Showing papers in "Addiction in 2005"

Outcome criteria in smoking cessation trials: proposal for a common standard

Abstract: Smoking cessation treatment is now integrated into many health-care systems and a major research effort is under way to improve current success rates. Until now results from randomized clinical trials have been reported in many different ways, leading to problems of interpretation. We propose six standard criteria comprising the 'Russell Standard' (RS). These criteria are applicable to trials of cessation aids where participants have a defined target quit date and there is face-to-face contact with researchers or clinic staff, as follows. (1) Follow-up for 6 months (RS6) or 12 months (RS12) from the target quit date or the end of a predefined 'grace period'; (2) self-report of smoking abstinence over the whole follow-up period allowing up to five cigarettes in total; (3) biochemical verification of abstinence at least at the 6-month or 12-month follow-up point; (4) use of an 'intention-to-treat' approach in which data from all randomized smokers are included in the analysis unless they have died or moved to an untraceable address (participants who are included in the analysis are counted as smokers if their smoking status at the final follow-up cannot be determined); (5) following-up 'protocol violators' and using their true smoking status in the analysis; and (6) collecting follow-up data blind to smokers' allocation to trial group. We believe that these criteria provide the best compromise between practicability and surrogacy for long-term cessation and will enable meaningful comparison between studies. There may be good reasons why other outcome criteria would also be reported, and studies that involve interventions with special groups or where there is no designated target quit date or face to face contact would need to adapt these criteria accordingly.

Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey

Abstract: Aims To examine the prevalence rates and correlates of non-medical use of prescription stimulants (Ritalin, Dexedrine or Adderall) among US college students in terms of student and college characteristics. Design A self-administered mail survey. Setting One hundred and nineteen nationally representative 4-year colleges in the United States. Participants A representative sample of 10 904 randomly selected college students in 2001. Measurements Self-reports of non-medical use of prescription stimulants and other substance use behaviors. Findings The life-time prevalence of non-medical prescription stimulant use was 6.9%, past year prevalence was 4.1% and past month prevalence was 2.1%. Past year rates of non-medical use ranged from zero to 25% at individual colleges. Multivariate regression analyses indicated non-medical use was higher among college students who were male, white, members of fraternities and sororities and earned lower grade point averages. Rates were higher at colleges located in the north-eastern region of the US and colleges with more competitive admission standards. Non-medical prescription stimulant users were more likely to report use of alcohol, cigarettes, marijuana, ecstasy, cocaine and other risky behaviors. Conclusions The findings of the present study provide evidence that nonmedical use of prescription stimulants is more prevalent among particular subgroups of US college students and types of colleges. The non-medical use of prescription stimulants represents a high-risk behavior that should be monitored further and intervention efforts are needed to curb this form of drug use.

Time for a change: putting the Transtheoretical (Stages of Change) Model to rest

Abstract: The Transtheoretical Model of behaviour change, known to many as the Stages of Change (SOC) model, states that with regard to chronic behaviour patterns such as smoking, individuals can be characterized as belonging to one of five or six ‘stages’ (Prochaska et al . 1985; Prochaska & Goldstein 1991; Prochaska & Velicer 1997). Stage definitions vary from behaviour to behaviour and across different versions of the model but in the case of smoking: ‘precontemplation’ involves an individual not thinking about stopping for at least 6 months; ‘contemplation’ involves an individual planning to stop between 31 days and 6 months, or less than 31 days if they have not tried to quit for 24 hours in the past year; ‘preparation’ involves the individual having tried to stop for 24 hours in the past year and planning to stop within 30 days (it has been accepted by the proponents of the model that having tried to stop should perhaps be dropped from this stage definition); ‘action’ involves the individual having stopped for between 0 and 6 months; ‘maintenance’ involves the individual having stopped for more than 6 months. In some versions of the model there is also a ‘termination’ stage in which the individual has permanently adopted the new behaviour pattern. The model further proposes that individuals progress through stages sequentially but usually revert to prior stages before achieving maintenance and then termination (Prochaska & Velicer 1997). The model also proposes that different self-change strategies (the so-called ‘processes of change’) are involved in moving between different stages (Prochaska & Velicer 1997) and that the different stages are associated with different beliefs (assessment of the ‘pros’ and ‘cons’ of the behaviour and self-confidence in ability to change the behaviour). It argues that interventions to promote change should be designed so that they are appropriate to an individual’s current stage (Prochaska & Goldstein 1991). Moving an individual from one stage to another is purported to be a worthwhile goal because it will increase the likelihood that this person will subsequently achieve the termination stage (Prochaska & Goldstein 1991). Proponents of the model have argued that the model has revolutionized health promotion, claiming that interventions that are tailored to the particular stage of the individual improve their effectiveness (Prochaska & Velicer 1997) (for a readily accessible outline of the model and the assessment tools that accompany it see: http://www.uri.edu/ research/cprc/transtheoretical.htm). There are serious problems with the model, many of which have been well articulated (Etter & Perneger 1999; Bunton et al . 2000; Whitelaw et al . 2000; Sutton 2001; Etter & Sutton 2002; Littell & Girvin 2002). However, its popularity continues largely unabated. This editorial does not seek to revisit the plethora of empirical evidence and conceptual analysis that has been ranged against the model. It simply argues that the problems with the model are so serious that it has held back advances in the field of health promotion and, despite its intuitive appeal to many practitioners, it should be discarded. It is now time for a change. A replacement is needed that more accurately reflects observations about behaviour change, is internally consistent, and generates useful ideas and predictions. It needs to provide a way of describing how people can change with apparent suddenness, even in response to small triggers. It needs to be a stimulus to research that will go beyond a simplistic decision-making model of behaviour and produce genuinely novel insights. However, even in the absence of a new theory, simply reverting to the common sense approach that was used prior to the Transtheoretical Model would better than staying with the model. In that approach people were asked simply about desire to change and ability to change and it was recognized that these were affected by a range of personal and situational factors including addiction. This editorial draws primarily from research in smoking. It is in this area that the model was first developed and where much of the research relating to it has been carried out. To give some idea of the extent of the dominance of smoking, of 540 articles found in PubMed using the search phrase ‘stages of change’, 174 also had ‘smoking’ in the abstract or title, 60 had ‘alcohol’, seven had cocaine, two had ‘heroin’ or ‘opiate’ and one had ‘gambling’.

