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

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

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

The rapid spread of Covid-19 and the increasing burden on mental health and wellbeing require new ways of supporting families that have to maintain the new norms of social distancing. Therefore, there is a great need to search for ways to minimise the effects of COVID-19 on mental health. The purpose of the research is to evaluate a yoga intervention offered online to school-aged children in the UK by Patanjali Yog Peeth Trust UK (PYPT). The research will use a mixed-methods approach. It is intended that the research will provide an evidence base that will aid future studies.

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

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

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

Background Alcohol consumption and related harm increase steeply from the ages of 12–20 years. Adolescents in the UK are among the heaviest drinkers in Europe. Excessive drinking in adolescents is associated with increased risk of accidents, injuries, self-harm, unprotected or regretted sex, violence and disorder, poisoning and accidental death. However, there is lack of clear evidence for the most clinically effective and cost-effective screening and brief interventions for reducing or preventing alcohol consumption in adolescents attending emergency departments (EDs). Objectives To estimate the distribution of alcohol consumption, alcohol-related problems and alcohol use disorders in adolescents attending EDs; to develop age-appropriate alcohol screening and brief intervention tools; and to evaluate the clinical effectiveness and cost-effectiveness of these interventions. Design The research has been conducted in three linked stages: (1) a prevalence study, (2) intervention development and (3) two linked randomised controlled trials (RCTs). Setting Twelve EDs in England (London, North East, and Yorkshire and The Humber). Participants A total of 5376 participants in the prevalence study [mean age 13.0 years, standard deviation (SD) 2.0 years; 46.2% female] and 1640 participants in the two linked RCTs (mean age 15.6 years, SD 1.0 years; 50.7% female). Interventions Personalised feedback and brief advice (PFBA) and personalised feedback plus electronic brief intervention (eBI), compared with alcohol screening alone. These age-appropriate alcohol interventions were developed in collaboration with the target audience through a series of focus groups and evaluations during stage 2 of the research programme and following two literature reviews. Main outcome measures Total alcohol consumed in standard UK units (1 unit = 8 g of ethanol) over the previous 3 months at 12-month follow-up, assessed using the Alcohol Use Disorders Identification Test, Consumption (3 items) (AUDIT-C). Results In the prevalence study, 2112 participants (39.5%) reported having had a drink of alcohol that was more than a sip in their lifetime, with prevalence increasing steadily with age and reaching 89.5% at the age of 17 years. The prevalence of at-risk alcohol consumption was 15% [95% confidence interval (CI) 14% to 16%] and the optimum cut-off point of the AUDIT-C in identifying at-risk drinking was ≥ 3. Associations of alcohol consumption and early onset of drinking with poorer health and social functioning were also found. In the RCT, the analysis of the primary outcome (average weekly alcohol consumption at month 12) identified no significant differences in effect between the three groups in both trials. In the high-risk drinking trial, the mean difference compared with control was 0.57 (95% CI –0.36 to 1.70) for PFBA and 0.19 (95% CI –0.71 to 1.30) for eBI. In the low-risk drinking trial, the mean difference compared with control was 0.03 (95% CI –0.07 to 0.13) for PFBA and 0.01 (95% CI –0.10 to 0.11) for eBI. The health economic analysis showed that eBI and PFBA were not more cost-effective than screening alone. Conclusions The ED can offer an opportunity for the identification of at-risk alcohol use in adolescents. A simple, short, self-completed screening instrument, the AUDIT-C, is an effective tool for identifying adolescents who are at risk of alcohol-related problems. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed in the prevalence study. The trials were feasible to implement and exceeded the recruitment target and minimum follow-up rates. However, PFBA and eBI were not found to be more effective than screening alone in reducing or preventing alcohol consumption in 14- to 17-year-olds attending EDs. Limitations and future work Only one-third of participants engaged with the application program; this is likely to have limited the effect of the intervention. We recommend that future research should focus on methods to maximise engagement with digital interventions and evaluate the effect of such engagement on clinical outcomes. Trial registration Current Controlled Trials ISRCTN45300218. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 2. See the NIHR Journals Library website for further project information.

