Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial.

BACKGROUND: Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking. METHODS: In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months. RESULTS: An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported. CONCLUSIONS: An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. TRIAL REGISTRATION NUMBER: NCT04854616.

What are the mental health impacts of epidemics on relatives of people affected, and relatives of healthcare workers: What interventions are available to support them? A systematic review and narrative synthesis.

BACKGROUND: Previous research has mainly focused on the impacts of epidemics on those people who are directly affected by the epidemic infection, or of healthcare workers caring for them. Less is known about the impact on mental health of their relatives, and potential interventions to support them. METHODS: Systematic review and narrative synthesis. OUTCOMES: 28 studies were identified, sixteen quantitative and twelve qualitative. One involved health workers' relatives, and the rest covered relatives of directly affected individuals. We found considerable burden of mental ill-health in both groups. Among relatives of healthcare workers, 29.4% reported symptoms consistent with probable anxiety disorder and 33.7% with probable depression. Prevalence rates for probable anxiety disorder ranged from 24-42% and probable depression 17-51% for the relatives of affected people. One study found a 2% prevalence of PTSD and another found odds of PTSS were significantly higher among relatives of affected individuals compared with the general population. Only two intervention studies were identified and both were descriptive in nature. INTERPRETATION: Available evidence suggests relatives of people affected by infective outbreaks report mental ill-health. Having a relative who died particularly increased risk. Good outcomes for relatives of affected individuals were promoted by practical and social support, public health guidance that recognises the caring role of relatives, and being supported to see the positives as well as negatives in their situation. Good outcomes for relatives of health workers were promoted by perceived effectiveness of protective equipment. High quality evidence on potential interventions to support relatives is lacking. FUNDING: No external funding sought.

Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review.

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.

Future smoking prevalence by socioeconomic status in England: a computational modelling study.

BACKGROUND: The difference in smoking across socioeconomic groups is a major cause of health inequality. This study projected future smoking prevalence by socioeconomic status, and revealed what is needed to achieve the tobacco-free ambition (TFA) by 2030 in England. METHODS: Using data from multiple sources, the adult (≥18 years) population in England was separated into subgroups by smoking and highest educational qualification (HEQ). A discrete time state-transition model was used to project future smoking prevalence by HEQ deterministically and stochastically. RESULTS: In a status quo scenario, smoking prevalence in England is projected to be 10.8% (95% uncertainty interval: 9.1% to 12.9%) by 2022, 7.8% (5.5% to 11.0%) by 2030 and 6.0% (3.7% to 9.6%) by 2040. The absolute difference in smoking rate between low and high HEQ is reduced from 12.2% in 2016 to 7.9% by 2030, but the relative inequality (low/high HEQ ratio) is increased from 2.48 in 2016 to 3.06 by 2030. When applying 2016 initiation/relapse rates, achievement of the TFA target requires no changes to future cessation rates among adults with high qualifications, but increased rates of 37% and 149%, respectively, in adults with intermediate and low qualifications. CONCLUSIONS: If the current trends continue, smoking prevalence in England is projected to decline in the future, but with substantial differences across socioeconomic groups. Absolute inequalities in smoking are likely to decline and relative inequalities in smoking are likely to increase in future. The achievement of England's TFA will require the reduction of both absolute and relative inequalities in smoking by socioeconomic status.

Online Information on Electronic Cigarettes: Comparative Study of Relevant Websites From Baidu and Google Search Engines.

BACKGROUND: Online information on electronic cigarettes (e-cigarettes) may influence people's perception and use of e-cigarettes. Websites with information on e-cigarettes in the Chinese language have not been systematically assessed. OBJECTIVE: The aim of this study was to assess and compare the types and credibility of Web-based information on e-cigarettes identified from Google (in English) and Baidu (in Chinese) search engines. METHODS: We used the keywords vaping or e-cigarettes to conduct a search on Google and the equivalent Chinese characters for Baidu. The first 50 unique and relevant websites from each of the two search engines were included in this analysis. The main characteristics of the websites, credibility of the websites, and claims made on the included websites were systematically assessed and compared. RESULTS: Compared with websites on Google, more websites on Baidu were owned by manufacturers or retailers (15/50, 30% vs 33/50, 66%; P<.001). None of the Baidu websites, compared to 24% (12/50) of Google websites, were provided by public or health professional institutions. The Baidu websites were more likely to contain e-cigarette advertising (P<.001) and less likely to provide information on health education (P<.001). The overall credibility of the included Baidu websites was lower than that of the Google websites (P<.001). An age restriction warning was shown on all advertising websites from Google (15/15) but only on 10 of the 33 (30%) advertising websites from Baidu (P<.001). Conflicting or unclear health and social claims were common on the included websites. CONCLUSIONS: Although conflicting or unclear claims on e-cigarettes were common on websites from both Baidu and Google search engines, there was a lack of online information from public health authorities in China. Unbiased information and evidence-based recommendations on e-cigarettes should be provided by public health authorities to help the public make informed decisions regarding the use of e-cigarettes.