Recovery from DSM-IV alcohol dependence: United States, 2001-2002.

Abstract: Aims To investigate the prevalence and correlates of recovery from Diagnostic and Statistical Manual version IV (DSM-IV) alcohol dependence by examining the past-year status of individuals who met the criteria for prior-to-past-year (PPY) dependence. Design Cross-sectional, retrospective survey of a nationally representative sample of US adults 18 years of age and over (first wave of a planned longitudinal survey). Methods This analysis is based on data from the 2001–02 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), in which data were collected in personal interviews conducted with one randomly selected adult in each sample household. A subset of the NESARC sample (total n = 43 093), consisting of 4422 US adults 18 years of age and over classified with PPY DSM-IV alcohol dependence, were evaluated with respect to their past-year recovery status: past-year dependence, partial remission, full remission, asymptomatic risk drinking, abstinent recovery (AR) and non-abstinent recovery (NR). Correlates of past-year status were examined in bivariate analyses and using multivariate logistic regression models. Findings Of people classified with PPY alcohol dependence, 25.0% were still classified as dependent in the past year; 27.3% were classified as being in partial remission; 11.8% were asymptomatic risk drinkers who demonstrated a pattern of drinking that put them at risk of relapse; 17.7% were low-risk drinkers; and 18.2% were abstainers. Only 25.5% of people with PPY dependence ever received treatment. Being married was associated positively with the odds of both AR and NR, and ethanol intake was negatively associated with both. Severity of dependence increased the odds of AR but decreased the odds of NR. The odds of AR (but not NR) increased with age and female gender but were decreased by the presence of a personality disorder. Treatment history modified the effects of college attendance/graduation, age at onset and interval since onset on the odds of recovery. Conclusions There is a substantial level of recovery from alcohol dependence. Information on factors associated with recovery may be useful in targeting appropriate treatment modalities.

The role of the therapeutic alliance in the treatment of substance misuse: a critical review of the literature.

Abstract: Background - In the past two decades, a number of studies investigating the role of the therapeutic alliance in drug treatment have been published and it is timely that their findings are brought together in a comprehensive review. Aims - This paper has two principal aims: (1) to assess the degree to which the relationship between drug user and counsellor predicts treatment outcome and (2) to examine critically the evidence on determinants of the quality of the alliance. Methods - Peer-reviewed research located through the literature databases Medline, PsycInfo and Ovid Full Text Mental Health Journals using predefined search-terms and published in the past 20 years is considered. Further papers were identified from the bibliographies of relevant publications. Findings - A key finding is that the early therapeutic alliance appears to be a consistent predictor of engagement and retention in drug treatment. With regard to other treatment outcomes, the early alliance appears to influence early improvements during treatment, but it is an inconsistent predictor of post-treatment outcomes. There is relatively little research on the determinants of the alliance. In studies that are available, clients' demographic or diagnostic pre-treatment characteristics did not appear to predict the therapeutic alliance, whereas modest but consistent relationships were reported for motivation, treatment readiness and positive previous treatment experiences. Conclusions - The therapeutic alliance plays an important role in predicting drug treatment process outcomes, but too little is known about what determines the quality of the relationship between drug users and counsellors.