Aims: To evaluate the effectiveness and cost-effectiveness of alcohol screening and brief intervention for adolescents delivered within the school setting. Method: Multi-centre, pragmatic, prospective randomised controlled trial conducted across different regions of England. We evaluated the effectiveness and cost-effectiveness of an Alcohol Screening and Brief Intervention (ASBI) in addition to Personal Health and Social Education (PHSE) compared to PHSE alone for adolescents aged 15 years in school. Our primary outcome was quantity of alcohol consumed at 12-months, assessed in units of alcohol. We also assessed alcohol-related problems, drinking motives and health and wellbeing. The trial was registered with current controlled trials (ISRCTN45691494). Results: While 60% of the study population had reduced their alcohol consumption at month 12, we found no difference in effectiveness between ASBI and PHSE for any of our outcome measures. The ASBI was not found to be cost-effective compared to PHSE. Conclusions: The results of the study suggest that it is not worthwhile implementing ASBI in a school setting. This concurs with other recent evidence of the effectiveness of ASBI for adolescent populations.

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

Background Alcohol consumption and related harm increase rapidly from the age of 12 years. We evaluated whether alcohol screening and brief intervention is effective and cost-effective in delaying hazardous or harmful drinking amongst low-risk or abstaining adolescents attending Emergency Departments (EDs). Methods This ten -centre, three-arm, parallel-group, single-blind, pragmatic, individually randomised trial screened ED attenders aged between 14 and 17 years for alcohol consumption. We sampled at random one third of those scoring at most 2 on AUDIT-C who had access to the internet and, if aged under 16, were Gillick competent or had informed consent from parent or guardian. We randomised them between: screening only (control intervention); one session of face-to-face Personalised Feedback and Brief Advice (PFBA); and PFBA plus an electronic brief intervention (eBI) on smartphone or web. We conducted follow-up after six and 12 months. The principal outcomes were alcohol consumed over the 3 months before 12-month follow up, measured by AUDIT-C; and quality-adjusted life-years. Findings Between October 2014 and May 2015, we approached 5,016 eligible patients of whom 3,326 consented to be screened and participate in the trial; 2,571 of these were low-risk drinkers or abstainers, consuming an average 0.14 units per week. We randomised: 304 to screening only; 285 to PFBA; and 294 to PFBA and eBI. We found no significant difference between groups, notably in weekly alcohol consumption: those receiving screening only drank 0.10 units (95% confidence interval 0.05 to 0.18); PFBA 0.12 (0.06 to 0.21); PFBA and eBI 0.10 (0.05 to 0.19). Interpretation While drinking levels remained low in this population, this trial found no evidence that PFBA with or without eBI was more effective than screening alone in reducing or delaying alcohol consumption.

Background: Whether alcohol and cannabis complement or substitute each other has been studied for over two decades. In the changing cannabis policy landscape, debates are moving rapidly and spill-over effects on other substances are of interest. Aims: update and extend a previous systematic review, by: (a) identifying new human behavioural studies reporting on substitution and/or complementarity of alcohol and cannabis, and (b) additionally including animal studies. Methods: We replicated the search strategy of an earlier systematic review, supplemented with a new search for animal studies. Search results were crossed checked against the earlier review and reference lists were hand searched. Findings were synthesised using a narrative synthesis. Results: Sixty-five articles were included (64 in humans, one in animals). We synthesised findings into categories: patterns of use, substitution practices, economic relationship, substance use disorders, policy evaluation, others and animal studies. Overall, 30 studies found evidence for substitution, 17 for complementarity, 14 did not find evidence for either, and four found evidence for both. Conclusions: Overall, the evidence regarding complementarity and substitution of cannabis and alcohol is mixed. We identified stronger support for substitution than complementarity, though evidence indicates different effects in different populations and to some extent across different study designs. The quality of studies varied and few were designed specifically to address this question. Dedicated high-quality research is warranted.

