Monday, 2 December 2013

Culture eats strategy for breakfast, but maybe strategy will have more luck over dinner: review of the North West Alcohol Conference 2013

We recently attended the North West Alcohol Conference in Liverpool. PhD students Natasha Clarke, Inge Kersbergen and Jay Duckworth summarise the highlights.

Natasha Clarke
Professor David Walker, Deputy Chief Medical Officer of the NHS, gave the first talk. This focussed on The National Alcohol Strategy; the proposal put forward by the government to tackle our society’s harmful use of alcohol. The key issue raised was the disappointment of Public Health England with the government’s reluctance to introduce minimum unit pricing (MUP), despite initial plans to implement it. Evidence from Canada and the Sheffield Alcohol Policy Model indicate the implementation of a 45p MUP may decrease alcohol consumption and reduce hospital admissions, yet the strategy states that more evidence is needed. The sudden backtrack is suggested to be due to intense lobbying from the alcohol industry; for example, the Wine and Spirit Trade Association (WTSA) launched a campaign against the proposal and claim that MUP would unfairly penalise the majority of responsible consumers. Previous research has shown that the industry will selectively use evidence in order to support policies that are in line with their commercial interests, and WHO stress that industry should have no role in forming alcohol policy.
So what is being done? The government has committed to a ban of “below cost sales”, with cost being duty + VAT. This is equal to roughly 21p per unit for beer and 28p per unit for spirits, prices significantly lower than the original proposed MUP. It is estimated that only 1.3% of all units of alcohol sold will be affected by this and that a threshold of 45p would have a considerably larger impact. The government also mentions a pledge through the responsibility deal to take 1 billion units out of the market by 2015; the Health Committee doesn’t think this will have any significant impact. A further emphasis was placed on education campaigns, despite evidence showing their ineffectiveness in reducing alcohol-related harm.
What was clear is that the government are not doing enough. Words and promises (especially ones that are broken) will not produce changes in the nations’ health. An audience member asked David Walker… “Can you change culture?” The answer was “Yes, we can”. Using smoking and driving behaviours as previous examples he explained that these are health aspects to which our outlook as a nation has changed. Smoking attitudes took decades to alter and faced similar pressure from the industry. The verdict was that we must continue to fight for better policy, but an equal match of input from public health and industry is continuing to prove difficult.

Inge Kersbergen
Discussions then continued in different breakout sessions. Colin Shevills and Ali Wheeler made a compelling case for changing licensing regulations. Licensed premises are popping up everywhere in the country. You can now buy alcohol in a large variety of places: in cinemas, indoor playgrounds, and even hairdressers. And the more traditional licensed premises keep growing in number as well. All whilst we know from research that the density of licensed premises is related to more alcohol-related harm and crime. The licensing act is still operating under the premise that licenses are granted where possible, even if licensing committees and communities want to limit the amount of licensed premises in an area.  Licensing committees have very limited power when it comes to restricting licenses in high density areas or taking licenses away. However, they do possess two powerful tools to limit alcohol availability: Early Morning Alcohol Restriction Orders (EMROs) and Late Night Levys (LNLs).  
An EMRO restricts sales of alcohol in a specific area at a set time between midnight and 6am. Premises that are in violation of this order will receive a fine. The LNL is an additional fee for licensed premises if they want to sell alcohol between midnight and 6am. At first glance these policies seem very similar. The difference lies in how voluntarily businesses restrict their selling times. At the start of November 2013 a LNL has been introduced in the city of Newcastle.  So far, it seems like this levy has the effect of an EMRO, as many businesses voluntarily decided not to pay the additional fee, but to stop selling alcohol at midnight instead. The proposed EMRO in Blackpool, on the other hand, was met with a lot of resistance from the business owners. The speakers argue that it is therefore important that businesses do not feel forced into restricting their selling hours to get their full cooperation. Local licensing committees should make more use of the tools they have, get more freedom to limit licensed premises in their area and be able to involve the local community in their decision making.