Age of onset of drinking and the use of alcohol in adulthood: a follow‐up study from age 8–42 for females and males

Abstract: Aim To investigate longitudinally for both genders the relation between the age of onset of drinking and several indicators of alcohol use. Design and setting In the Finnish Jyvaskyla Longitudinal Study of Personality and Social Development, data have been collected by interviews, inventories, and questionnaires. Data on alcohol consumption was gathered at ages 14, 20, 27, 36 and 42 years; behavioural data at age 8. Participants A total of 155 women and 176 men; 90.4% of the original sample consisting of 12 complete school classes in 1968. Measurements The age of onset of drinking was determined based on participants’ responses that were closest to the actual age of onset of drinking. Four indicators of the adult use of alcohol were used: frequency of drinking, binge drinking, Cut-down, Annoyed, Guilt, Eye-opener (CAGE) and Malmo modified Michigan Alcoholism Screening Test (Mm-MAST). Socio-emotional behaviour at age 8 was assessed using teacher ratings and peer nominations. Findings Early onset of drinking was related to the four indicators of the use of alcohol in adulthood both in men and women. The level of adult alcohol use and alcohol problems was significantly higher in men. The risk for heavy drinking was highest in men and women if drinking was started at less than age 16 years. Socio-emotional behaviour and school success at age 8 did not predict the age of onset of drinking. Conclusions Delaying the initiation of drinking from early adolescence to late adolescence is an important goal for prevention efforts. No clear risk group for early initiators of drinking could be identified on the basis of preceding behaviour among 8-year-olds.

Gender differences in drinking: why do they still exist?

Abstract: Aims The paper discusses the kinds of reasoning that have been presented as possible mechanisms and reasons for gender differences in alcohol consumption. Design and methods An overview of the existing literature from different countries is presented. Findings The existing studies provide a picture of great cultural variance in patterns of alcohol use among men and women. The gender differences in drinking behaviour have been shown to be linked with many aspects of biological differences between men and women leading to women's greater vulnerability to alcohol, of women's and men's differing needs, reasons and motivations in relation to drinking, of gender-specific roles in other areas of life and of ways in which societies regulate peoples’ behaviour, often giving women the role of warden or moderator of others’ drinking. Conclusions The gender differences in drinking behaviour continue to be considerable and are found in all cultures studied so far. Several studies have argued for reasons underlying these differences, but they still remain largely unexplained.

The English smoking treatment services: one‐year outcomes

Abstract: Aims To assess the impact of English treatment services on CO-validated quit rates at 52-week follow-up, to explore the relationship between service-related characteristics and socio-demographic and behavioural factors with cessation outcomes, and to compare the characteristics of service users lost to follow-up with CO-validated quitters. Design Observational study of administrative information linked with survey data for 2069 recipients of smoking treatment services who set a quit date between May and November 2002. Setting Two contrasting areas of England, Nottingham and North Cumbria, consisting of nine primary care trust (PCT) localities. Measurements Routine monitoring data specified by the Department of Health included information about basic demographic characteristics, postcode of residence from which a deprivation category was identified, nature of intervention, and smoking status at 4-week follow-up. These data were supplemented with information about smoking status at 52 weeks, referral pathways, relapse experiences, number of follow-up contact attempts, socio-economic status and smoking-related behaviours obtained from consenting service recipients by treatment advisers. Findings One user in seven (14.6%) reported prolonged abstinence and was CO-validated as a successful quitter at 52 weeks. This rose to 17.7% when self-report cases were included. Relapse rates between 4 and 52 weeks were almost identical between the two study areas—75%. Relapse was most likely to occur in the first 6 months following treatment. Users who self-reported quitting at 4 weeks were less likely (13.7%) than those with biochemical verification of smoking status at 4 weeks (25.2%) to be CO-validated quitters at 52 weeks (P = 0.004). Older users (OR 1.023; CI 1.014–1.032), people who smoke mainly for pleasure rather than to cope (OR 1.38; CI 1.02–1.87), and those who were extremely determined (OR 1.58; CI 1.21–2.05) were more likely to be quitters at 52-week follow-up, whereas those with lower socio-economic status (OR 0.86; CI 0.78–0.96), who smoked their first cigarette of the day within 5 minutes of waking (OR 0.73; CI 0.55–0.96) or had another smoker in their household (OR 0.65; CI 0.49–0.86) were less likely. In contrast, users lost to follow-up tended to be younger and experienced different referral pathways than CO-validated quitters. Gender was not statistically significantly associated with cessation at 52 weeks and nor were any of the key characteristics of intervention, such as group or one-to-one counselling. Conclusions These results obtained from routine services are consistent with those obtained from clinical trials in relation to abstinence at one year. Given that a high proportion of smokers relapsed between 4 weeks and 1 year it is important that future assessments of longer-term outcomes are conducted. However, following-up service users many months after an intervention is expensive, and reasonable estimates of quit rates can be estimated from short-term outcomes, provided that they have been CO-validated. Future studies should monitor outcomes from a selection of services treating different groups of smokers, particularly if more is to be learned about the role of smoking treatment services in reducing inequalities in health.