Purpose The Warwick–Edinburgh Mental Well-being Scale (WEMWBS), 14 positively worded statements, is a validated instrument to measure mental wellbeing on a population level. Less is known about the population distribution of the shorter seven-item version (SWEMWBS) or its performance as an instrument to measure wellbeing. Methods Using the Health Survey for England 2010–2013 (n = 27,169 adults aged 16+, nationally representative of the population), age- and sex-specific norms were estimated using means and percentiles. Criterion validity was examined using: (1) Spearman correlations (ρ) for SWEMWBS with General Health Questionnaire (GHQ-12), happiness index, EQ-VAS (2) a multinomial logit model with SWEMWBS (low, medium and high wellbeing) as the outcome and demographic, social and health behaviours as explanatory variables. Relative validity was examined by comparing SWEMWBS with WEMWBS using: (1) Spearman correlations (continuous data), and (2) the weighted kappa statistic (categorical), within population subgroups. Results Mean (median) SWEMWBS was 23.7 (23.2) for men and 23.2 (23.2) for women (p = 0.100). Spearman correlations were moderately sized for the happiness index (ρ = 0.53, P

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

Some links between transport and health are widely known, such as active travel, physical (in)activity, air pollution and injuries. Others are not as apparent and are much less studied, for example social interactions. This article reviews the evidence that transport impacts on social interactions, and that social interactions impact on health. It is an updated version of part of chapter 5 from Health on the Move 2 . There is growing evidence that aspects of transport influence social exclusion, social capital, social cohesion and social networks. Numerous studies have identified associations between these aspects of social interaction and morbidity and mortality. Community severance – where transport infrastructure or the speed or volume of traffic act as a physical or psychological barrier – impacts on individuals׳ travel, social networks, and the accessibility of goods, services and facilities, and has scope to influence health through a number of routes. With the development of more comprehensive measures, such as of community severance, it is likely that there will be stronger evidence that transport influences health through these pathways.

Objective To use the relation between cigarette consumption and cardiovascular disease to quantify the risk of coronary heart disease and stroke for light smoking (one to five cigarettes/day). Design Systematic review and meta-analysis. Data sources Medline 1946 to May 2015, with manual searches of references. Eligibility criteria for selecting studies Prospective cohort studies with at least 50 events, reporting hazard ratios or relative risks (both hereafter referred to as relative risk) compared with never smokers or age specific incidence in relation to risk of coronary heart disease or stroke. Data extraction/synthesis MOOSE guidelines were followed. For each study, the relative risk was estimated for smoking one, five, or 20 cigarettes per day by using regression modelling between risk and cigarette consumption. Relative risks were adjusted for at least age and often additional confounders. The main measure was the excess relative risk for smoking one cigarette per day (RR1_per_day−1) expressed as a proportion of that for smoking 20 cigarettes per day (RR20_per_day−1), expected to be about 5% assuming a linear relation between risk and consumption (as seen with lung cancer). The relative risks for one, five, and 20 cigarettes per day were also pooled across all studies in a random effects meta-analysis. Separate analyses were done for each combination of sex and disorder. Results The meta-analysis included 55 publications containing 141 cohort studies. Among men, the pooled relative risk for coronary heart disease was 1.48 for smoking one cigarette per day and 2.04 for 20 cigarettes per day, using all studies, but 1.74 and 2.27 among studies in which the relative risk had been adjusted for multiple confounders. Among women, the pooled relative risks were 1.57 and 2.84 for one and 20 cigarettes per day (or 2.19 and 3.95 using relative risks adjusted for multiple factors). Men who smoked one cigarette per day had 46% of the excess relative risk for smoking 20 cigarettes per day (53% using relative risks adjusted for multiple factors), and women had 31% of the excess risk (38% using relative risks adjusted for multiple factors). For stroke, the pooled relative risks for men were 1.25 and 1.64 for smoking one or 20 cigarettes per day (1.30 and 1.56 using relative risks adjusted for multiple factors). In women, the pooled relative risks were 1.31 and 2.16 for smoking one or 20 cigarettes per day (1.46 and 2.42 using relative risks adjusted for multiple factors). The excess risk for stroke associated with one cigarette per day (in relation to 20 cigarettes per day) was 41% for men and 34% for women (or 64% and 36% using relative risks adjusted for multiple factors). Relative risks were generally higher among women than men. Conclusions Smoking only about one cigarette per day carries a risk of developing coronary heart disease and stroke much greater than expected: around half that for people who smoke 20 per day. No safe level of smoking exists for cardiovascular disease. Smokers should aim to quit instead of cutting down to significantly reduce their risk of these two common major disorders.

