METHOD: Applying Foxcroft et al.'s [(2015) Accuracy of Alcohol Use Disorders Identification Test for detecting problem drinking in 18-35 year-olds in England: method comparison study. Alcohol Alcohol 50, 244-50] suggested cut off scores of nine for males and four for females to the most recent Adult Psychiatric Morbidity Survey (2007) data. RESULTS: This more than doubles the prevalence of female hazardous drinkers, and significantly increases the overall rate for that age group when compared with the standard threshold of >8. CONCLUSION: The prevalence of hazardous drinking among females ages 18-30 may be significantly higher than current estimates.

Unravelling the alcohol harm paradox: a population-based study of social gradients across very heavy drinking thresholds.

BACKGROUND: There is consistent evidence that individuals in higher socioeconomic status groups are more likely to report exceeding recommended drinking limits, but those in lower socioeconomic status groups experience more alcohol-related harm. This has been called the 'alcohol harm paradox'. Such studies typically use standard cut-offs to define heavy drinking, which are exceeded by a large proportion of adults. Our study pools data from six years (2008-2013) of the population-based Health Survey for England to test whether the socioeconomic distribution of more extreme levels of drinking could help explain the paradox. METHODS: The study included 51,498 adults from a representative sample of the adult population of England for a cross-sectional analysis of associations between socioeconomic status and self-reported drinking. Heavy weekly drinking was measured at four thresholds, ranging from 112 g+/168 g + (alcohol for women/men, or 14/21 UK standard units) to 680 g+/880 g + (or 85/110 UK standard units) per week. Heavy episodic drinking was also measured at four thresholds, from 48 g+/64 g + (or 6/8 UK standard units) to 192 g+/256 g + (or 24/32 UK standard units) in one day. Socioeconomic status indicators were equivalised household income, education, occupation and neighbourhood deprivation. RESULTS: Lower socioeconomic status was associated with lower likelihoods of exceeding recommended limits for weekly and episodic drinking, and higher likelihoods of exceeding more extreme thresholds. For example, participants in routine or manual occupations had 0.65 (95 % CI 0.57-0.74) times the odds of exceeding the recommended weekly limit compared to those in 'higher managerial' occupations, and 2.15 (95 % CI 1.06-4.36) times the odds of exceeding the highest threshold. Similarly, participants in the lowest income quintile had 0.60 (95 % CI 0.52-0.69) times the odds of exceeding the recommended weekly limit when compared to the highest quintile, and 2.30 (95 % CI 1.28-4.13) times the odds of exceeding the highest threshold. CONCLUSIONS: Low socioeconomic status groups are more likely to drink at extreme levels, which may partially explain the alcohol harm paradox. Policies that address alcohol-related health inequalities need to consider extreme drinking levels in some sub-groups that may be associated with multiple markers of deprivation. This will require a more disaggregated understanding of drinking practices.

Drinking pattern is more strongly associated with under-reporting of alcohol consumption than socio-demographic factors: evidence from a mixed-methods study.

BACKGROUND: Under-reporting of alcohol consumption is widespread; surveys typically capture 40-60% of alcohol sales. However the population distribution of under-reporting is not well understood. METHODS: Mixed-methods study to identify factors associated with under-reporting, using the nationally-representative Health Survey for England (HSE) 2011 (overall response rate 66%). Comparison of retrospective computer-assisted personal interview and seven-day drinking diary (n = 3,774 adults 18+, 50% women, diary response rate 69%) to identify factors associated with diary responses exceeding those of the interview using multivariable linear regression for three outcomes: drinking days in the week recorded, volume consumed on heaviest drinking day in the week recorded, and weekly alcohol consumption. Qualitative semi-structured interviews (n = 10) explored reasons for under-reporting in further detail. RESULTS: Number of drinking days was slightly greater in the diary than the interview (P < 0.001). Reported consumption was higher in the diary than in the interview for heaviest drinking day in the week recorded (0.7 units greater among men, 1.2 units among women, P < 0.001), and weekly alcohol consumption in women only (1.1 units among women, P = 0.003). Participants who drank more frequently, more heavily, and had a more varied drinking pattern with respect to the types of drink consumed or choice of drinking venues had a larger difference between their diary week and their interview week.The qualitative interviews identified having a non-routine drinking pattern, self-perception as a non-frequent drinker, and usually tracking drinking using experiential approaches as linked to more drinking being reported in the diary than the retrospective interview. CONCLUSIONS: Heavy drinking and non-routine drinking patterns may be associated with greater under-reporting of alcohol consumption. Estimates of drinking above recommended levels are likely to be disproportionately under-estimated.