Reconsidering the evaluation of addiction treatment: From retrospective follow-up to concurrent recovery monitoring.

Abstract: Historically, addiction treatments have been delivered and evaluated under an acute-care format. Fixed amounts or durations of treatment have been provided and their effects evaluated 6-12 months after completion of care. The explicit expectation of treatment has been enduring reductions in substance use, improved personal health and social function, generally referred to as 'recovery'. In contrast, treatments for chronic illnesses such as diabetes, hypertension and asthma have been provided for indeterminate periods and their effects evaluated during the course of those treatments. Here the expectations are for most of the same results, but only during the course of continuing care and monitoring. The many similarities between addiction and mainstream chronic illnesses stand in contrast to the differences in the ways addiction is conceptualized, treated and evaluated. This paper builds upon established methods of during-treatment evaluation developed for the treatment of other chronic illnesses and suggests a parallel evaluation system for out-patient, continuing-care forms of addiction treatment. The suggested system retains traditional patient-level, behavioral outcome measures of recovery, but suggests that these outcomes should be collected and reported immediately and regularly by clinicians at the beginning of addiction treatment sessions, as a way of evaluating recovery progress and making decisions about continuing care. We refer to this paradigm as 'concurrent recovery monitoring' and discuss its potential for producing more timely, efficient, clinically relevant and accountable evaluations.

The nature, time course and severity of methamphetamine withdrawal.

Abstract: Aims To characterize the natural history of methamphetamine withdrawal during the first 3 weeks of abstinence. Design Cross-sectional study with comparison group. Setting A substance use treatment facility in Chiang Mai Province, Thailand. Participants The sample comprised 21 in-patients undergoing treatment for methamphetamine dependence. Nine age- and sex-matched non-dependent individuals provided comparison data. Measurements Instruments including: the Amphetamine Withdrawal Ques- tionnaire, a modified version of the Cocaine Selective Severity Assessment, Clin- ical Global Impression scale and the St Mary's Hospital Sleep Questionnaire were completed daily for the first 3 weeks of abstinence. Findings Methamphetamine withdrawal severity declined from a high initial peak within 24 hours of the last use of amphetamines reducing to near control levels by the end of the first week of abstinence (the acute phase). The acute phase of amphetamine withdrawal was characterized by increased sleeping and eating, a cluster of depression-related symptoms and less severely, anxiety and craving-related symptoms. Following the acute withdrawal phase most with- drawal symptoms remained stable and at low levels for the remaining 2 weeks of abstinence. Conclusions This study has provided evidence of a methamphetamine with- drawal syndrome that can be categorized into two phases, the acute phase last- ing 7-10 days during which overall symptom severity declined in a linear pattern from a high initial peak, and a subacute phase lasting at least a further 2 weeks.

Electronic gaming machines: are they the 'crack-cocaine' of gambling?

Abstract: BACKGROUND: There is a general view that electronic gaming is the most 'addictive' form of gambling, in that it contributes more to causing problem gambling than any other gambling activity. As such, electronic gaming machines have been referred to as the 'crack-cocaine' of gambling. While this analogy has popular appeal, it is only recently that the scientific community has begun to investigate its validity. In line with the belief that electronic gambling has a higher 'addictive' potential than other forms of gambling, research has also begun to focus on identifying the characteristics of gaming machines that may be associated with problem gambling behaviour. AIMS AND METHODS: Aims and methods This paper will review the different types of modern electronic gaming machines, and will use the introduction of gaming machines to Australia to examine the association between electronic gaming and problem gambling, with particular reference to the characteristics of modern electronic gaming machines. FINDINGS AND CONCLUSIONS: Despite overwhelming acceptance that gaming machines are associated with the highest level of problem gambling, the empirical literature provides inconclusive evidence to support the analogy likening electronic gaming to 'crack-cocaine'. Rigorous and systematic evaluation is required to establish definitively the absolute 'addictive' potential of gaming machines and the degree to which machine characteristics influence the development and maintenance of problem gambling behaviour.

Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence.

Abstract: Aims To examine the risk posed by cannabis use in young people for tobacco use disorders. Specifically we examined whether cannabis use in non-smokers predicted later initiation of tobacco use and whether cannabis use predicted later nicotine dependence in tobacco users. Design A 10-year eight-wave cohort study. Setting State of Victoria, Australia. Participants A community sample of 1943 participants initially aged 14-15 years. Measurements Self-report of tobacco and cannabis use was assessed in the teens using a computerized interview assessment and in young adulthood with a CATI assessment. The Fagerstrom Test for Nicotine Dependence was used to define nicotine dependence. Findings For teen non-smokers, at least one report of weekly cannabis use in the teens predicted a more than eightfold increase in the odds of later initiation of tobacco use (OR 8.3; 95% CI 1.9-36). For 21-year-old smokers, not yet nicotine-dependent, daily cannabis use raised the odds of nicotine dependence at the age of 24 years more than threefold (OR 3.6, 1.2, 10) after controlling for possible confounders, including level of tobacco use and subsyndromal signs of nicotine dependence. Conclusions Weekly or more cannabis use during the teens and young adulthood is associated with an increased risk of late initiation of tobacco use and progression to nicotine dependence. If this effect is causal, it may be that a heightened risk of nicotine dependence is the most important health consequence of early frequent cannabis use.