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

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

The links between transport and health are well documented, but the extent of these benefits and disbenefits is not widely understood by non-health professionals. Additionally, there are less obvious, indirect ways in which transport and health are linked. This paper provides a broad overview of the literature, compiling empirical evidence that describes, and where possible quantifies, the health effects of transport planning for the reference of transport professionals. The paper makes the case for considering health alongside the environment when assessing a policy or development′s sustainability, and provides empirical evidence to assist transport professionals in considering benefits or disbenefits involved.

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

PurposeGlobally, alcohol use is the leading cause of ill health and life years lost in adolescents, although its clinical impact is often overlooked, particularly in England where most research is based in schools. This study aims to examine the prevalence of alcohol consumption and the association between alcohol consumption and age of onset with health and social consequences among adolescents presenting to emergency departments (EDs). Methods Consecutive attenders (n = 5,576) aged 10–17 years at 10 EDs were included. Information was collected on general health and functioning, quality of life, alcohol use, and alcohol-related health and social consequences. Results Nearly 40% of adolescents reported the consumption of alcohol that was more than a sip in their lifetime. Age of the first alcohol consumption before the age of 15 years was associated with tobacco use (p < .001), lower quality of life (p = .003), and evidence of an alcohol use disorder (p = .002). It was also associated with general social functioning (problems with conduct p = .001 and hyperactivity p = .001) and alcohol-related health and social consequences (accident p = .046, problems with a parent p = .017, school p = .0117, or police p = .012). Conclusions Rates of alcohol consumption in adolescents presenting to the ED were similar to those reported in schools in England and globally. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed. The ED can offer an opportunity for the identification of hazardous alcohol use in adolescents. National Institute for Health Research (NIHR) Programme Grants for Applied Research (RP-PG-0609-10162)

BACKGROUND: Previous studies have shown heavier drinkers are less likely to respond to surveys and require extended efforts to recruit. This study applies the continuum of resistance model to explore how survey estimates of alcohol consumption may be affected by non-response bias in three consecutive years of a general population survey in England.METHODS: Using the Health Survey for England (HSE) survey years 2011-13, number of contact attempts (1-6 and 7+) were explored by socio-demographic and drinking characteristics. The odds of drinking more than various thresholds were modelled using logistic regression. Assuming that non-participants were similar to those who were difficult to contact (the continuum of resistance model), the effect of non-response on measures of drinking was investigated.RESULTS: In the fully-adjusted regression model, women who required 7+ calls were significantly more likely to drink more than the UK Government's recommended daily limit (OR 1.19, 95% CI 1.06-1.33, P = 0.003) and to engage in heavy episodic drinking (OR 1.23, 95% CI 1.07-1.42, P = 0.004), however this was not significant in men in the fully-adjusted model. When the continuum of resistance model was applied, there was an increase in average weekly alcohol consumption of 1.8 units among men (a 12.6% relative increase), and an increase of 1.5 units among women (a 20.5% relative increase). There was also an increase in the prevalence of heavy episodic drinking of 2.5% among men (an 12.0% relative increase) and of 2.0% among women (a 15.8% relative increase), although other measures of drinking were less affected.CONCLUSION: Overall alcohol consumption and the prevalence of heavy episodic drinking were higher among HSE participants who required more extended efforts to contact. The continuum of resistance model suggests non-response bias does affect survey estimates of alcohol consumption.

