Animal-assisted and robotic animal-assisted interventions within dementia care: A systematic review.

BACKGROUND: Animal-assisted interventions and robotic animal interventions are becoming increasingly popular to support the care of people with dementia and may have the potential to improve a range of psychosocial outcomes. This review aims to identify, describe, and compare animal-assisted and robotic animal interventions delivered to people with dementia, their characteristics, effectiveness, and the proposed mechanisms underlying any potential impact. METHODS: A systematic literature search was conducted in MEDLINE, AMED, EMBASE, PsycINFO, OVID Nursing, PubMed, CINAHL and Web of Science. Random-effects meta-analyses of randomised controlled trials (RCTs) were conducted to summarise studies that evaluated common outcomes (agitation, depression, quality of life). A narrative approach was used to synthesise other findings. RESULTS: Fifty-one studies were included: 18 RCTs; 12 non-randomised trials, 13 cohort studies, 7 qualitative studies and one mixed-methods study. Meta-analyses were conducted for a small number of RCTs, with effectiveness of animal-assisted interventions demonstrated for agitation. Narrative findings suggested animal-assisted and robotic animal interventions may be promising in improving depression, agitation, and quality of life. Three potential mechanisms of action were identified for both animal-assisted and robotic animal interventions, namely enhancing social connections, providing engaging and meaningful activities, and the affect-generating aspect of the human-animal bond. A fourth mechanism was identified for animal-assisted interventions only: promoting physical activity. Robotic animals appear to have a place in complex human-animal relationships, but a greater understanding of robotic animal interventions is required to harness the benefits that may be derived from their use. CONCLUSION: Delivering these interventions appear promising in improving psychosocial outcomes for people with dementia. As most included studies had methodological limitations, these findings are preliminary, but contribute to the body of evidence providing an understanding in terms of intervention characteristics and mechanisms of action. When developing intervention guidance, attention should be given to potential mechanisms and fundamental characteristics such as session content, delivery format and facilitator role.

Promoting and Maintaining Changes in Smoking Behavior for Patients Following Discharge from a Smoke-free Mental Health Inpatient Stay: Development of a Complex Intervention Using the Behavior Change Wheel.

INTRODUCTION: Evidence suggests that smokers can successfully quit, remain abstinent or reduce smoking during a smoke-free mental health inpatient stay, provided behavioral/pharmacological support are offered. However, few evidence-based strategies to prevent the return to prehospital smoking behaviors post-discharge exist. AIMS AND METHODS: We report the development of an intervention designed to support smoking-related behavior change following discharge from a smoke-free mental health stay. We followed the Behavior Change Wheel (BCW) intervention development process. The target behavior was supporting patients to change their smoking behaviors following discharge from a smoke-free mental health stay. Using systematic reviews, we identified the barriers and enablers, classified according to the Theoretical Domains Framework (TDF). Potential intervention functions to address key influences were identified by consulting the BCW and Behavior Change Technique (BCT) taxonomy. Another systematic review identified effectiveness of BCTs in this context. Stakeholder consultations were conducted to prioritize and refine intervention content. RESULTS: Barriers and enablers to supporting smoking cessation were identified within the domains of environmental context and resources (lack of staff time); knowledge (ill-informed interactions about smoking); social influences, and intentions (lack of intention to deliver support). Potential strategies to address these influences included goal setting, problem-solving, feedback, social support, and information on health consequences. A strategy for operationalizing these techniques into intervention components was agreed upon: Pre-discharge evaluation sessions, a personalized resource folder, tailored behavioral and text message support post-discharge, and a peer interaction group, delivered by a trained mental health worker. CONCLUSIONS: The intervention includes targeted resources to support smoking-related behavior change in patients following discharge from a smoke-free mental health setting. IMPLICATIONS: Using the BCW and TDF supported a theoretically and empirically informed process to define and develop a tailored intervention that acknowledges barriers and enablers to supporting smoking cessation in mental health settings. The result is a novel complex theory- and evidence-based intervention that will be formally tested in a randomized controlled feasibility study.

The impact of Covid-19 on animal-assisted interventions: perceptions of UK animal-assisted intervention providers.