Alcohol policy changes during the first three-months of the COVID-19 pandemic: Development and application of a classification scheme.

BACKGROUND: Policy changes in response to the COVID-19 pandemic have impacted on alcohol control. This study describes the development and application of a classification scheme to map alcohol policy changes during the first three-months of the COVID-19 pandemic in five countries and/or subnational jurisdictions. METHOD: A pre-registered systematic review of policy decisions from March to May 2020, in Australia/New South Wales, Canada/Ontario, Chile, Italy and the United Kingdom. One author extracted the data for each jurisdiction using a country-specific search strategy of government documents. We coded policy changes using an adapted WHO classification scheme, whether the policy was expected to tighten or loosen alcohol control, have mainly immediate or delayed impact on consumption and harm and impact the general population versus specific populations. We present descriptive statistics of policy change. RESULTS: We developed a classification scheme with four levels. Existing policy options were insufficient to capture policy changes in alcohol availability, thus we added seventeen new sub-categories. We found 114 alcohol control policies introduced across the five jurisdictions, covering five (out of ten) WHO action areas. The majority aimed to change alcohol availability, by regulating the operation of alcohol outlets. All countries introduced closures to on-premise alcohol outlets and, except Chile, allowed off-sales via take away or home delivery. We also observed several pricing policies introducing subsidies to support the alcohol industry. Seventy-four percent of policy changes were expected to tighten alcohol control and 12.3 % to weaken control. Weakening policy changes were mostly related to retail mode switching or expansion (allowing take away or home delivery). CONCLUSION: Alcohol control policies during the first three months of the COVID-19 pandemic were targeted primarily at alcohol availability and about one tenth might weaken alcohol control. Temporary changes to alcohol retail during the COVID-19 pandemic, if made permanent, could significantly expand alcohol availability.

Actual and perceived units of alcohol in a self-defined "usual glass" of alcoholic drinks in England.

BACKGROUND: Several studies have found participants pour more than 1 standard drink or unit as their usual glass. This is the first study to measure actual and perceived amounts of alcohol in a self-defined usual glass of wines and spirits in the general population. METHODS: Participants were a convenience sample of adults who drink alcohol or who pour drinks for other people (n = 283, 54% women) at 6 sites in South East England. The survey was face to face and comprised a self-completion questionnaire and pouring task. Estimation accuracy, categorised as correct (±0.5 units), underestimate (>0.5 units), or overestimate (>0.5 units) was the main outcome. RESULTS: The mean number of units poured was 1.90 (SD 0.80; n = 264) for wine and 1.93 (SD 0.78; n = 201) for spirits. The amount of alcohol in a self-defined usual glass was estimated in 440 glasses (248 wine and 192 spirits). Overestimation took place in 42% glasses of spirit poured and 29% glasses of wine poured, and underestimation in 17 and 19%, respectively. Multinomial logistic regression found volume poured to be significantly associated with underestimating both wines and spirits, and additionally for wine only, belonging to a non-white ethnic group and being unemployed or retired. Not having a university degree was significantly associated with overestimating both drink types. CONCLUSIONS: This study is the first in the general population and did not identify systematic underestimation of the amount of alcohol in a self-defined usual glass. Underestimation is significantly associated with volume poured for both drink types; therefore, advocating pouring smaller glasses could reduce underestimation of alcohol consumption.

How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario.