No abstract available.

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

BACKGROUND ; There is uncertainty over whether maternal smoking is associated with birth defects. We conducted the first ever comprehensive systematic review to establish which specific malformations are associated with smoking. METHODS ; Observational studies published 1959-2010 were identified (Medline), and included if they reported the odds ratio (OR) for having a non-chromosomal birth defect among women who smoked during pregnancy compared with non-smokers. ORs adjusted for potential confounders were extracted (e.g. maternal age and alcohol), otherwise unadjusted estimates were used. One hundred and seventy-two articles were used in the meta-analyses: a total of 173 687 malformed cases and 11 674 332 unaffected controls. RESULTS ; Significant positive associations with maternal smoking were found for: cardiovascular/heart defects [OR 1.09, 95% confidence interval (CI) 1.02-1.17]; musculoskeletal defects (OR 1.16, 95% CI 1.05-1.27); limb reduction defects (OR 1.26, 95% CI 1.15-1.39); missing/extra digits (OR 1.18, 95% CI 0.99-1.41); clubfoot (OR 1.28, 95% CI 1.10-1.47); craniosynostosis (OR 1.33, 95% CI 1.03-1.73); facial defects (OR 1.19, 95% CI 1.06-1.35); eye defects (OR 1.25, 95% CI 1.11-1.40); orofacial clefts (OR 1.28, 95% CI 1.20-1.36); gastrointestinal defects (OR 1.27, 95% CI 1.18-1.36); gastroschisis (OR 1.50, 95% CI 1.28-1.76); anal atresia (OR 1.20, 95% CI 1.06-1.36); hernia (OR 1.40, 95% CI 1.23-1.59); and undescended testes (OR 1.13, 95% CI 1.02-1.25). There was a reduced risk for hypospadias (OR 0.90, 95% CI 0.85-0.95) and skin defects (OR 0.82, 0.75-0.89). For all defects combined the OR was 1.01 (0.96-1.07), due to including defects with a reduced risk and those with no association (including chromosomal defects). CONCLUSIONS ; Birth defects that are positively associated with maternal smoking should now be included in public health educational materials to encourage more women to quit before or during pregnancy.

Most published research utilizes an AUDIT score of8 as the threshold for hazardous drinking. Recent research suggests that this limit should be amended for younger drinkers (aged 18-35 years). This study aimed to explore the effect of a revision to AUDIT cut scores.Applying Foxcroft et al.'s [(2015) Accuracy of Alcohol Use Disorders Identification Test for detecting problem drinking in 18-35 year-olds in England: method comparison study. Alcohol Alcohol 50, 244-50] suggested cut off scores of nine for males and four for females to the most recent Adult Psychiatric Morbidity Survey (2007) data.This more than doubles the prevalence of female hazardous drinkers, and significantly increases the overall rate for that age group when compared with the standard threshold of8.The prevalence of hazardous drinking among females ages 18-30 may be significantly higher than current estimates.

Study objective We adopt a comparative framework to measure the extent to which variance in the efficacy of alcohol brief interventions to reduce hazardous and harmful drinking at less than or equal to 5-, 6-, and 12-month follow-up in emergency department settings can be determined by differences between study populations (targeted injury and noninjury specific). Methods A systematic review and meta-analysis of randomized controlled trials published before September 2016 was undertaken. Twenty-three high-quality and methodologically similar randomized controlled trials were eligible, with a total number of 15,173 participants included. Primary outcome measure was efficacy of brief intervention compared with a control group in reducing quantity of alcohol consumed. An inverse variance model was applied to measure the effect of treatment in standard mean differences for brief intervention and control groups. Results At 6-month follow-up, an effect in favor of brief intervention over control was identified for targeted injury studies (standardized mean difference=–0.10; 95% confidence interval [CI] –0.17 to –0.02; I 2 =0%). For pooled noninjury-specific studies, small benefits of brief intervention were evident at less than or equal to 5-month follow-up (standardized mean difference=–0.15; 95% CI –0.24 to –0.07; I 2 =0%), at 6-month follow–up (standardized mean difference=–0.08; 95% CI –0.14 to –0.01; I 2 =1%), and at 12-month follow-up (standardized mean difference=–0.08; 95% CI –0.15 to –0.01; I 2 =0%). Conclusion Meta-analysis identified noninjury-specific studies as associated with better response to brief intervention than targeted injury studies. However, the inclusion of injured patients with noninjured ones in the experimental and control groups of noninjury-specific studies limited the interpretation of this finding.