BACKGROUND: Animal-assisted interventions (AAIs) are increasingly common in UK health settings. The Covid-19 pandemic has impacted on their delivery, with many organizations offering AAIs virtually during lockdown periods. This small-scale survey aims to explore the impact of Covid-19 on the delivery of AAIs, and associated challenges and opportunities. METHODS: A cross-sectional, retrospective questionnaire survey was conducted with UK AAI providers. The anonymized survey was distributed via academic and third sector networks and social media. Descriptive statistics and free-text responses are presented. RESULTS: Thirty-six AAI providers completed the survey. Of these, 83.3% continued to deliver AAIs during the pandemic. Twenty-eight delivered AAIs remotely and highlighted associated challenges, such as clients being unable to touch the animal, and clients having restricted access to the required technology. Over half reported their animal missed face-to-face interaction. However, they also reported advantages to remote delivery, such as for those who are allergic or fearful of animals. The most commonly reported challenges of in situ delivery included difficulty maintaining distance from the client and the use of face masks, which were perceived to hinder communication. CONCLUSION: The transition to remote delivery has highlighted challenges and opportunities. Further research could explore these in greater depth and compare the impact of different delivery modes.

A Systematic Review of Mental Health Professionals, Patients, and Carers' Perceived Barriers and Enablers to Supporting Smoking Cessation in Mental Health Settings.

INTRODUCTION: Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited. AIMS AND METHODS: We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance. RESULTS: Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms). CONCLUSIONS: The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted. IMPLICATIONS: Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

Pet Ownership and Multiple Sclerosis during COVID-19.

Background: Multiple sclerosis (MS) is associated with lower quality of life, reduced social participation, and decreased self-efficacy. The COVID-19 pandemic has had documented effects on the health and wellbeing of people with and without MS. Previous research has demonstrated the positive impact pets can have for people living with long-term conditions. Objectives: To explore the rates of pet ownership and pet attachment in people living with MS and pet ownership associations with quality of life, satisfaction with social roles, and self-efficacy scores; and to explore the effects of the COVID-19 outbreak on people's perceived relationships with their pets. Materials and Methods: A postal questionnaire was distributed to members of a local MS Register and a control group of people without MS. The questionnaire assessed quality of life, satisfaction with social roles, self-efficacy, the perceived roles of pets, and pet-related concerns experienced during the COVID-19 pandemic. Results: No apparent difference in attachment to pets was found between the patient and control groups. Pet ownership and level of attachment were not associated with differences in quality of life or self-efficacy scores in people living with MS. Using multiple regression analysis, pet ownership was associated with a decrease in satisfaction with participation in social roles, but with the estimated effect being small compared to having a diagnosis of MS or being unemployed. Most participants reported that pets had positive roles during the pandemic, and the most reported pet-related concern was access to veterinary treatment. Conclusion: Pet owners both with and without MS reported subjective benefits to their wellbeing from pet ownership during COVID-19, although analysis suggested that pet ownership was associated with a reduction in satisfaction with social roles. The study had several limitations and suggestions are made for future work.

The Role of Animal Ownership for People with Severe Mental Illness during the COVID-19 Pandemic: A Mixed-Method Study Investigating Links with Health and Loneliness.

Research has reported the benefits of companion animals for people with severe mental illness (SMI). However, this evidence base is fragmented and unclear. The COVID-19 pandemic presents an opportunity to explore the role of companion animals in the context of social distancing and isolation measures for people with SMI. Therefore, we aimed to investigate the links between mental and physical health and animal ownership in people with SMI and to explore animal owners' perceptions related to human-animal interactions during the pandemic restrictions. A survey was conducted with a previously assembled cohort of individuals with SMI in the UK. The survey included previously validated and new bespoke items measuring demographics, and outcomes related to mental and physical health, and human-animal interactions. The survey also included a question inviting free-text responses, allowing participants to describe any experiences of their human-animal relationships during the pandemic. Of 315 participants who consented to participate, 249 (79%) completed the survey. Of these, 115 (46.2%) had at least one companion animal. Regression analyses indicated that animal ownership was not significantly associated with well-being and loneliness. However, animal ownership was associated with a self-reported decline in mental health (b = 0.640, 95% CI [0.102-1.231], p = 0.025), but no self-reported change in physical health. Thematic analysis identified two main themes relating to the positive and negative impact of animal ownership during pandemic restrictions. Animal ownership appeared to be linked to self-reported mental health decline in people with SMI during the second wave of the pandemic in the UK. However, the thematic analysis also highlighted the perceived benefit of animal ownership during this time. Further targeted investigation of the role of human-animal relationships and the perceived human-animal bond for human health is warranted.