Reported patterns of vaping to support long-term abstinence from smoking: a cross-sectional survey of a convenience sample of vapers.

BACKGROUND: E-cigarettes are the most popular aid to smoking cessation attempts in England and the USA. This research examined associations between e-cigarette device characteristics and patterns of use, tobacco-smoking relapse, and smoking abstinence. METHODS: A convenience sample of 371 participants with experience of vaping, and tobacco-smoking abstinence and/or relapse completed an online cross-sectional survey about e-cigarettes. Factors associated with smoking relapse were examined using multiple linear and logistic regression models. RESULTS: Most participants were self-reported long-term abstinent smokers (86.3%) intending to continue vaping. Most initiated e-cigarette use with a vape pen (45.8%) or cig-a-like (38.7%) before moving onto a tank device (89%). Due to missing data, managed through pairwise deletion, only around 70 participants were included in some of the main analyses. Those using a tank or vape pen appeared less likely to relapse than those using a cig-a-like (tank vs. cig-a-like OR = 0.06, 95% CI 0.01-0.64, p = 0.019). There was an inverse association between starting self-reported e-cigarette liquid nicotine concentration and relapse, interacting with device type (OR = 0.79, 95% CI 0.63-0.99, p = 0.047), suggesting that risk of relapse may have been greater if starting with a low e-cigarette liquid nicotine concentration and/or cig-a-like device. Participants reported moving from tobacco-flavored cig-a-likes to fruit/sweet/food flavors with tank devices. CONCLUSIONS: Knowledge of how people have successfully maintained tobacco-smoking abstinence using vaping could help other tobacco smokers wishing to quit tobacco smoking through vaping.

Are Electronic Cigarettes an Effective Aid to Smoking Cessation or Reduction Among Vulnerable Groups? A Systematic Review of Quantitative and Qualitative Evidence.

INTRODUCTION: Smoking prevalence remains high in some vulnerable groups, including those who misuse substances, have a mental illness, are homeless, or are involved with the criminal justice system. E-cigarette use is increasing and may support smoking cessation/reduction. METHODS: Systematic review of quantitative and qualitative data on the effectiveness of e-cigarettes for smoking cessation/reduction among vulnerable groups. Databases searched were MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, ProQuest Dissertations and Theses, and Open Grey. Narrative synthesis of quantitative data and thematic synthesis of qualitative data. RESULTS: 2628 records and 46 full texts were screened; 9 studies were identified for inclusion. Due to low quality of evidence, it is uncertain whether e-cigarettes are effective for smoking cessation in vulnerable populations. A moderate quality study suggested that e-cigarettes were as effective as nicotine replacement therapy. Four studies suggested significant smoking reduction; however, three were uncontrolled and had sample sizes below 30. A prospective cohort study found no differences between e-cigarette users and nonusers. No significant adverse events and minimal side effects were identified. Qualitative thematic synthesis revealed barriers and facilitators associated with each component of the COM-B (capability, opportunity, motivation, and behavior) model, including practical barriers; perceptions of effectiveness for cessation/reduction; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity. CONCLUSION: Further research is needed to identify the most appropriate device types for practicality and safety, level of support required in e-cigarette interventions, and to compare e-cigarettes with current best practice smoking cessation support among vulnerable groups. IMPLICATIONS: Smoking prevalence among people with mental illness, substance misuse, homelessness, or criminal justice system involvement remains high. E-cigarettes could support cessation. This systematic review found limited quantitative evidence assessing effectiveness. No serious adverse events were identified. Qualitative thematic synthesis revealed barriers and facilitators mapping to each component of the COM-B (capability, opportunity, motivation, and behavior) model, including practical barriers; perceived effectiveness; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity. Further research should consider appropriate devices for practicality and safety, concurrent support, and comparison with best practice smoking cessation support.