Background Under-reporting of alcohol consumption is widespread; surveys typically capture 40-60% of alcohol sales. However the population distribution of under-reporting is not well understood. Methods Mixed-methods study to identify factors associated with under-reporting, using the nationally-representative Health Survey for England (HSE) 2011 (overall response rate 66%). Comparison of retrospective computer-assisted personal interview and seven-day drinking diary (n = 3,774 adults 18+, 50% women, diary response rate 69%) to identify factors associated with diary responses exceeding those of the interview using multivariable linear regression for three outcomes: drinking days in the week recorded, volume consumed on heaviest drinking day in the week recorded, and weekly alcohol consumption. Qualitative semi-structured interviews (n = 10) explored reasons for under-reporting in further detail. Results Number of drinking days was slightly greater in the diary than the interview (P

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

Background Community severance, where transport infrastructure or traffic volume/speed prevents access to goods, services and people, is often mentioned by transport planners but is rarely studied. Severance probably affects travel patterns, social networks, and wellbeing but without measurement tools, this is uncertain. The UCL Street Mobility project is developing a questionnaire to measure community severance and its impacts on individuals in two London case studies. Methods Questionnaire content was informed by a literature search of existing questionnaires. Additional questions were developed with input from community engagement workshops. After cognitive testing and piloting, a random sample of households was selected and invited to answer a self-completion questionnaire (n=100 in Hackney and n=200 in Camden). A mapping exercise was conducted with a subsample of face-to-face interviews in both areas (n=54) to explore neighbourhood boundaries and perceptions in more detail. Results Pilot work in the two case study areas (n=54, 52% women) is complete. Half the pilot sample was aged 55+; a minority lived alone (24%). and The mapping exercise showed that neighbourhood boundaries occasionally followed the main road, but were primarily drawn to include places frequently visited in day-to-day routines. Most participants reported their health was good or very good (75%) and did not have a disability that affected their ability to get around their area (79%). Nevertheless, the majority (62%) experienced problems getting around their local area: busy road or danger from traffic (37%), noise or air pollution (27%), and fear of crime (24%). When asked about their ability to walk to places, 45% reported the volume of traffic and 37% reported speed of traffic as problems. Participants commonly avoided the busiest road near their home (39% answered ‘yes’ or ‘yes, when I can’). Participants knew more neighbours on their side of their road (mean 6.6, SD 1.1) than on the opposite side (3.1 (0.82)) (p=0.002). Those who reported difficulties getting around their area saw and spoke to their neighbours less often than those without difficulties, however this was not statistically significant in our pilot sample. Recruitment is ongoing for the full sample (Jan 2015); we will report findings based on 300 participants across the two case studies. Conclusions In our community severance case studies, participants frequently reported problems getting around their local area. These particularly related to road traffic or its consequences (e.g. pollution). In our larger sample, we will investigate associations with social networks and wellbeing in detail.