The Perceived Impact of The First UK COVID-19 Lockdown on Companion Animal Welfare and Behaviour: A Mixed-Method Study of Associations with Owner Mental Health.

BACKGROUND: Companion animals may be a positive presence for their owners during the COVID-19 pandemic. However, the welfare of a companion animal is strongly influenced by the behaviour of their owners, as well as their physical and social environment. We aimed to investigate the reported changes in companion animal welfare and behaviour and to examine the association between these changes and companion animal owners' mental health. METHODS: A cross-sectional online survey of UK residents over 18 years of age was conducted between April and June 2020 (n = 5926). The questionnaire included validated, bespoke items measuring outcomes related to mental health, human-animal bonds and reported changes in animal welfare and behaviour. The final item of the survey invited open-ended free-text responses, allowing participants to describe experiences associated with human-animal relationships during the first UK lockdown phase. RESULTS: Animal owners made up 89.8% of the sample (n = 5323), of whom 67.3% reported changes in their animal's welfare and behaviour during the first lockdown phase (n = 3583). These reported changes were reduced to a positive (0-7) and negative (0-5) welfare scale, following principal component analysis (PCA) of 17 items. Participants reported more positive changes for cats, whereas more negative changes were reported for dogs. Thematic analysis identified three main themes relating to the positive and negative impact on companion animals of the COVID-19 pandemic. Generalised linear models indicated that companion animal owners with poorer mental health scores pre-lockdown reported fewer negative changes in animal welfare and behaviour. However, companion animal owners with poorer mental health scores since lockdown reported more changes, both positive and negative, in animal welfare and behaviour. CONCLUSION: Our findings extend previous insights into perceived welfare and behaviour changes on a very limited range of species to a wider range of companion animals. Owner mental health status has a clear, albeit small, effect on companion animal welfare and behaviour.

Investigating smoking and nicotine dependence among people with severe mental illness during the COVID-19 pandemic: analysis of linked data from a UK Closing the Gap cohort.

Smoking rates are higher for people who use mental health services, which contributes substantially to health inequalities. Smoking can lead to worse COVID-19 outcomes, yet it remains unclear whether smoking has changed for people who use mental health services. We examined smoking patterns in a large clinical cohort of people with severe mental illness, before and during the pandemic. We found high levels of nicotine dependence and heavier patterns of smoking. Although some people had reported quitting, it is likely that smoking inequalities have become further entrenched. Mental health services should seek to mitigate this modifiable risk and source of poor health.

Supporting smoking cessation and preventing relapse following a stay in a smoke-free setting: a meta-analysis and investigation of effective behaviour change techniques.

BACKGROUND AND AIMS: Admission to a smoke-free setting presents a unique opportunity to encourage smokers to quit. However, risk of relapse post-discharge is high, and little is known about effective strategies to support smoking cessation following discharge. We aimed to identify interventions that maintain abstinence following a smoke-free stay and determine their effectiveness, as well as the probable effectiveness of behaviour change techniques (BCTs) used in these interventions. METHODS: Systematic review and meta-analyses of studies of adult smokers aged ≥ 18 years who were temporarily or fully abstinent from smoking to comply with institutional smoke-free policies. Institutions included prison, inpatient mental health, substance misuse or acute hospital settings. A Mantel-Haenszel random-effects meta-analysis of randomized controlled trials (RCTs) was conducted using biochemically verified abstinence (7-day point prevalence or continuous abstinence). BCTs were defined as 'promising' in terms of probable effectiveness (if BCT was present in two or more long-term effective interventions) and feasibility (if BCT was also delivered in ≥ 25% of all interventions). RESULTS: Thirty-seven studies (intervention n = 9041, control n = 6195) were included: 23 RCTs (intervention n = 6593, control n = 5801); three non-randomized trials (intervention n = 845, control n = 394) and 11 cohort studies (n = 1603). Meta-analysis of biochemically verified abstinence at longest follow-up (4 weeks-18 months) found an overall effect in favour of intervention [risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.08-1.49, I2  = 42%]. Nine BCTs (including 'pharmacological support', 'goal-setting (behaviour)' and 'social support') were characterized as 'promising' in terms of probable effectiveness and feasibility. CONCLUSIONS: A systematic review and meta-analyses indicate that behavioural and pharmacological support is effective in maintaining smoking abstinence following a stay in a smoke-free institution. Several behaviour change techniques may help to maintain smoking abstinence up to 18 months post-discharge.