Incentives for smoking cessation.

BACKGROUND: Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes. OBJECTIVES: To determine the long-term effect of incentives and contingency management programmes for smoking cessation. SEARCH METHODS: For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018. SELECTION CRITERIA: We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations. MAIN RESULTS: Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I2 = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I2 = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I2 = 41%), in favour of incentives. AUTHORS' CONCLUSIONS: Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Serious Gaming and Gamification Education in Health Professions: Systematic Review.

BACKGROUND: There is a worldwide shortage of health workers, and this issue requires innovative education solutions. Serious gaming and gamification education have the potential to provide a quality, cost-effective, novel approach that is flexible, portable, and enjoyable and allow interaction with tutors and peers. OBJECTIVE: The aim of this systematic review was to evaluate the effectiveness of serious gaming/gamification for health professions education compared with traditional learning, other types of digital education, or other serious gaming/gamification interventions in terms of patient outcomes, knowledge, skills, professional attitudes, and satisfaction (primary outcomes) as well as economic outcomes of education and adverse events (secondary outcomes). METHODS: A comprehensive search of MEDLINE, EMBASE, Web of Knowledge, Educational Resources Information Centre, Cochrane Central Register of Controlled Trials, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature was conducted from 1990 to August 2017. Randomized controlled trials (RCTs) and cluster RCTs were eligible for inclusion. Two reviewers independently searched, screened, and assessed the study quality and extracted data. A meta-analysis was not deemed appropriate due to the heterogeneity of populations, interventions, comparisons, and outcomes. Therefore, a narrative synthesis is presented. RESULTS: A total of 27 RCTs and 3 cluster RCTs with 3634 participants were included. Two studies evaluated gamification interventions, and the remaining evaluated serious gaming interventions. One study reported a small statistically significant difference between serious gaming and digital education of primary care physicians in the time to control blood pressure in a subgroup of their patients already taking antihypertensive medications. There was evidence of a moderate-to-large magnitude of effect from five studies evaluating individually delivered interventions for objectively measured knowledge compared with traditional learning. There was also evidence of a small-to-large magnitude of effect from 10 studies for improved skills compared with traditional learning. Two and four studies suggested equivalence between interventions and controls for knowledge and skills, respectively. Evidence suggested that serious gaming was at least as effective as other digital education modalities for these outcomes. There was insufficient evidence to conclude whether one type of serious gaming/gamification intervention is more effective than any other. There was limited evidence for the effects of serious gaming/gamification on professional attitudes. Serious gaming/gamification may improve satisfaction, but the evidence was limited. Evidence was of low or very low quality for all outcomes. Quality of evidence was downgraded due to the imprecision, inconsistency, and limitations of the study. CONCLUSIONS: Serious gaming/gamification appears to be at least as effective as controls, and in many studies, more effective for improving knowledge, skills, and satisfaction. However, the available evidence is mostly of low quality and calls for further rigorous, theory-driven research.

A systematic review of the health and well-being impacts of school gardening: synthesis of quantitative and qualitative evidence.

BACKGROUND: School gardening programmes are increasingly popular, with suggested benefits including healthier eating and increased physical activity. Our objectives were to understand the health and well-being impacts of school gardens and the factors that help or hinder their success. METHODS: We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42014007181). We searched multiple databases and used a range of supplementary approaches. Studies about school gardens were included if they reported on physical or mental health or well-being. Quantitative studies had to include a comparison group. Studies were quality appraised using appropriate tools. Findings were narratively synthesised and the qualitative evidence used to produce a conceptual framework to illustrate how benefits might be accrued. RESULTS: Evidence from 40 articles (21 quantitative studies; 16 qualitative studies; 3 mixed methods studies) was included. Generally the quantitative research was poor. Evidence for changes in fruit and vegetable intake was limited and based on self-report. The qualitative research was better quality and ascribed a range of health and well-being impacts to school gardens, with some idealistic expectations for their impact in the long term. Groups of pupils who do not excel in classroom activities were thought to particularly benefit. Lack of funding and over reliance on volunteers were thought to threaten success, while involvement with local communities and integration of gardening activities into the school curriculum were thought to support success. CONCLUSION: More robust quantitative research is needed to convincingly support the qualitative evidence suggesting wide ranging benefits from school gardens.

Cost-utility analysis of provision of e-cigarette starter kits for smoking cessation in emergency departments: An economic evaluation of a randomized controlled trial.