Background The Warwick-Edinburgh Mental Well-being scale (WEMWBS), a set of 14 positive worded statements, has been validated as an instrument to measure mental wellbeing on a population level. A shorter, seven-item version (SWEMWBS) was developed after applying the Rasch measurement model, however little is known on how SWEMWBS is distributed in the population, and how well it performs as an instrument to measure wellbeing. Using data from nationally-representative samples, we computed age- and sex-specific norms for the SWEMWBS for use in interpreting individual- and group-scores, and examined relative- and criterion-validity. Methods Based on adults aged 16+ from The Health Survey for England 2010–13 (n = 27,169), four nationally representative surveys of the population living in private households, age- and sex-specific norms were estimated using means and percentiles. Criterion-validity was examined using: (1) Spearman correlations (ρ) for SWEMWBS versus instruments expected to be correlated with wellbeing (e.g. General Health Questionnaire (GHQ-12), Happiness Index, EQ-5D), and (2) a multinomial logit model with SWEMWBS (grouped into low, medium, and high wellbeing) as the outcome variable and the following explanatory variables: sex, age, general health, marital status, ethnicity, education, income, body mass index, fruit and vegetable intake, alcohol consumption on the heaviest drinking day, and smoking status. Relative validity was examined by comparing SWEMWBS with WEMWBS using: (1) Spearman correlations (continuous data), and (2) the weighted Kappa statistic (categorical), within population sub-groups. Results Mean (median) SWEMWBS was 23.7 (23.2) for men and 23.2 (23.2) for women (p Conclusion SWEMWBS distinguishes wellbeing between groups, similarly to WEMWBS. SWEMWBS can be used to measure wellbeing where there are time and resource constraints.

Background Motorised traffic inhibits walking, with possible effects on physical exercise, social contacts, and access to services, and ultimately on people’s health and wellbeing. Road traffic may also lead pedestrians to engage in risky behaviours. This paper analyses pedestrian flows and behaviour in relation to the characteristics of roads and traffic in two areas in London. The work is part of the Street Mobility and Network Accessibility project to develop tools to overcome barriers to walking among older people. Methods Video surveys were used to observe pedestrians walking along the main road and side streets and crossing at formal and informal points during the day. The information gathered on pedestrian flows and behaviour was then related to motorised traffic levels, the results of an audit of the street environment, the estimated shortest routes to major local destinations, and data on passengers boarding and alighting buses. Results The Woodberry Down area is surrounded by roads and canals and is divided by a busy road with few formal crossings. The results show that pedestrian flows in the main road are lower than in parallel streets and that the propensity to cross (overall and informally) and the share of people with mobility restrictions in the total flow correlate negatively with hourly traffic levels. Flows were lower in streets with poorer walking environment and away from the main routes to bus stops. Several types of risky behaviour were observed near bus stops, including crossing the road at a shallow angle or in-between stopped traffic, walking along the road’s central reservation, and changing speed or path while crossing. The Finchley Road area is split by a busy road with guard rails separating pedestrian pavements from the carriageway. Walking and crossing flows are much higher in the main road than in side streets and correlate positively with traffic levels. The proportion of pedestrians walking along one side of the main road and the propensity to cross the road seem to be related to the location of destinations (supermarkets and underground stations) rather than characteristics of traffic and street environment. Risky behaviours were observed in signalised crossings, with a large proportion of pedestrians crossing during the red phase. Conclusions The differences in the results in the two areas suggest that the impact of busy roads on pedestrian flows and behaviour depends on local aspects such as land use, street layout, and crossing facilities, so the health impacts may also vary.

