Stubbing out the public health problem of an era | Blog piece by Tim Coleman | #myresearchlegend

Sir Richard Doll had an illustrious career. Through his efforts, the world learned much about the causes of cancer and the dangers of asbestos, radiation and, of course, smoking. Following his research into smoking and lung cancer during the 1950s, the realisation dawned that tobacco use was the public health problem of the era and not a harmless pastime. We all know what’s happened since. How many other 20th century epidemiologists have had such a transformative impact on peoples’ understanding of the determinants of disease?

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To what extent do I consider Sir Richard Doll to be a research ‘legend’? I’m not sure I’ve earned the right to bestow that honour, so I’ve taken advice. The Cambridge English Dictionary says a ‘legend’ is “someone very famous and admired, usually because of their ability in a particular area”. Just considering the one area of Doll’s work emphasised above, this is a no-brainer; ‘legend’ threshold is clearly surpassed. Don’t take my word for this, though, Google ‘Richard Doll’ and see if you can find reason to disagree.

Am I hasty in allocating ‘legend’ status? Doll certainly changed the world’s knowledge of many illnesses; shouldn’t an NIHR research legend demonstrate clear NHS impact too? Fortunately Doll’s influence here doesn’t disappoint, even if one again only considers smoking. I am a GP. How would this be different if Sir Richard had never lived? Firstly, I’d probably smoke. A pipe would give me more gravitas than cigarettes and I’d have to either smoke in my consulting room, like some doctors did, or schedule regular ‘pipe breaks’ into my day. I would be blissfully ignorant about harms from smoking and more likely to offer patients cigarettes than help with stopping, even if they developed lung cancer or heart disease.

Smoking Kills

Thankfully, Sir Richard did exist. Although I tried smoking as a teenager, a friend’s mum made me think again and I didn’t ever fully adopt the habit. Immature, teenage me was saved from smoking because Doll had shown how harmful smoking is. Fast forward to my GP work in 2018; again due to Doll, I fully realise that smoking kills my patients and wrecks their lives.

crop.jpgAlso, due to research which was only possible because of his early work, I can offer smokers numerous types of cessation support. It’s even possible to refer on to Stop Smoking Services (SSS) for specialist help, though a major cloud on the horizon is that these vital services are no longer universal; they are endangered.

Through their work at the Statistical research Unit of the MRC, Doll and Hill demonstrated that smoking causes lung cancer; before this smoking was ubiquitous across social classes and many doctors smoked. By 1954, the government accepted the link and the middle classes started quitting in droves. When he died in 2005, Doll would very likely have been delighted that UK smoking rates were falling fast. However, improvements were chiefly amongst the better off, so smoking had become disproportionately concentrated amongst society’s poorest. Given his well-documented non-conformist views, my bet is that he would have been saddened that those with most to gain benefited least from such massive social change. Nevertheless, he might have been heartened by the government’s national and vigorous action against smoking. Back then, although SSS were a very new NHS entity, it was mandatory for Primary Care Trusts to deliver them and SSS were closely performance-managed by the then Department of Health. Any smoker could access services’ evidenced-based support to increase their chances of permanent cessation.

Smoking Prevention

Worldwide, legions of researchers, including me, have followed Doll by trying to find ways of treating or preventing smoking. Few epidemiologists have caused such a seismic shift in the international research agenda. Take a look at the thousands of randomised controlled trials (RCTs) reviewed in the tobacco section of the Cochrane Library. All of these studies test interventions against smoking. This necessary work continues today and NIHR is a leading supporter funding, for example, the largest ever RCTs of Nicotine Replacement Therapy used in pregnancy* or for ‘preloading’.

The NHS is 70. Celebrating research legends is a great idea but it’s important we remember what they did and why they are lauded. It took almost half a century after Doll and Hill’s landmark paper for the NHS to implement national treatment services for smokers, and sadly less than 20 years later these have become an optional extra with patchy coverage across the country. Smoking is less prevalent than in the past but there are still millions of UK citizens who want to stop and can’t manage this alone. Smoking is still a national problem and requires a national NHS response. A crucial component of this response should be to help quitters by giving them the very best support.

Sir Richard’s work has had a great impact, as all research should. The demise of SSS suggests we risk forgetting this when instead we should continue to build on his significant achievements.