The Influence of Human-Animal Interactions on Mental and Physical Health during the First COVID-19 Lockdown Phase in the U.K.: A Qualitative Exploration.

The coronavirus disease 2019 (COVID-19) pandemic presents an opportunity to explore the role of animals as sources of emotional and physical support during a period when most of the population is experiencing social and environmental challenges. We investigated how companion animal owners perceived the influence of human-animal interaction on their physical and mental health during the first COVID-19 lockdown phase in the U.K., and what concerns they had regarding their animals at this time. We also explored the impact of participants' interaction with non-companion animals during this phase. A cross-sectional online survey of U.K. residents aged over 18 was conducted between April and June 2020. The final item of the survey invited open-ended free-text responses, allowing participants to describe any experiences and/or perceptions of their human-animal relationships during the COVID-19 lockdown phase. A qualitative thematic analysis of responses was undertaken. Four main themes related to the following aspects of human-animal interactions during the COVID-19 lockdown phase were identified: the positive impact of animal ownership during the COVID-19 lockdown (e.g., amelioration of wellbeing and mental health), concerns relating to animal ownership during the COVID-19 lockdown (e.g., concerns over animals carrying the COVID-19 virus), grief and loss of an animal during the COVID-19 lockdown and the impact of engaging with non-companion animals during the COVID-19 lockdown. The findings complement and extend previous insights into the impact of human-animal interaction with both companion and non-companion animals. They also highlight the challenges of caring for an animal during the lockdown phase and indicate the need to consider the development of further targeted support strategies, such as "day care" for the companion animals of key workers in this context.

Tobacco Smoking and Associated Factors Among People Living With HIV in Uganda.

INTRODUCTION: The prevalence of smoking among people living with HIV (PLWH) in Uganda is high. AIMS AND METHODS: We assessed the smoking patterns, behaviors, and associated factors among PLWH in Uganda through a cross-sectional survey. Descriptive statistics were used to describe smoking patterns and behaviors. Logistic regression was used to identify factors associated with current smoking status. RESULTS: We recruited 777 participants between October and November 2019: 387 (49.8%) current smokers and 390 (50.2%) nonsmokers. 60.9% were males, and the mean age was 40.5 (SD 10.7) years. In multivariate logistic regression, the following increased the odds of being a current smoker: being male (odds ratio [OR] 6.60 [95% confidence interval, CI = 4.34-10.04]), having at least two smokers among five closest friends (OR 3.97 [95% CI = 2.08-7.59]), living in smoking-permitted households (OR 5.83 [95% CI = 3.32-10.23]), alcohol use (OR 3.96 [95% CI = 2.34-6.71]), a higher perceived stress score (OR 2.23 [95% CI = 1.50-3.34]), and higher health-related quality of life (OR 5.25 [95% CI = 1.18-23.35]). Among smokers, the mean Fagerström Test for Nicotine Dependence score was 3.0 (SD 1.9), and 52.5% were making plans to quit. Self-efficacy to resist smoking and knowledge of the impact of smoking on PLWH's health were low. CONCLUSIONS: Being male, having at least two smokers among five closest friends, living in smoking-permitted households, alcohol use, higher perceived stress scores, and higher health-related quality of life were associated with being a current smoker. Smokers had low to moderate nicotine dependence, high willingness to quit, and low self-efficacy. IMPLICATIONS: Future behavioral smoking cessation interventions for PLWH should address co-consumption with alcohol and comorbid mental health conditions that are common among PLWH such as stress. In addition, they should take into account the lack of knowledge among this population of the impact of smoking on their health, and low self-efficacy. Given the relatively low levels of nicotine dependency and high levels of willingness to quit in our sample, smoking cessation interventions, if offered, are likely to support this population in achieving long-term smoking abstinence.