Jay Duckworth
Further suggestions for policy change came from Mark Gilman, Strategic Recovery Lead at Public Health England and the National Treatment Agency for Substance Misuse. Gilman, a passionate speaker, offered advice which he concedes many see as “unscientific, folky [and] quirky”. His idea is that we need to place more emphasis on twelve-step programs in which addicts are forced to confront matters of “spirituality”. Initiatives such as Alcoholics Anonymous (AA) are of this breed, asking addicts to admit they are “powerless over alcohol” and to recognise that a “Power greater than they can restore their sanity”. As Gilman admits, this may be a difficult pill to swallow for many. First, non-spiritual individuals will find it problematic to attain the “spiritual awakening” necessary for success in many 12-step approaches. Additionally, though AA is effective at reducing rates of drinking there are many equally effective treatments available which come without the mystical baggage. That being said, there is an essential feature of 12-step programs which should be acknowledged as an important part of recovery: social support from people who are abstinent from alcohol. Social networks of abstainers appear to be one of the primary reasons why involvement in 12 step programs helps people to abstain from alcohol.
The next speaker was Wim van den Brink, Professor of Psychiatry and Addiction at the Academic Medical Centre of the University of Amsterdam. Following directly from the previous speaker, van den Brink started by saying that, “I agreed with almost everything you said, but I’m going to disagree on some points just to make it interesting…” And so he did. He focused on his own recently published research which tested the efficacy of the drug Nalmefene on an alcohol-dependent population. Two clinical trials had shown that Nalmefene reduced drinking significantly in patients relative to placebo. In his talk, van den Brink focussed on additional analyses that compared the effects of the drug on those who reduced their drinking between screening (when their drinking was assessed by a doctor) and randomization (to receive either Nalmefene or placebo), and those who did not. These analyses showed that many of the patients reduced their drinking after screening and for this group, Nalmefene had no effect. On the other hand, Nalmefene led to large reductions in drinking among patients who did not reduce their drinking after the initial clinical assessment.

These two talks complemented each other nicely because they suggest that broad social factors play an important role in recovery from alcohol problems. For some problem drinkers, simple assessment of drinking by a doctor (which can be considered a ‘minimal’ psychological intervention) is enough to help them to reduce their drinking. Whereas others may need medication, such as Nalmefene, in order to cut down. 

Sunday, 1 December 2013

Quitting smoking is the easy part, staying quit is hard

This article was originally written by Paul Christiansen for the Lifestyle Elf website, you can find the original here

During 2010/11 there were 1.53 million hospital admissions for illnesses directly attributable to smoking in the UK. These admissions, along with other smoking-related expenses, cost the NHS approximately £5 billion pounds per year.

Fortunately, the NHS is spending £88.2 million per year on cessation treatments, many of which have been repeatedly demonstrated to be highly efficacious. Indeed, Dr Andrew Jones and I recently wrote a Mental Elf blog on a Cochrane review that reported impressive outcomes for several pharmacological smoking cessation treatments.

Sounds good doesn’t it? A relatively small outlay on cessation treatment should have a massive impact on reducing smoking-related illness saving the NHS billions.

Things are, of course, not so simple; quitting is one thing staying abstinent is another. Indeed, 75% of quitters relapse within 12 months (Agboola, 2009) and, problematically, frequency of previous relapses are associated with decreased chances of maintaining abstinence following future attempts to quit (Zhou, 2009).
Three out of four people who quit smoking will start again within 1 year
Three out of four people who quit smoking will start again within one year

The efficacy of relapse prevention treatments are the focus of this Cochrane review. The authors analyse the efficacy of behavioural based strategies (e.g. face to face and web-based counselling) of differing durations, as well as pharmacological treatments (e.g. nicotine replacement therapy [NRT] and bupropion).

This review also investigates whether treatment efficacy differs in people quitting for different reasons, i.e. forced cessation (due to pregnancy, hospitalization or military training) or voluntary cessation.


The authors conducted a meta analysis on 63 studies that explicitly focused upon relapse prevention and had a minimum 6 month follow up. 

The primary outcome was the number of individuals who maintained abstinence in the longest follow-up. It is notable that the authors reported risk ratios (RR), rather than odds ratios. Risk ratios are generally a conservative measure (unless event rates are particularly low). Analyses were conducted separately for ‘trials in abstainers’ and ‘trials in those allocated before quit date’.

Trials in abstainers
This refers to those who were abstinent on presentation to the trial and includes special populations (pregnant, hospitalisation and military recruits; behavioural interventions only) as well as those from unselected populations (those who quit voluntarily or as part of a program; behavioural and pharmacological interventions).

Trials in those allocated before quit date
Only behavioural interventions are reported for those assigned to treatment groups before their quit day, (although one behavioural + NRT is reported). Analyses in this group are broken down into different forms of intervention.