BACKGROUND: This study predicts the implications of under-reporting of alcohol consumption in England for alcohol consumption above Government drinking thresholds. METHODS: Two nationally representative samples of private households in England were used: General LiFestyle survey (GLF) and Health Survey for England (HSE) 2008. Participants were 9608 adults with self-reported alcohol consumption on heaviest drinking day in the last week (HSE) and 12 490 adults with self-reported average weekly alcohol consumption (GLF). Alcohol consumption in both surveys was revised to account for under-reporting in three hypothetical scenarios. The prevalence of drinking more than UK Government guidelines of 21/14 (men/women) alcohol units a week, and 4/3 units per day, and the prevalence of binge drinking (>8/6 units) were investigated using logistic regression. RESULTS: Among drinkers, mean weekly alcohol intake increases to 20.8 units and mean alcohol intake on heaviest drinking day in the last week increases to 10.6 units. Over one-third of adults are drinking above weekly guidelines and over three-quarters drank above daily limits on their heaviest drinking day in the last week. The revision changes some of the significant predictors of drinking above thresholds. In the revised scenario, women have similar odds to men of binge drinking and higher odds of drinking more than daily limits, compared with lower odds in the original survey. CONCLUSION: Revising alcohol consumption assuming equal under-reporting across the population does not have an equal effect on the proportion of adults drinking above weekly or daily thresholds. It is crucial that further research explores the population distribution of under-reporting.

The effects of yoga on mental health in school-aged children: A Systematic Review and Narrative Synthesis of Randomised Control Trials.

It is becoming increasingly common for frontline clinicians to see children and teenagers struggle with their mental health. Since mental health issues have increased over the past ten years in the UK, they are now the leading cause of disability and cost the British economy £105 billion annually. The review discusses the evidence base underpinning the effect of yoga on children's mental health and summarises the results of 21 research papers. The Cumulative Index to Nursing and Allied Health Literature, PsycINFO, ERIC, Web of Science, PubMed, Medline and Cochrane Library were searched through Ovid from January 2008 until May 2022. The keywords 'yoga OR mindfulness - AND school AND children OR child OR youth OR adolescent' were used. The search was limited to studies in the English language. The quality of each study was rated against Version 2 of the Cochrane risk-of-bias tool for randomised control trials and a set of inclusion and exclusion criteria. The evidence for yoga therapies in children is encouraging, although studies include methodological flaws such as small sample sizes and sparse information on interventions. This review has highlighted that yoga interventions may be implemented in schools as a preventative and therapeutic measure for mental health issues.

Co-use of cannabis and alcohol before and after Canada legalized nonmedical cannabis: A repeat cross-sectional study.

BACKGROUND: This study examined changes in population-level co-use of cannabis and alcohol before and 12 months after nonmedical cannabis legalization in Canada, relative to the United States that had previously legalized and not legalized (US legal and illegal states, respectively). METHODS: Data are from waves 1 and 2 of the International Cannabis Policy Study, collected in 2018 (before) and 2019 (12 months after legalization in Canada). Respondents aged 16-65 years from Canada (n = 25,313) and US legal (n = 25,189) and US illegal (n = 19,626) states completed an online survey. Changes in co-use between 2018 and 2019 in US legal and illegal states compared to those in Canada were assessed using multinomial logistic regression. RESULTS: Descriptive analyses show increases in cannabis use and monthly or more frequent (MMF) co-use between 2018 and 2019 in all jurisdictions. Compared to no MMF use of cannabis or alcohol, there was no evidence suggesting differences in changes in MMF co-use in US legal or illegal states relative to Canada. However, respondents in US legal states had 33% higher odds of MMF alcohol-only use (OR = 1.33, 99% CI: 1.12, 1.57) compared to no MMF use relative to Canada. CONCLUSIONS: Increases in co-use were observed between 2018 and 2019 in all jurisdictions regardless of the legal status of cannabis. These shifts were largely due to increases in cannabis use across the population, including those that use alcohol, and may indicate changing societal norms toward cannabis generally. As the cannabis legalization transition in Canada matures, evaluation over the longer term will improve understanding of the influence of cannabis liberalization on co-use.

Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT.