AIMS: To assess the cost-effectiveness of the Cessation of Smoking Trial in Emergency Department (COSTED) intervention compared with signposting to local stop smoking service (SSS) from the National Health Service (NHS) and personal social services (PSS) perspective. DESIGN, SETTING AND PARTICIPANTS: This was a two-group, multi-centre, pragmatic, individually randomized controlled trial set in six Emergency Departments (EDs) in urban and rural areas in the United Kingdom. Adult (≥ 18 years) daily smokers (at least one cigarette or equivalent per day) but not daily e-cigarette users, with carbon monoxide reading ≥ 8 parts per million, attending the ED (n = 972) were included. The intervention consisted of provision of an e-cigarette starter kit plus brief smoking cessation advice and referral to a local SSS. Control was an information card on how to access local SSS. MEASUREMENTS: Intervention costs included costs of training and delivery. Control costs included costs of printing information cards. Costs of smoking cessation and health-care services were estimated based on quantities reported by participants and unit costs extracted from secondary sources. The effects were measured by quality-adjusted life years (QALYs) derived from EQ-5D-5L. Other outcomes were smoking cessation measures. The primary outcome was incremental cost-effectiveness ratio (ICER), which was calculated by dividing the difference in costs by the difference in QALYs between groups. FINDINGS: The mean intervention costs were £48 [standard error (SE) = £0] per participant and the mean control costs were £0.2 (SE = £0) per participant. Using regression estimates, total costs were £31 [95% confidence interval (CI) = -£341 to £283] higher and 6-month QALYs were 0.004 (95% CI = -0.004 to 0.014) higher in the intervention group than in the control group. The ICER was calculated at £7750 (probability of cost-effective at range £20 000-30 000: 72.2-76.5%). CONCLUSIONS: The UK Cessation of Smoking Trial in Emergency Department (COSTED) intervention (provision of an e-cigarette starter kit plus brief smoking cessation advice) was cost-effective compared with signposting to local stop smoking services under the current recommendations of the maximum acceptable thresholds.

Erythrocytes encapsulated with phenylalanine hydroxylase exhibit improved pharmacokinetics and lowered plasma phenylalanine levels in normal mice.

Enzyme replacement therapy is often hampered by the rapid clearance and degradation of the administered enzyme, limiting its efficacy and requiring frequent dosing. Encapsulation of therapeutic molecules into red blood cells (RBCs) is a clinically proven approach to improve the pharmacokinetics and efficacy of biologics and small molecule drugs. Here we evaluated the ability of RBCs encapsulated with phenylalanine hydroxylase (PAH) to metabolize phenylalanine (Phe) from the blood and confer sustained enzymatic activity in the circulation. Significant quantities of PAH were successfully encapsulated within murine RBCs (PAH-RBCs) with minimal loss of endogenous hemoglobin. While intravenously administered free PAH enzyme was rapidly eliminated from the blood within a few hours, PAH-RBCs persisted in the circulation for at least 10days. A single injection of PAH-RBCs was able to decrease Phe levels by nearly 80% in normal mice. These results demonstrate the ability of enzyme-loaded RBCs to metabolize circulating amino acids and highlight the potential to treat disorders of amino acid metabolism.

Telephone communication of HIV testing results for improving knowledge of HIV infection status.