The role of alcohol-specific socialization in adolescents' drinking behaviour.

Abstract: Aims To determine which alcohol-specific socialization practices are related to adolescents' alcohol use, and to investigate whether parents differ in their alcohol-specific socialization towards their children. Design In a sample of 428 families, both parents and two adolescents (aged 13-16 years) completed a questionnaire at home about alcohol-specific parenting and their own alcohol use. Based on the reports of each family member, three different models of alcohol-specific socialization were formulated: from the perspective of the siblings, the mother and the father. Findings Results of structural equation modelling generally showed the same associations between alcohol-specific socialization and drinking of younger and older adolescents. The strongest association was found for providing alcohol-specific rules. Applying strict rules about alcohol use was negatively related to adolescents' alcohol use; this was also the case for having confidence in the effectiveness of alcohol-specific socialization. Unexpectedly, frequency of communication about alcohol issues was positively associated with alcohol consumption of adolescents. Conclusions This study is one of the first to examine associations between alcohol-specific socialization and adolescents' drinking using a between- and a within-family design. Results showed strong associations between alcohol-specific socialization (particularly of enforcing rules) and adolescent alcohol use. Although parents strongly differentiated their socialization practices between children, no differences in associations between alcohol-specific socialization and drinking were found between older and younger adolescents.

Does alcohol advertising promote adolescent drinking? Results from a longitudinal assessment

Abstract: Aims To examine the relationship between exposure to different forms of alcohol advertising and subsequent drinking among US adolescents and assess whether exposure to an alcohol and drug prevention program mitigates any such relationship. Design Regression models with multiple control variables examined the relationship between exposure to alcohol advertising in grade 8 and grade 9 drinking for two groups of South Dakotan adolescents: (1) seventh-grade non-drinkers (n = 1206) and (2) seventh-grade drinkers (n = 1905). Interactions between the intervention program and the significant advertising predictors were tested. Setting Forty-one middle schools in South Dakota, USA. Participants A total of 3111 seventh-graders followed through grade 9. Measurements Advertising variables were constructed for four types of alcohol advertising—television, in-store displays, magazines and concession stands. Other predictors tested included measures tapping social influences, social bonds, problem behavior, alcohol beliefs, television exposure and demographics. Findings For seventh-grade non-drinkers, exposure to in-store beer displays predicted drinking onset by grade 9; for seventh-grade drinkers, exposure to magazines with alcohol advertisements and to beer concession stands at sports or music events predicted frequency of grade 9 drinking. Although exposure to television beer advertising had a significant bivariate relationship with alcohol use for grade 7 non-drinkers, it was not a significant predictor of drinking for either group in multivariate analyses. Participation in the prevention program, ALERT Plus, reduced future drinking for both groups and counteracted the effect of in-store beer displays. Conclusions Several forms of alcohol advertising predict adolescent drinking; which sources dominate depends on the child's prior experience with alcohol. Alcohol prevention programs and policies should help children counter alcohol advertising from multiple sources and limit exposure to these sources.

Randomized controlled trial of a web-based computer-tailored smoking cessation program as a supplement to nicotine patch therapy

Abstract: Aim To assess the efficacy of World Wide Web-based tailored behavioral smoking cessation materials among nicotine patch users. Design Two-group randomized controlled trial. Setting World Wide Web in England and Republic of Ireland. Participants A total of 3971 subjects who purchased a particular brand of nicotine patch and logged-on to use a free web-based behavioral support program. Intervention Web-based tailored behavioral smoking cessation materials or web-based non-tailored materials. Measurements Twenty-eight-day continuous abstinence rates were assessed by internet-based survey at 6-week follow-up and 10-week continuous rates at 12-week follow-up. Findings Using three approaches to the analyses of 6- and 12-week outcomes, participants in the tailored condition reported clinically and statistically significantly higher continuous abstinence rates than participants in the nontailored condition. In our primary analyses using as a denominator all subjects who logged-on to the treatment site at least once, continuous abstinence rates at 6 weeks were 29.0% in the tailored condition versus 23.9% in the nontailored condition (OR = 1.30; P = 0.0006); at 12 weeks continuous abstinence rates were 22.8% versus 18.1%, respectively (OR = 1.34; P = 0.0006). Moreover, satisfaction with the program was significantly higher in the tailored than in the non-tailored condition. Conclusions The results of this study demonstrate a benefit of the web-based tailored behavioral support materials used in conjunction with nicotine replacement therapy. A web-based program that collects relevant information from users and tailors the intervention to their specific needs had significant advantages over a web-based non-tailored cessation program.