Background: Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed. Objectives: To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption. Design: Multicentre, three-arm, parallel-group, randomised controlled clinical trial. Setting: Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands). Participants: Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate. Interventions: (1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation. Main outcome measures: Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule. Results: Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported. Limitations: The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted. Conclusions: Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate. Future work: Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence. Trial registration: This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Many people who are trying to stop drinking alcohol can find it difficult to remain alcohol free. There is a medication called acamprosate (Campral) that can reduce cravings thereby increasing the likelihood of abstinence. However, some people have trouble taking the right amount of acamprosate tablets needed every day at the right time, preferably at mealtimes. This means the medication is not as effective. We have tested some new ways to help support people taking acamprosate. We tested three different strategies to find the best way to support people taking acamprosate. We recruited 739 people aged 18 and over who were receiving alcohol treatment to stop drinking and were taking acamprosate. We randomly allocated these people to three groups. The first was Standard Support, the usual support people receive when taking acamprosate. The second group received Standard Support plus Medication Management. This consisted of 12 telephone calls over 6 months with a trained pharmacist to discuss the importance of taking the right amount of the medication, how the medication works and strategies to help people take the medication correctly. The third group received Standard Support, Medication Management and Contingency Management. This involved giving people shopping vouchers for participating with Medication Management calls. The maximum value of vouchers per person was £120. People who were in the group receiving Medication Management and Contingency Management took a greater number of acamprosate tablets. We also found that Medication Management plus Contingency Management was more cost-effective; there were greater gains in health with a smaller cost per person compared to Standard Support alone. This shows that there is likely to be a benefit to patients of Medication Management plus Contingency Management for supporting people taking acamprosate.

The COVID-19 hangover: why we need to take harm caused by alcohol seriously as an indirect effect of the pandemic.

In the UK, harm caused by alcohol has worsened since 2020. A recent report from the Institute of Alcohol Studies projecting future rates of major alcohol-related diseases highlights what this means for health and healthcare. The authors argue that this additional burden is not inevitable if effective policies are introduced.

Effectiveness and cost-effectiveness of face-to-face and electronic brief interventions versus screening alone to reduce alcohol consumption among high-risk adolescents presenting to emergency departments: three-arm pragmatic randomized trial (SIPS Junior high risk trial).

BACKGROUND AND AIMS: Alcohol use increases throughout adolescence. Emergency department (ED) attendance is an opportunity for alcohol screening and brief intervention (ASBI), which is effective for adults. This trial evaluated the effectiveness and cost-effectiveness of ASBI compared with screening alone (SA) in high-risk adolescents. DESIGN, SETTING AND PARTICIPANTS: Multi-centre, three-group, single-blind, individually randomized trial with follow-ups after 6 and 12 months in 10 ED settings in England. From October 2014 to May 2015 we screened 3327 adolescents aged 14 to 18 years, of whom 756 (22.7%) scored at least 3 on the Alcohol Use Disorders Identification Test: consumption (AUDIT-C) and consented to participate in this trial. Mean age was 16.1 years; 50.2% were female and 84.9% were white. INTERVENTIONS: Interventions were personalized feedback and brief advice (PFBA), personalized feedback plus electronic brief intervention (eBI) and SA. MEASURES: The primary outcome was the weekly alcohol consumed in standard UK units (8 g ethanol) at 12 months post-randomization, derived from extended AUDIT-C. Economic outcomes included quality of life and service use, from perspectives of both the National Health Service and personal social services (NHS&PSS) and society. FINDINGS: At 12 months, mean weekly consumption was 2.99 [95% confidence interval (CI) = 2.38-3.70] standard units for the SA group, 3.56 (95% CI = 2.90, 4.32) for PFBA and 3.18 (95% CI = 2.50, 3.97) for eBI, showing no significant differences. The PFBA group consumed mean 0.57 (-0.36, 1.70) units more than SA; and eBIs consumed 0.19 (-0.71, 1.30) more. Bayes factors suggested lack of effectiveness explained non-significance. From the NHS&PSS perspective, economic analysis showed that PFBA and eBI were not cost-effective compared with SA: PFBA yielded incremental cost-effectiveness ratio of £6213 (-£736 843, £812 884), with the intervention having 54% probability of being cost-effective compared with SA at the £20 000 WTP threshold. CONCLUSIONS: In emergency departments in England, neither personalized feedback and brief advice nor personalized feedback plus electronic brief intervention showed evidence of being effective or cost-effective when compared with screening alone in reducing alcohol consumption among adolescents.