BACKGROUND: This is one of three Cochrane reviews that examine the role of the telephone in HIV/AIDS services. Both in developed and developing countries there is a large proportion of people who do not know they are infected with HIV. Knowledge of one's own HIV serostatus is necessary to access HIV support, care and treatment and to prevent acquisition or further transmission of HIV. Using telephones instead of face-to-face or other means of HIV test results delivery could lead to more people receiving their HIV test results. OBJECTIVES: To assess the effectiveness of telephone use for delivery of HIV test results and post-test counselling.To evaluate the effectiveness of delivering HIV test results by telephone, we were interested in whether they can increase the proportion of people who receive their HIV test results and the number of people knowing their HIV status. SEARCH METHODS: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed Central, PsycINFO, ISI Web of Science, Cumulative Index to Nursing & Allied Health (CINAHL), WHOs The Global Health Library and Current Controlled Trials from 1980 to June 2011. We also searched grey literature sources such as Dissertation Abstracts International,CAB Direct Global Health, OpenSIGLE, The Healthcare Management Information Consortium, Google Scholar, Conference on Retroviruses and Opportunistic Infections, International AIDS Society and AEGIS Education Global Information System, and reference lists of relevant studies for this review. SELECTION CRITERIA: Randomised controlled trials (RCTs), quasi-randomised controlled trials (qRCTs), controlled before and after studies (CBAs), and interrupted time series (ITS) studies comparing the effectiveness of telephone HIV test results notification and post-test counselling to face-to-face or other ways of HIV test result delivery in people regardless of their demographic characteristics and in all settings. DATA COLLECTION AND ANALYSIS: Two reviewers independently searched, screened, assessed study quality and extracted data. A third reviewer resolved any disagreement. MAIN RESULTS: Out of 14 717 citations, only one study met the inclusion criteria; an RCT conducted on homeless and high-risk youth between September 1998 and October 1999 in Portland, United States. Participants (n=351) were offered counselling and oral HIV testing and were randomised into face-to-face (n=187 participants) and telephone (n=167) notification groups. The telephone notification group had the option of receiving HIV test results either by telephone or face-to-face. Overall, only 48% (n=168) of participants received their HIV test results and post-test counselling. Significantly more participants received their HIV test results in the telephone notification group compared to the face-to-face notification group; 58% (n=106) vs. 37% (n=62) (p < 0.001). In the telephone notification group, the majority of participants who received their HIV test results did so by telephone (88%, n=93). The study could not offer information about the effectiveness of telephone HIV test notification with HIV-positive participants because only two youth tested positive and both were assigned to the face-to-face notification group. The study had a high risk of bias. AUTHORS' CONCLUSIONS: We found only one eligible study. Although this study showed the use of the telephone for HIV test results notification was more effective than face-to-face delivery, it had a high-risk of bias. The study was conducted about 13 years ago in a high-income country, on a high-risk population, with low HIV prevalence, and the applicability of its results to other settings and contexts is unclear. The study did not provide information about telephone HIV test results notification of HIV positive people since none of the intervention group participants were HIV positive. We found no information about the acceptability of the intervention to patients' and providers', its economic outcomes or potential adverse effects. There is a need for robust evidence from various settings on the effectiveness of telephone use for HIV test results notification.

Telephone delivered interventions for reducing morbidity and mortality in people with HIV infection.

BACKGROUND: This is one of three Cochrane reviews examining the role of the telephone in HIV/AIDS services. Telephone interventions, delivered either by landline or mobile phone, may be useful in the management of people living with HIV (PLHIV) in many situations. Telephone delivered interventions have the potential to reduce costs, save time and facilitate more support for PLHIV. OBJECTIVES: To assess the effectiveness of voice landline and mobile telephone delivered interventions for reducing morbidity and mortality in people with HIV infection. SEARCH METHODS: We searched The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed Central, EMBASE, PsycINFO, ISI Web of Science, Cumulative Index to Nursing & Allied Health, World Health Organisation's The Global Health Library and Current Controlled Trials from 1980 to June 2011. We searched the following grey literature sources: Dissertation Abstracts International, Centre for Agriculture Bioscience International Direct Global Health database, The System for Information on Grey Literature Europe, The Healthcare Management Information Consortium database, Google Scholar, Conference on Retroviruses and Opportunistic Infections, International AIDS Society, AIDS Educational Global Information System and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series studies comparing the effectiveness of telephone delivered interventions for reducing morbidity and mortality in persons with HIV infection versus in-person interventions or usual care, regardless of demographic characteristics and in all settings. Both mobile and landline telephone interventions were included, but mobile phone messaging interventions were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently searched, screened, assessed study quality and extracted data. Primary outcomes were change in behaviour, healthcare uptake or clinical outcomes. Secondary outcomes were appropriateness of the mode of communication, and whether underlying factors for change were altered. Meta-analyses, each of three studies, were performed for medication adherence and depressive symptoms. A narrative synthesis is presented for all other outcomes due to study heterogeneity. MAIN RESULTS: Out of 14 717 citations, 11 RCTs met the inclusion criteria (1381 participants).Six studies addressed outcomes relating to medication adherence, and there was some evidence from two studies that telephone interventions can improve adherence. A meta-analysis of three studies for which there was sufficient data showed no significant benefit (SMD 0.49, 95% CI -1.12 to 2.11). There was some evidence from a study of young substance abusing HIV positive persons of the efficacy of telephone interventions for reducing risky sexual behaviour, while a trial of older persons found no benefit. Three RCTs addressed virologic outcomes, and there is very little evidence that telephone interventions improved virologic outcomes. Five RCTs addressed outcomes relating to depressive and psychiatric symptoms, and showed some evidence that telephone interventions can be of benefit. Three of these studies which focussed on depressive symptoms were combined in a meta-analysis, which showed no significant benefit (SMD 0.02, 95% CI -0.18 to 0.21 95% CI). AUTHORS' CONCLUSIONS: Telephone voice interventions may have a role in improving medication adherence, reducing risky sexual behaviour, and reducing depressive and psychiatric symptoms, but current evidence is sparse, and further research is needed.