*More information on the trial: Double-blind, randomised, placebo-controlled trial of nicotine replacement therapy (NRT) in pregnancy – SNAP is available on the NIHR Journals Library website.

Tim Coleman, Professor of Primary Care, Faculty of Medicine & Health Sciences
University of Nottingham and NIHR Senior Investigator

The NIHR is highlighting seven research legends whose work has shaped the NHS, as part of its celebrations for the NHS’s 70th birthday and the NIHR’s I Am Research campaign.

Original post on NIHR website. – Posted: 04 May 2018

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Alcohol Policy in Practice | Continuing Professional Development Course | 11th-13th September 2018

Following the successful Alcohol CPD courses held in 2014-2017; we are delighted to announce the line-up for our 2018 course, featuring some exciting new inputs!

This year’s course will feature inputs from Prof. Anna Gilmore and colleagues from the University of Bath, Dr Carol Emslie from Glasgow Caledonian University, Dr James Nicholls from Alcohol Research UK, and Professor Karine Gallopel-Morvan from the EHESP School of Public Health, France. We also welcome the return of highly-rated inputs from leading experts such as Katherine Brown from the Institute of Alcohol Studies and Colin Shevills of Balance North East.

What previous participants said:

“Great range of content and world-class speakers. Organisers did an amazing job including looking after us all while we were here. The mix of lectures / Q & As / panel discussions was great. Really worth taking time away from work/home to attend this.”
“Extremely informative course and relevant to current alcohol policy challenges. Good venue, convenient location and lovely setting. Module well organised and brilliant range of speakers.”
“Thank you very much. It was a great privilege to listen and attend this course. Lectures and lecturers were outstanding.”
“Very informative useful training, well worth my time and travel.”
“Wonderful networking opportunity.”
“Thank you for such a brilliant training event – the content was spot on, all the presentations and sessions were really, really good and I came away feeling that I had learned masses: a rich diet of fact and opinion. I can honestly say that I have rarely – if ever – enjoyed such an event quite as much as this one.”

Anyone wishing to gain an in-depth understanding and up to date insight into evidence and innovative practice in alcohol policy in the UK and internationally.
Previous participants have included people working in public health, local and national alcohol policy, or alcohol research; from Iceland to New Zealand.
Places are filling up fast and the early-bird rate applies until Friday 15th June 2018! 

Apply Here!

New Systematic Review: Effectiveness of Mass Media Campaigns to Reduce Alcohol Consumption and Harm

This systematic review, published in Alcohol and Alcoholism, assessed the effectiveness of mass media messages to reduce alcohol consumption and related harms. Eight databases were searched along with reference lists of eligible studies. Studies of any design in any country were included, provided that they evaluated a mass media intervention targeting alcohol consumption or related behavioural, social cognitive or clinical outcomes. This was the first comprehensive systematic review of evidence of the effectiveness of mass media to reduce alcohol consumption, allowing those who make decisions about whether and how to develop and implement such campaigns to do so informed by a synthesis of the evidence base.
a&a1The search produced 10,212 results and 24 studies were included in the review. Most of the campaigns used TV or radio in combination with other media channels. There was little evidence of reduction in alcohol consumption associated with exposure to campaigns based on 13 studies which measured consumption, although most did not state this as a specific aim of the campaign. There were some increases in treatment seeking and information seeking and mixed evidence of changes in intentions, motivation, beliefs and attitudes about alcohol. Campaigns were associated with increases in knowledge about alcohol consumption, especially where levels had initially been low.The evidence suggests mass media health campaigns about alcohol can be recalled by individuals and can achieve changes in knowledge, attitudes and beliefs about alcohol, based mainly on weak quality studies. Findings of studies that measured alcohol consumption suggest campaigns have not reduced consumption, although most did not state that they directly aim to do so.

The finding that campaigns can be recalled suggests appropriate media channels, targeting strategies, durations and intensities have been utilized to reach target audiences. These campaign characteristics were not always reported by studies so it is not possible to draw a link between types of campaign strategies and levels of recall or exposure. Recall of tobacco mass media campaigns has been shown to be positively associated with smoking cessation (Jepson et al., 2007) so the outcome may be an important first step towards subsequent behaviour change in populations.