Trials in abstainers

Special populations:
Caption here...
Although many women quit smoking during pregnancy, subsequent relapse remains high

  • There was no evidence that any behavioral relapse prevention interventions had a significant effect on relapse following: 

  • - birth (RR 1.04 95% CI 0.95 – 1.11), 
  • - the postpartum period (RR 1.08 95% CI 0.99 – 1.19)
  • - or in those hospitalized for other reasons (RR 0.94 95% CI 0.78 – 1.13).

  • The picture in military recruits was less clear, there was some evidence that behavioural interventions could increase abstinence (OR [reported in this case only] 1.23 95% CI 1.07-1.41) although the absolute rates of abstinence in this sample were still very low.

Unselected populations:

  • - There was no significant impact of behavioural relapse prevention interventions in unaided quitters (RR 1.08 95% CI 0.98 – 1.19)
  • - Although there was some evidence for the efficacy of NRT (RR 1.24 95% CI 1.04 to 1.47).

With regards to those who quit through formal treatment behavioural interventions (RR 1.00 95% CI 0.87 -1.15), NRT (RR 1.04 95% CI 0.77 to 1.40), bupropion (RR 1.15 CI 0.98 to 1.35) and bupropion in combination with NRT (RR 1.18 95% CI 0.75 to 1.87) all failed to reduce relapse. However, varenicline (1 study; RR 1.18 95% CI 1.03 to 1.36) and rimonbant significantly reduced relapse although the latter recently had its license withdrawn due to safety concerns.

Trials in those allocated before quit date

Data revealed a similar pattern of results to the abstainers; there was no evidence that relapse rates were reduced by:

  • Caption here...
    Evidence for the efficacy of telephone and face-to-face counselling is lacking
    - face to face intervention (RR 1.01 95% CI 0.80 to 1.27),
  • - extended contact phone calls (RR 1.06 95% CI 0.90 to 1.23),
  • - or web support (RR 1.27 95% CI 0.70 to 2.31).

Furthermore telephone counseling in conjunction with NRT also failed to reduce relapse (RR 1.28 95% CI 0.94 to 1.75).


This review highlights two fundamental issues in the area of relapse prevention in ex-smokers. Firstly, there was a near universal failure to detect any clinically efficacious interventions. This is perhaps surprising, many pharmacological interventions for smoking cessation have very good efficacy.

Indeed, it is notable that one of the only relapse prevention techniques that had a significant effect on relapse prevention was varenicline which is also the most efficacious quitting agent.
Caption here...
There are many effective interventions to help you quit, but this is only half the battle

Then again, the results reported may not be so surprising. The overall GRADE quality of the reviewed studies was relatively low; sample sizes tended to be relatively small and behavioural treatments focused on single treatments rather than addressing the multiple causes of relapse such as craving, stress and cue reactivity in a more holistic manner.
Indeed, a combination of behavioural and incentive based strategies are associated with reduces relapse rates at 6 months (Gadomski, 2011). Furthermore, we are starting to see a first wave of studies looking at E-Cigarettes which have promising results (Etter, in press).

So although the current review seems to offer little encouragement for quitters, tailored interventions dealing with multiple aspects of the causes of relapse as well as continuing pharmacological-based developments offer some real hope.


Hajek P, Stead LF, West R, Jarvis M, Hartmann-Boyce J, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003999. DOI: 10.1002/14651858.CD003999.pub4.

Agboola SA, Coleman TJ, McNeill AD. Relapse prevention in UK Stop Smoking Services: a qualitative study of health professionals’ views and beliefs. BMC Health Serv Res. 2009 Apr 24;9:67. doi: 10.1186/1472-6963-9-67.

Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009 Apr;34(4):365-73. doi: 10.1016/j.addbeh.2008.11.013. Epub 2008 Nov 24. [PubMed abstract]

Gadomski A, Adams L, Tallman N, Krupa N, Jenkins P. Effectiveness of a combined prenatal and postpartum smoking cessation program. Matern Child Health J. 2011 Feb;15(2):188-97. doi: 10.1007/s10995-010-0568-9. [Pubmed Abstract]

Etter, JF Bullen, C. A longitudinal study of electronic cigarette users. Addictive Behaviors, in press. doi10.1016/j.addbeh.2013.10.028. [Science direct abstract].

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