Telephone delivered interventions for preventing HIV infection in HIV-negative persons.

BACKGROUND: This is one of the three Cochrane reviews that examine the role of the telephone in HIV/AIDS services. Although HIV infection can be prevented, still a large number of new infections occur. More effective HIV prevention interventions are needed to reduce the number of people newly infected with HIV. Phone calls can be used to potentially more effectively deliver HIV prevention interventions. They have the potential to save time, reduce costs and facilitate easier access. OBJECTIVES: To assess the effectiveness of voice landline and mobile telephone delivered HIV prevention interventions in HIV-negative persons. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed Central, EMBASE, PsycINFO, Web of Science, Cumulative Index to Nursing & Allied Health, the World Health Organization's Global Health Library and Current Controlled Trials from 1980 to June 2011. We searched the following grey literature sources: Dissertation Abstracts International and the Centre for Agricultural Bioscience International Direct Global Health database, the System for Information on Grey Literature Europe, The Healthcare Management Information Consortium, Google Scholar, Conference on Retroviruses and Opportunistic Infections database, International AIDS Society conference database, AIDS Education Global Information System and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series studies comparing the effectiveness of delivering HIV prevention by phone calls to usual care in HIV-negative people regardless of their demographic characteristics and in all settings. DATA COLLECTION AND ANALYSIS: Two reviewers independently searched databases, screened citations, assessed study quality and extracted data. A third reviewer resolved any disagreement. Primary outcomes were knowledge about the causes and consequences of HIV/AIDS, change in behaviour, healthcare uptake and clinical outcomes. Secondary outcomes were users' and providers' views on the intervention, economic outcomes and adverse outcomes. MAIN RESULTS: Out of 14,717 citations, only one study met the inclusion criteria. The included RCT recruited women and girl children who received post-exposure prophylaxis (PEP) after rape from sexual assault services in South Africa between August 2007 and May 2008.Participants (n (number) =274) were randomised into a telephone support (n=136) and control (n=138) group. Control group participants received usual care (an interactive information session) from the sexual assault service during the 28 days in which they had to take PEP, with no further contact from the study staff. Telephone support group participants received standard care and phone calls from a counsellor throughout the 28 days when they had to take PEP.Overall, adherence to PEP was not significantly (P=0.13) different between the intervention (38.2%) and control (31.9 %) groups. Also, the proportion of participants who read a pamphlet, did not return to collect medication or with a depression were not significantly different between the intervention and control groups (P=0.006, P=0.42, P=0.72 respectively). The proportion of participants who used a diary was significantly (P=0.001) higher in the intervention group (78.8%) versus the control group (69.9%). The study authors reported that there were no recorded adverse events. The RCT did not provide information about participants' and providers' evaluation outcomes, or economic outcomes. The study had a moderate risk of bias. AUTHORS' CONCLUSIONS: We found only one RCT, with a moderate risk of bias, which showed that providing PEP support by phone calls did not result in higher adherence to PEP. However, the RCT was conducted in an upper-middle-income country with high HIV prevalence, on a high-risk population and the applicability of its results on other settings and contexts is unclear. There is a need for robust evidence from various settings on the effectiveness of using phone calls for providing PEP support and for other HIV prevention interventions.

Youth use of e-liquid flavours-a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation.