Most campaigns that aimed to improve knowledge were shown to be effective. This was particularly evident in areas where knowledge was initially low, for example, knowledge of unit consumption guidelines and of the link between alcohol and cancer. Mass media can yield sustained knowledge, which may lay the groundwork for reductions in consumption that are achieved using other public health measures.

There was evidence of increases in information seeking and treatment seeking. However, alcohol campaigns have not presented the simple call to action of tobacco messages (‘quit’) or provided offers of tangible help such as ‘quitlines’. Furthermore, as alcohol support services have historically been aimed at very heavy drinkers there may be a perception that current services do not cater for those who drink less. Mass media might therefore have limited utility in promoting service uptake.

Most studies found no impact on alcohol consumption, consistent with the conclusion of a previous review that there should be modest expectations of behaviour change from such campaigns (Snyder et al., 2004). Longer term evaluations conducted following sustained and repeated exposure to campaigns might be expected to be better able to detect effects on behaviour. However, the relationship between tobacco mass media campaign duration and effectiveness has been difficult to gauge due to confounding influences and trends over time (Durkin et al., 2012). The context in which alcohol health promotion campaigns operate is particularly challenging because of the ubiquity and power of alcohol marketing (de Bruijn et al., 2016) and pro-alcohol cultural norms (Gordon et al., 2012). This is another key difference to tobacco, where health campaigns in recent years have run in a context where most tobacco marketing has been banned or strictly regulated and social norms have become increasingly anti-smoking. The current review found evidence of impact on short term intermediate outcomes, suggesting mass media can play a supportive role for other actions which are more likely to have an impact on behaviour. These might include price-based measures (Babor et al., 2010), advertising restrictions (Siegfried et al., 2014), limiting availability and access to alcohol (Anderson et al., 2009) with the targeting of high risk groups (Foxcroft et al., 2015).

Alcohol and Alcoholismhttps://doi.org/10.1093/alcalc/agx094
Published: 10 January 2018

Upcoming Tobacco & Alcohol courses now taking applications: limited places available!

nottingham

“Tobacco Control Interventions”
29th Jan – 2nd Feb 2018
University of Nottingham

Closing date for applications: 16th January 2018

This year we will be discussing important factors in tobacco control including; youth smoking, the role of the tobacco industry, use of mass media for smoking prevention and cessation, smokefree legislation, harm reduction and the neurobiology of nicotine addiction.


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“Alcohol, Problems, Policy & Practice” 
5th – 9th February 2018
Kings College London

Early bird deadline: 21st December 2017

The course is a mixture of blended learning, with face-to-face lectures being held in February 2018. It is open to all UKCTAS researchers as well as students of the MSc in Addiction Studies.


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“Nicotine and Tobacco CPD”
21st – 24th May 2018
University of Stirling

Early bird deadline: 28th February 2018

In addition to the topics covered on our previous tobacco control CPD, we will also be examining in detail the current evidence on tobacco harm reduction, electronic cigarettes and other nicotine-containing devices.


More information about these courses can be found on our website @ UKCTAS.net

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

Exposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. Researchers from UKCTAS at the University of Nottingham trialed a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking.

This was an open-label, parallel, randomised controlled trial carried out in deprived communities around Nottingham City and County.

The trial worked with caregivers who live 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.

The research compared a complex intervention that combined personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care.

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.

Geometric 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.

The team concluded that 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.

Read the full research report in the BMJ here.

This trial was funded by the UK National Institute for Health Research.

To find more information about this trial and the Smoke Free Homes project click here.

John Britton speaks to RegWatchCanada on #COP7FCTC and the World Health Organization’s view of E-cigarettes

Just as vapers in several countries began to feel like events may finally be turning in favor of e-cigarettes as a harm reduction tool, the harsh realities of the global public health movement shattered any optimism.

The World Health Organization is just wrapping its Conference of the Parties to the Framework Convention on Tobacco Control, known as COP7, in India and according to professor John Britton, Chair of the Tobacco Advisory Group at the Royal College of Physicians in Britain (RCP), the future for vaping looks bleak.

The RCP, Public Health England and the UK Centre for Tobacco and Alcohol Studies have all endorsed e-cigarettes as a vital tool in the battle to end the tobacco epidemic.