Introduction Metabolic syndrome (MetS) is defined as a cluster of risk factors for cardiovascular disease and type II diabetes which occur together and include hyperglycaemia, hypertension, raised triglyceride levels, low HDL levels and central obesity. The The aim of the study was to evaluate the association between MetS and colorectal cancer. A meta-analysis was performed on the studies that investigated the association between MetS and CRC. Methods Medline/PubMed and Embase were searched for all articles published in English language related to MetS and CRC using the PRISMA guidelines. Articles published between 1965 and 2011 were reviewed to identify studies that reported the association of MetS, or syndromes that were indicative of the present day definition of MetS and CRC. There were 445 articles identified from the literature. A total of 374 abstracts were reviewed (by MA-W and AS) and 71 papers were examined. Results The studies included 739,231 participants, which included 395,572 males and 337,756 females. This involved 11,769 cases of CRC. Significant associations between MetS and CRC were observed. Based on 14 studies, the overall OR for CRC incidence or mortality in MetS in both genders is 1.51, with a 95% C.I of 1.32 to 1.73 (p Conclusion This meta-analysis suggests a significant effect of metabolic syndrome on colorectal cancer, and emphasizes the importance of preventing and controlling MetS components; CRC is a disease to some extent preventable with changes in lifestyle and dietary habits. Malignancy itself may be the factor causing effects on lipids, so further confounding the influence of MetS, which has both systemic and hormonal effects in cancer pathogenesis. The exact mechanism how MetS relates to CRC pathophysiology is yet to be clarified and we suspect that MetS is more likely to precede the diagnosis of CRC. Therefore, understanding the pathophysiology of MetS would enable the development of therapeutic and preventative strategies in relation to the CRC, which could be made at a personalised level through, identify individuals more at risk.

Background Under-reporting of alcohol consumption is widespread: surveys typically capture only 40-60% of alcohol sales. Little is known about the population distribution of under-reporting. Methods This study uses mixed methods to identify social, demographic, and alcohol-related ‘risk factors’ for under-reporting, using the nationally-representative Health Survey for England (HSE) 2011. Two methods of measuring alcohol consumption were used: a retrospective computer-assisted personal interview (CAPI), and a seven-day drinking diary (n = 5,040 adults, 55% women). Predictors of an individual’s diary being greater than the CAPI were identified using multivariate linear regression. Three outcomes were investigated: drinking days in the week recorded, heaviest drinking day in the week recorded (in UK units), and weekly alcohol consumption (in UK units). Qualitative semi-structured interviews (n = 10) were conducted with HSE 2011 participants who completed the drinking diary in participants’ homes or workplaces. Emergent themes were identified to reveal additional ‘risk factors’ for under-reporting. Results Number of drinking days was similar in the diary and the CAPI. The diary estimates were higher than those of the CAPI for heaviest drinking day in the week recorded (0.7 units greater among men, 0.8 units among women), and weekly alcohol consumption (2.9 units greater among men, 3.0 units among women). Unfortunately, the results from the quantitative study are embargoed until the HSE 2011 dataset is deposited in the UK Data Archive in spring 2013. I am happy to update this section once the embargo has been lifted. The qualitative interviews identified having a non-routine drinking pattern, perception of the self as a less frequent drinker, and usually tracking drinking using qualitative approaches as being linked to experiencing surprise at the diary. Conclusion Heavier drinking and more ‘chaotic’ drinking patterns may be associated with under-reporting of alcohol consumption. Estimates of the prevalence of drinking above the recommended levels, hazardous levels, or even harmful levels that are based on self-reported consumption may be disproportionately under-estimated.

This commentary about alcohol marketing regulation in the UK draws on a conference held by the Institute of Alcohol Studies, highlighting a need for policy interventions to prevent harm and improve public health. Hazardous and harmful alcohol use is associated with many health conditions, wider social consequences, and harms to others. Following no improvement in alcohol mortality rates in the past decade, 2020 saw alcohol-specific deaths rise to record levels in the UK. Bans or comprehensive restrictions on alcohol advertising across multiple types of media are listed by the World Health Organization (WHO) as one of the ‘best buy’ policies to reduce alcohol harm. The UK’s current complaints-led self-regulatory approach fails to protect consumers and vulnerable groups from being exposed to influential alcohol marketing. There are few meaningful sanctions to deter brands and companies from violating existing codes, processes are retrospective, reactive and slow, and the codes fail in their stated aim of protecting young people. Other important impacts on heavier drinkers and those in recovery, as well as on gender and health equity, are also inadequately addressed. Innovation is also urgently needed to effectively regulate ever-evolving digital alcohol marketing. Addressing these issues through a combination of comprehensive restrictions, content controls, labelling, and replacing self-regulation with an independent body will benefit public health as well as protecting the vulnerable, including heavier drinkers, people in recovery, and children and young people.