General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review.

Abstract: Objective To estimate the proportion of general practitioners (GPs) and family physicians (FPs) with negative beliefs and attitudes towards discussing smoking cessation with patients. Methods A systematic review. Study selection All studies published in English, in peer-reviewed journals, which allowed the extraction of the proportion of GPs and FPs with negative beliefs and attitudes towards discussing smoking cessation. Data synthesis Negative beliefs and attitudes were extracted and categorised. Proportions were synthesized giving greater weight to those obtained from studies with larger samples. Those assessed in two or more studies are reported. Results Across 19 studies, eight negative beliefs and attitudes were identified. While the majority of GPs and FPs do not have negative beliefs and attitudes towards discussing smoking with their patients, a sizeable minority do. The most common negative beliefs were that such discussions were too timeconsuming (weighted proportion: 42%) and were ineffective (38%). Just over a quarter (22%) of physicians reported lacking confidence in their ability to discuss smoking with their patients, 18% felt such discussions were unpleasant, 16% lacked confidence in their knowledge, and relatively few considered discussing smoking outside of their professional duty (5%), or that this intruded upon patients’ privacy (5%), or that such discussion were inappropriate (3%). Conclusions In addition to providing skills training, interventions designed to increase the implementation of smoking cessation interventions by primary care physicians may be more effective if they address a range of commonly held negative beliefs and attitudes towards discussing smoking cessation. These include beliefs and values that influence primary care physicians’ judgements about whether discussing smoking is an effective use of their time.

Tests of causal linkages between cannabis use and psychotic symptoms.

Abstract: Aim To examine possible causal linkages between cannabis use and psychosis using data gathered over the course of a 25-year longitudinal study. Design A 25-year longitudinal study of the health, development and adjustment of a birth cohort of 1265 New Zealand children (635 males, 630 females). Setting The Christchurch Health and Development Study, a general community sample. Participants A total of 1055 participants from the Christchurch Health and Development Study (CHDS) cohort for whom data on cannabis use and psychotic symptoms were available on at least one occasion from 18, 21 and 25 years. Measurements As part of this study, data were gathered on frequency of cannabis use and psychotic symptoms at ages 18, 21 and 25 years. Findings Regression models adjusting for observed and non-observed confounding suggested that daily users of cannabis had rates of psychotic symptoms that were between 1.6 and 1.8 times higher ( P < 0.001) than non-users of cannabis. Structural equation modelling suggested that these associations reflected the effects of cannabis use on symptom levels rather than the effects of symptom levels on cannabis use. Conclusions The results of the present study add to a growing body of evidence suggesting that regular cannabis use may increase risks of psychosis. The present study suggests that: (a) the association between cannabis use and psychotic symptoms is unlikely to be due to confounding factors; and (b) the direction of causality is from cannabis use to psychotic symptoms.

Alcohol and intimate partner violence: when can we say that heavy drinking is a contributing cause of violence?

Abstract: s of these reports will be available at 0500 UTC Monday by visiting: http://www.safetylit.org Alcohol and Other Drugs: Accidents in the workplace caused by alcohol intoxication. Rygol K, Kabiesz-Neniczka S, Olszowy Z. Arch Med Sadowej Kryminol 2004; 54(4): 234-41. Alcohol and intimate partner violence: when can we say that heavy drinking is a contributing cause of violence? Leonard KE. Addiction 2005; 100(4): 422-5. Alcohol consumption and intimate partner violence by alcoholic men: comparing violent and nonviolent conflicts. Murphy CM, Winters J, O'farrell TJ, Fals-Stewart W, Murphy M. Psychol Addict Behav 2005; 19(1): 3542. Are educational aspirations associated with the risk of alcohol use and alcohol use-related problems among adolescents? Crum RM, Storr CL, Anthony JC. Subst Use Misuse 2005; 40(2): 151-69. Drug use and the severity of a traffic accident. Smink BE, Ruiter B, Lusthof KJ, Gier JJ, Uges DR, Egberts AC. Accid Anal Prev 2005; 37(3): 427-33. Drunk driving in Belgium: results from the third and improved roadside survey. Vanlaar W. Accid Anal Prev 2005; 37(3): 391-7. Elementary school drinking: the role of temperament and learning. Anderson KG, Smith GT, McCarthy DM, Fischer SF, Fister S, Grodin D, Boerner LM, Hill KK. Psychol Addict Behav 2005; 19(1): 21-7.

Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection.