Tune in to this special edition of RegWatch and learn why officials from England’s top public health organizations fear that pending WHO regulatory action on e-cigarettes could kill millions of people.

RegulatorWatch.com

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Click here to read the UKCTAS commentary on the WHO report on e-cigarettes. –  Released 26/10/2016

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Teenagers who play video games with alcohol & tobacco content are more likely to drink & smoke.

Images and references to alcohol and tobacco in popular video games may be influencing UK teens who play the games and the age restriction system is not working, according to a new study. 

Experts from the UK Centre for Tobacco and Alcohol Studies at The University of Nottingham have carried out the first ever analysis of best-selling video games to find out the extent to which the games include this content and to assess the link between playing the games and drinking and smoking behaviour.

They found that teenagers who play video games featuring alcohol and tobacco references appeared to be directly influenced because they were twice as likely to have tried smoking or drinking themselves.

‘Cut scenes’ on YouTube

The research examined the content of 32 UK best-selling video games of 2012/2013 and carried out a large online survey of adolescents playing games with alcohol and tobacco content. An analysis of ‘cut scenes’ uploaded by gamers to YouTube from the five most popular games was also carried out. All the games studied were from the genres of stealth, action adventure, open world, shooter and survival/horror because they involve avatars that look and act like real people.

The study, published in the journal Cyberpsychology, Behavior and Social Networking, found alcohol and tobacco content in 44% of the most popular video games. They also found this content was not reported by the official regulator, the Pan-European Games Information (PEGI) system which informs the Video Standards Council age ratings that help parents decide whether game content is suitable for their children.

Subliminal messages

The researchers used YouGov survey tools to ask 1,094 UK adolescents aged 11-17 whether they had played any of the most popular video games identified as containing either tobacco or alcohol imagery. They were also asked whether and to what extent they smoked or drank alcohol. The study found that adolescents who had played at least one game with tobacco or alcohol content were twice as likely to have tried smoking or consumed alcohol themselves.

Out of the top five most popular games, Grand Theft Auto V & VI contained the highest level of alcohol and smoking content using fictitious brands only. The other top games containing these references were Call of Duty:Black Ops II, Call of Duty:Modern Warfare 3 and Assassin’s Creed III. There was no electronic cigarette content.

Video and Film
FIG. 1.  Percentage of total coding intervals containing alcohol content by category in the five games.
Video and Film
FIG. 2.  Percentage of total coding intervals containing tobacco content by category in the five games.

 

Psychologist Dr Joanne Cranwell from the UK Centre for Tobacco and Alcohol Studies, said:

”Although around 54% of UK adolescents play video games online, parental concern over exposure to inappropriate content while playing video games seems to be lower than for other media, like movies for example. While 80% of children aged 10-15 play packaged or online video games with an age rating higher than their age, more than half of British parents are unaware of the harmful content this exposes them to.

Video games are clearly attractive to adolescents regardless of age classification. It appears that official PEGI content descriptors are failing to restrict youth access to age inappropriate content. We think that the PEGI system needs to include both alcohol and tobacco in their content descriptors. Also, game developers could be offered incentives to reduce the amount of smoking and drinking in their games or to at least reference smoking and drinking on their packaging and websites.

As a child protection method it is naïve for both the games industry and the Interactive Software Federation of Europe, who regulate the PEGI system, to rely on age ratings alone. Future research should focus on identifying the levels of exposure in terms of dose that youth gamers are exposed to during actual gameplay and the effects of this on long- term alcohol and smoking behaviour.”

A copy of the full paper is online here: Alcohol and tobacco content in UK video games and their association with alcohol and tobacco use among young people.

News Reports:

Teenagers influenced by video games with alcohol, smoking content – ScienceDaily

Nottingham study finds teenagers ‘are influenced’ by smoking and alcohol in video games – NottsTV

GRAND THEFT WARNING – Teenagers who play video games are ‘TWICE as likely to smoke and drink alcohol’ – TheSUN

Teens who play Grand Theft Auto are ‘twice as likely to smoke or drink alcohol’ – AngleNews

Does YOUR teenager play Grand Theft Auto? They are ‘twice as likely to smoke or drink alcohol’ – DailyMail