Investigating Changes in Patients' Smoking Behavior, Tobacco Dependence, and Motivation to Stop Smoking Following a "Smoke-Free" Mental Health Inpatient Stay: Results From a Longitudinal Survey in England.

INTRODUCTION: In line with national guidance, mental health Trusts in England are implementing complete smoke-free policies. We investigated inpatients' changes in smoking behavior, tobacco dependence, vaping, and motivation to stop smoking between pre-admission and post-discharge. METHODS: We surveyed acute adult mental health inpatients from 14 wards in three mental health Trusts in England in 2019. Structured face-to-face and telephone interviews with patients who smoked on or during admission were conducted during the admission period and at one week and one month after discharge. Data on smoking status; daily cigarette consumption; Heaviness of Smoking Index (HSI); Strength of Urges to Smoke (SUTS); Motivation to Stop Smoking (MTSS) and vaping were collected and analyzed using regression and probit models. RESULTS: Inpatient smoking prevalence was 51.9%, and a total of 152 of all 555 eligible smokers (27%) were recruited. Attrition was high: 49.3% at the first and 50.7% at the second follow-up interview. Changes in self-reported smoking status, motivation to quit, and vaping did not change significantly over the study period. Cigarette consumption (p < 0.001) and Heaviness of Smoking Index (p < 0.001) modestly reduced. The frequency and strength of urges to smoke (p = 0.011 and 0.012, respectively) decreased modestly after discharge but were scored as high by 57% and 60% of participants during admission respectively. Just over half (56%) reported being offered smoking cessation support on admission. CONCLUSIONS: This study identified very modest changes in smoking-related outcomes during and after admission and indicates major challenges to smoke-free policy implementation, including limited support for patients who smoke. IMPLICATIONS: Despite mental health Trusts in England had developed and implemented smoke-free policies to meet national guidelines, adherence to these policies and provision of effective smoking cessation and temporary abstinence support for inpatients admitted to acute adult mental health wards appear to be limited. Patients who smoke on admission are likely to continue to do so during admission and after discharge, and only a very modest change in smoking behaviors appears to take place. Important opportunities to promote smoking cessation in this population are missed. Barriers to effective support need to be identified and addressed.

Human-animal relationships and interactions during the Covid-19 lockdown phase in the UK: Investigating links with mental health and loneliness.

BACKGROUND: The Covid-19 pandemic raises questions about the role that relationships and interactions between humans and animals play in the context of widespread social distancing and isolation measures. We aimed to investigate links between mental health and loneliness, companion animal ownership, the human-animal bond, and human-animal interactions; and to explore animal owners' perceptions related to the role of their animals during lockdown. METHODS: A cross-sectional online survey of UK residents over 18 years of age was conducted between April and June 2020. The questionnaire included validated and bespoke items measuring demographics; exposures and outcomes related to mental health, wellbeing and loneliness; the human-animal bond and human-animal interactions. RESULTS: Of 5,926 participants, 5,323 (89.8%) had at least one companion animal. Most perceived their animals to be a source of considerable support, but concerns were reported related to various practical aspects of providing care during lockdown. Strength of the human-animal bond did not differ significantly between species. Poorer mental health pre-lockdown was associated with a stronger reported human-animal bond (b = -.014, 95% CI [-.023 - -.005], p = .002). Animal ownership compared with non-ownership was associated with smaller decreases in mental health (b = .267, 95% CI [.079 - .455], p = .005) and smaller increases in loneliness (b = -.302, 95% CI [-.461 - -.144], p = .001) since lockdown. CONCLUSION: The human-animal bond is a construct that may be linked to mental health vulnerability in animal owners. Strength of the human-animal bond in terms of emotional closeness or intimacy dimensions appears to be independent of animal species. Animal ownership seemed to mitigate some of the detrimental psychological effects of Covid-19 lockdown. Further targeted investigation of the role of human-animal relationships and interactions for human health, including testing of the social buffering hypothesis and the development of instruments suited for use across animal species, is required.

Smoke-free prisons in England: indoor air quality before and after implementation of a comprehensive smoke-free policy.