Abstract: Aims To examine the long-term impact of methadone maintenance treatment (MMT) on mortality, re-incarceration and hepatitis C seroconversion in imprisoned male heroin users. Design, setting and participants The study cohort comprised 382 imprisoned male heroin users who had participated in a randomized controlled trial of prison-based MMT in 1997/98. Subjects were followed-up between 1998 and 2002 either in the general community or in prison. Measurements All-cause mortality, re-incarceration, hepatitis C and HIV serostatus and MMT retention. Findings There were no deaths recorded while subjects were enrolled in MMT. Seventeen subjects died while out of MMT, representing an untreated mortality rate of 2.0 per 100 person-years (95% CI, 1.2‐3.2). Re-incarceration risk was lowest during MMT episodes of 8 months or longer (adjusted hazard ratio 0.3 (95% CI, 0.2‐0.5; P < 0.001), although MMT periods 2 months or less were associated with greatest risk of re-incarceration ( P < 0.001). Increased risk of hepatitis C seroconversion was significantly associated with prison sentences of less than 2 months [adjusted hazard ratio 20 (95% CI, 5‐76; < P = 0.001)] and MMT episodes less than 5 months [adjusted hazard ratio 4.2 (95% CI, 1.4‐ 12.6; P = 0.01)]. Subjects were at greatest risk of MMT dropout during short prison sentences of 1 month or less (adjusted hazard ratio 10.4 (95% CI, 7.0‐ 15.7; P < 0.001). HIV incidence was 0.3 per 100 person-years (95% CI, 0.03‐ 0.99). Conclusions Retention in MMT was associated with reduced mortality, reincarceration rates and hepatitis C infection. Prison-based MMT programmes are integral to the continuity of treatment needed to ensure optimal outcomes for individual and public health.

Outcome of psychological treatments of pathological gambling: a review and meta‐analysis

Abstract: Aims To investigate the short- and long-term effect of psychological treatments of pathological gambling and factors relating to treatment outcome. Design and setting This study provides a quantitative meta-analytical review of psychotherapeutic treatments of pathological gambling. Studies were identified by computer search in the PsycINFO and Medline databases covering the period from 1966 to 2004, as well as from relevant reference lists. Inclusion criteria The target problem was pathological gambling, the treatment was psychological, the study was published in English and outcomes directly pertaining to gambling were employed. Single case studies, studies where elimination of gambling not was the priority and studies with insufficient statistical information were excluded from the present meta-analysis. Participants A total of 37 outcome studies, published or reported between 1968 and 2004, were identified. Of these 15 were excluded, thus 22 studies were included, involving 1434 subjects. The grand mean age was 40.1 years. The overall proportion of men was 71.5%. Measurements The included studies were coded for outcome measures of pathological gambling. For each condition, means and standard deviations for gambling-related outcome measures, all based upon self-reports or therapist ratings, were compiled at three points in time: baseline, post-treatment and the last follow-up reported. Findings Effect sizes represent the difference between the mean score in a treatment condition and a control condition or the difference between mean scores at separated points in time for one group, expressed in terms of standard deviation units. At post-treatment the analysis indicated that psychological treatments were more effective than no treatment, yielding an overall effect size of 2.01 (P < 0.01). At follow-up (averaging 17.0 months) the corresponding effect size was 1.59 (P < 0.01). A multiple regression analysis showed that the magnitude of effect sizes at post-treatment were lower in studies including patients with a formal diagnosis of pathological gambling only, compared to studies not employing such inclusion criteria. Effect sizes were also higher in randomized controlled trials compared to not randomized controlled trials, higher in within subjects designs compared to between subjects designs and also positively related to number of therapy sessions. No mediator variables were significantly related to the magnitude of the effect sizes at follow-up. Conclusion Psychological interventions for pathological gamble seem to be yield very favourable short- and long-term outcomes.

Challenging implicit and explicit alcohol‐related cognitions in young heavy drinkers

Abstract: Aims To test whether an expectancy challenge (EC) changes implicit and explicit alcohol-related cognitions and binge drinking in young heavy drinkers. This is important for theoretical and practical reasons: the EC presents a critical test for the hypothesized mediational role of alcohol cognitions and the EC has been presented as a promising intervention to counter alcohol problems in heavy drinking youth. Setting, participants and intervention Ninety-two heavy drinking college and university students (half women) were assigned randomly to the EC or control condition (a sham alcohol experiment in the same bar-laboratory). Measurements Explicit alcohol cognitions and alcohol use were assessed with paper-and-pencil measures. Alcohol use was assessed prior to the experiment and during a 1-month follow-up. Implicit alcohol-related cognitions were assessed with two versions of the Implicit Association Test (IAT), adapted to assess implicit valence and arousal associations with alcohol. Findings and conclusions The EC resulted in decreased explicit positive arousal expectancies in men and women alike. There was some evidence for a differential reduction in implicit arousal associations, but findings depended on the version of the IAT and on the scoring-algorithm used. In men (but not in women) there was a short-lived differential reduction in prospective alcohol use (significant in week 3 of the follow-up), and this reduction was partially mediated by the decrease in explicit positive arousal expectancies. These findings suggest that an EC successfully changes explicit alcohol cognitions and that this may have short-lived beneficial effects in heavy drinking young men.

Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain.