BACKGROUND AND AIMS: There is concern that young people may be attracted to e-liquid flavours, prompting long-term vaping in naive users and potentially subsequent tobacco smoking. We aimed to review the use of e-liquid flavours by young people and describe associations with uptake or cessation of both regular vaping and tobacco smoking, adverse effects and subjective experiences. DESIGN: Systematic review, including interventional, observational and qualitative studies reporting on the use of e-cigarette flavours by young people (aged < 18 years). SETTING: Studies published in English language from any country or cultural setting. PARTICIPANTS: Young people and their carers (aged < 18 years). MEASUREMENTS: A meta-analysis was not possible due to substantial heterogeneity, inconsistency in reporting of flavour categorizations and non-interventional study designs; thus, we narratively report findings. FINDINGS: In total, 58 studies were included. The quality of the evidence was extremely low. Most (n = 39) studies were cross-sectional survey designs. In total, 11 longitudinal cohort studies assessed trajectories; eight qualitative studies reported on user experiences. Studies reported views and experiences of a total of 512 874 young people. Both cross-sectional and longitudinal studies suggested that flavours are important for initiation and continuation of vaping. Qualitative evidence shows interest and enjoyment in flavours. There was judged to be insufficient evidence that use of e-liquid flavours specifically is associated with uptake of smoking. No studies found clear associations between flavours and cessation in this population. We found no included reports of adverse effects of flavours. CONCLUSIONS: Flavours may be an important motivator for e-cigarette uptake, but the role of flavours in tobacco smoking uptake or cessation is unclear. The quality of the evidence on use of e-cigarette flavours by young people is low overall.

Interventions to reduce social isolation and loneliness during COVID-19 physical distancing measures: A rapid systematic review.

BACKGROUND: A significant proportion of the worldwide population is at risk of social isolation and loneliness as a result of the COVID-19 pandemic. We aimed to identify effective interventions to reduce social isolation and loneliness that are compatible with COVID-19 shielding and social distancing measures. METHODS AND FINDINGS: In this rapid systematic review, we searched six electronic databases (Medline, Embase, Web of Science, PsycINFO, Cochrane Database of Systematic Reviews and SCOPUS) from inception to April 2020 for systematic reviews appraising interventions for loneliness and/or social isolation. Primary studies from those reviews were eligible if they included: 1) participants in a non-hospital setting; 2) interventions to reduce social isolation and/or loneliness that would be feasible during COVID-19 shielding measures; 3) a relevant control group; and 4) quantitative measures of social isolation, social support or loneliness. At least two authors independently screened studies, extracted data, and assessed risk of bias using the Downs and Black checklist. Study registration: PROSPERO CRD42020178654. We identified 45 RCTs and 13 non-randomised controlled trials; none were conducted during the COVID-19 pandemic. The nature, type, and potential effectiveness of interventions varied greatly. Effective interventions for loneliness include psychological therapies such as mindfulness, lessons on friendship, robotic pets, and social facilitation software. Few interventions improved social isolation. Overall, 37 of 58 studies were of "Fair" quality, as measured by the Downs & Black checklist. The main study limitations identified were the inclusion of studies of variable quality; the applicability of our findings to the entire population; and the current poor understanding of the types of loneliness and isolation experienced by different groups affected by the COVID-19 pandemic. CONCLUSIONS: Many effective interventions involved cognitive or educational components, or facilitated communication between peers. These interventions may require minor modifications to align with COVID-19 shielding/social distancing measures. Future high-quality randomised controlled trials conducted under shielding/social distancing constraints are urgently needed.

A Qualitative Exploration of Consumers' Perceived Impacts, Behavioural Reactions, and Future Reflections of the EU Tobacco Products Directive (2017) as Applied to Electronic Cigarettes.

BACKGROUND: Electronic cigarette regulations included in the Tobacco Products Directive (TPD), Article 20, implemented in Europe by May 2017, aimed to improve safety for e-cigarette consumers, and prevent uptake among non-smokers, particularly young people. Before implementation, there were significant concerns from consumers, industry, and some in the scientific community about the potential negative impact of the TPD on people using e-cigarettes to remain abstinent from smoking. To date, there is limited evidence on how the TPD has affected consumers. This study aimed to add insight into how consumers perceived and experienced the regulations. METHODS: Qualitative data, collected between March 2018 and March 2019, relating to participant views of the TPD were extracted from 160 interviews/extended surveys of e-cigarette consumers as part of a wider study into e-cigarette use trajectories (ECtra study). Data were thematically analysed. RESULTS: Awareness of the TPD among consumers was not universal. Participants' smoking behaviour did not appear to be influenced by the legislation. Participants were reassured by manufacturing regulations and requirements for ingredients labels. Participants responded negatively to changes perceived to cause inconvenience and extra plastic waste. The product restrictions prompted some participants to purchase non-compliant products illegally, potentially putting their safety at risk. CONCLUSIONS: E-cigarette regulation should focus on ensuring product safety. Raising awareness of the TPD among consumers and smokers could be beneficial.