OBJECTIVES: High levels of particulate pollution due to secondhand smoke (SHS) have previously been recorded in English prisons. As part of an evaluation to ascertain whether a new comprehensive smoke-free policy introduced in the first four prisons in England was successfully implemented, this study compares indoor air quality on prison wing landing locations three months before and three months after going smoke-free. DESIGN: An indoor air quality monitoring study, comparing SHS levels before and after a comprehensive smoke-free prison policy. SETTING: The first four prisons in England to implement a comprehensive smoke-free policy. PRIMARY AND SECONDARY MEASURES: We compared concentrations of airborne particulate matter <2.5 microns in diameter (PM2.5), as a marker for SHS, on wing landing locations three months before and three months after the smoke-free policy was implemented. Static battery operated aerosol monitors were used to sample concentrations of PM2.5 on wing landings. RESULTS: After discarding data from monitors that had been tampered with we were able to analyse paired data across four prisons from 74 locations, across 29 wing landing locations, for an average sampling time of five hours and eight minutes. When comparing samples taken three months before with the paired samples taken three months after policy implementation (paired for prison, day of the week, time of day, wing location and position of monitor), there was a 66% reduction in mean PM2.5 concentrations across the four prisons sampled, from 39 to 13 µg/m³ (difference 26 µg/m³, 95% CI 25 to 26 µg/m³). CONCLUSION: Prison smoke-free policies achieve significant improvements in indoor air quality. A national smoke-free policy would therefore be an effective means of protecting prisoners and staff from harm due to SHS exposure in the prison environment.

Cost-effectiveness of a complex intervention to reduce children's exposure to second-hand smoke in the home.

BACKGROUND: Second-hand smoke (SHS) causes numerous health problems in children such as asthma, respiratory tract infections and sudden infant death syndrome. The home is the main source of exposure to SHS for children, particularly for young children. We estimated the cost-effectiveness of a complex intervention designed to reduce SHS exposure of children whose primary caregiver feels unable or unwilling to quit smoking. METHODS: A cost-effectiveness analysis was carried out alongside an open-label, parallel, randomised controlled trial in deprived communities in Nottingham, England. A complex intervention combining behavioural support, nicotine replacement therapy and personalised feedback on home air quality was compared with usual care. A total number of 205 households were recruited, where the main caregivers were aged 18 and over, with a child aged under five years living in their household reporting smoking inside their home. Analyses for this study were undertaken from the National Health Service/Personal Social Services perspective. All costs were estimated in UK pounds (£) at 2013/14 prices. The primary outcome was the incremental cost-effectiveness of change in air quality in the home, measured as average 16-24 h levels of particulate matter of < 2.5 µm diameter (PM2.5), between baseline and 12 weeks. Secondary outcomes included incremental cost per quitter, quit attempts and cigarette consumption in the home. A non-parametric bootstrap re-sampling technique was employed to explore uncertainty around the calculated incremental cost-effectiveness ratios. RESULTS: The complex intervention achieved reduced PM2.5 by 21.6 µg/m3 (95% CI: 5.4 to 37.9), with an incremental cost of £283 (95% CI: £254-£313), relative to usual care. The incremental cost-effectiveness ratio was £131 (bootstrapped 95% CI: £72-£467) per additional 10µg/m3 reduction in PM2.5, or £71 (bootstrapped 95% CI: -£57-£309) per additional quitter. CONCLUSIONS: This trial targeted a socio-economically disadvantaged population that has been neglected within the literature. The complex intervention was more costly but more effective in reducing PM2.5 compared with the usual care. It offers huge potential to reduce children's' tobacco-related harm by reducing exposure to SHS in the home. The intervention is considered cost-effective if the decision maker is willing to pay £131 per additional 10µg/m3 of PM2.5 reduction. TRIAL REGISTRATION: The Smoke Free Homes trial was registered with isrctn.com on 29 January 2013 with the identifier ISRCTN81701383 .

Complete smokefree policies in mental health inpatient settings: results from a mixed-methods evaluation before and after implementing national guidance.

BACKGROUND: Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government's tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation. METHODS: This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis. RESULTS: Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified. CONCLUSIONS: Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required.

Alcohol consumption and risk of common cancers: evidence from a cohort of adults from the UK.

Background: Recent guidelines from the UK recommend that men and women should drink no more than 14 units of alcohol per week. This recommendation takes into account the link between alcohol and several cancers; however, there is a dearth of high quality evidence from the UK to support this. Methods: Alcohol consumption using a detailed diary was obtained from 8670 adults representative of the UK population in 1984/5, with follow-up data from cancer registries until 2009. Hazard ratios (HRs) adjusted for several variables including cigarette smoking were calculated for cancers of the breast, lung, colorectum and prostate separately using Cox regression. Results: Units per week on a typical basis, fitted as a linear term, was associated with breast cancer in women (HR = 1.27 per 10 units/week; 95% CI 1.03-1.58) and lung cancer in men (HR = 1.16; 95% CI 1.06-1.27). Increased risks of lung (HR = 2.23; 95% CI 1.18-4.24) and colorectal (HR = 2.28; 95% CI 1.13-4.57) cancer were seen in men at 15-28 units/week along with higher levels of consumption. Some findings differed by alcohol type. Conclusions: Overall, alcohol consumption of 15-28 units/week may be harmful in men with respect to common cancers. A linear association between alcohol consumption and risk of breast cancer was observed in women.

A randomised controlled trial of a complex intervention to reduce children's exposure to secondhand smoke in the home.

OBJECTIVES: Exposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. We report a trial of a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking. DESIGN: An open-label, parallel, randomised controlled trial. SETTING: Deprived communities in Nottingham City and County, England PARTICIPANTS: Caregivers resident in Nottingham City and County in England who were at least 18 years old, the main caregiver of a child aged under 5 years living in their household, and reported that they were smoking tobacco inside their home. INTERVENTIONS: We compared a complex intervention combining personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care. MAIN OUTCOMES: The primary outcome was change in air quality in the home, measured as average 16-24 hours levels of particulate matter of < 2.5 µm diameter (PM2.5), between baseline and 12 weeks. Secondary outcomes included changes in maximum PM2.5, proportion of time PM2.5 exceeded WHO recommended levels of maximum exposure of 25 µg/mg3, child salivary cotinine, caregivers' cigarette consumption, nicotine dependence, determination to stop smoking, quit attempts and quitting altogether during the intervention. RESULTS: Arithmetic mean PM2.5 decreased significantly more (by 35.2 %; 95% CI 12.7% to 51.9 %) in intervention than in usual care households, as did the proportion of time PM2.5 exceeded 25 µg/mg3, child salivary cotinine concentrations, caregivers' cigarette consumption in the home, nicotine dependence, determination to quit and likelihood of having made a quit attempt. CONCLUSIONS: By reducing exposure to SHS in the homes of children who live with smokers unable or unwilling to quit, this intervention offers huge potential to reduce children's' tobacco-related harm. TRIAL REGISTRATION NUMBER: ISRCTN81701383.This trial was funded by the UK National Institute for Health Research (NIHR): RP-PG-0608-10020.

Study protocol of the German Study on Tobacco Use (DEBRA): a national household survey of smoking behaviour and cessation.

BACKGROUND: The prevalence of tobacco smoking in Germany is high (~27%). Monitoring of national patterns of smoking behaviour and data on the "real-world" effectiveness of cessation methods are needed to inform policies and develop campaigns aimed at reducing tobacco-related harm. In England, the Smoking Toolkit Study (STS) has been tracking such indicators since 2006, resulting in the adaptation of tobacco control policies. However, findings cannot be directly transferred into the German health policy context. The German Study on Tobacco Use (DEBRA: "Deutsche Befragung zum Rauchverhalten") aims to provide such nationally representative data. METHODS/DESIGN: In June 2016, the study started collecting data from computer-assisted, face-to-face household interviews in people aged 14 years and older. Over a period of 3 years, a total of ~36,000 respondents will complete the survey with a new sample of ~2000 respondents every 2 months (=18 waves). This sample will report data on demographics and the use of tobacco and electronic (e-)cigarettes. Per wave, about 500-600 people are expected to be current or recent ex-smokers (<12 months since quitting). This sample will answer detailed questions about smoking behaviour, quit attempts, exposure to health professionals' advice on quitting, and use of cessation aids. Six-month follow-up data will be collected by telephone. DISCUSSION: The DEBRA study will be an important source of data for tobacco control policies, health strategies, and future research. The methodology is closely aligned to the STS, which will allow comparisons with data from England, a country with one of the lowest smoking prevalence rates in Europe (18%). TRIAL REGISTRATION: This study has been registered at the German Clinical Trials Register ( DRKS00011322 ) on 25th November 2016.