Abstract: Aims To assess the relationship between methadone treatment (MT) and overdose and HIV/AIDS mortality among heroin users resident in Barcelona city. Design All patients who started treatment in any treatment centre between 1992 and 1997 were included in a cohort the first time they were admitted for heroin addiction treatment. Follow-up controls were carried out every 9 months, on average, until 31 December 1999. Variables, both constant and varying over time, were fitted into Cox regression models. Findings The study recruited 5049 patients, which provided 23 048.2 person-years. Fifty per cent were in MT during the study period; of the total cohort 1005 patients died: 38.4% due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record. Conclusions The observed mortality decline could be linked to the effectiveness of low-threshold MT. The life expectancy of heroin users increased by 21 years during the study period.

A multi-center randomized trial of buprenorphine–naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network

Abstract: Aims The clinical effectiveness of buprenorphine–naloxone (bup-nx) and clonidine for opioid detoxification in in-patient and out-patient community treatment programs was investigated in the first studies of the National Institute of Drug Abuse Clinical Trials Network.

Selection and socialization effects of fraternities and sororities on US college student substance use: a multi-cohort national longitudinal study.

Abstract: Aims To examine how membership in fraternities and sororities relates to the prevalence and patterns of substance use in a national sample of full-time US college students. Design Nationally representative probability samples of US high school seniors (modal age 18 years) were followed longitudinally across two follow-up waves during college (modal ages 19/20 and 21/22). Setting Data were collected via self-administered questionnaires from US high school seniors and college students. Participants The longitudinal sample consisted of 10 cohorts (senior years of 1988‐97) made up of 5883 full-time undergraduate students, of whom 58% were women and 17% were active members of fraternities or sororities. Findings Active members of fraternities and sororities had higher levels of heavy episodic drinking, annual marijuana use and current cigarette smoking than non-members at all three waves. Although members of fraternities reported higher levels than non-members of annual illicit drug use other than marijuana, no such differences existed between sorority members and nonmembers. Heavy episodic drinking and annual marijuana use increased significantly with age among members of fraternities or sororities relative to non-members, but there were no such differential changes for current cigarette use or annual illicit drug use other than marijuana. Conclusions The present study provides strong evidence that higher rates of substance use among US college students who join fraternities and sororities predate their college attendance, and that membership in a fraternity or sorority is associated with considerably greater than average increases in heavy episodic drinking and annual marijuana use during college. These findings have important implications for prevention and intervention efforts aimed toward college students, especially members of fraternities and sororities.

Pain and use of alcohol to manage pain: prevalence and 3‐year outcomes among older problem and non‐problem drinkers

Abstract: Aims Most older adults report having recently experienced pain, and many older adults have late-life drinking problems. However, to our knowledge, the intersection of pain and alcohol misuse by older adults has not been studied. This research focuses on the implications of pain for older individuals who have problems with alcohol. Design Longitudinal survey. Setting, participants and measurement Older community-residing adults (n = 401) were classified as problem and non-problem drinkers. At baseline and 3 years later they were asked to provide information about their pain, use of alcohol to manage pain, drinking behavior, chronic health problems and recent serious injury. Findings At baseline, older problem drinkers reported more severe pain, more disruption of daily activities due to pain and more frequent use of alcohol to manage pain than did older non-problem drinkers. More pain was associated with more use of alcohol to manage pain; this relationship was stronger among older adults with drinking problems than among those without drinking problems. Among older men, more baseline drinking problems interacted with use of alcohol to manage pain to predict more health problems and serious injury 3 years later. Among older women, more baseline drinking problems interacted with use of alcohol to manage pain to predict more drinking problems 3 years later. Conclusions The results highlight the importance of monitoring the drinking behavior of older patients who present with pain complaints, especially patients who have pre-existing problems with alcohol.

Is there a case for extended interventions for alcohol and drug use disorders

Abstract: Aims To determine whether there is evidence to support the implementation of extended interventions (i.e. longer than 6 months) for individuals with alcohol or other drug use disorders. Methods Literature on extended behavioral and pharmacotherapy interventions was reviewed, along with findings from studies of extended monitoring and monitoring paired with adjunctive counseling. Studies were identified through database searches, citations in prior reviews and examinations of recent volumes of relevant journals. Key terms were defined, and a theoretical rationale was presented for extended treatment. Several adaptive treatment studies that made use of stepped care or continuation protocols were also described. Measurements The primary outcomes that were considered were alcohol and drug use during the intervention and post-intervention follow-ups. Other outcomes were examined when they were included in the articles reviewed. Findings Most of the studies in the review provided support for the effectiveness of extended interventions for alcohol and drug abusers, whether the extended care was delivered through face-to-face contact or via the telephone. These findings held across all types of interventions that were examined (e.g. behavioral treatment, pharmacotherapy and monitoring). However, only a few studies directly compared extended and standard length version of the same intervention. New developments in addiction treatment with implications for extended care models were also described and discussed. Conclusions The findings of the review indicate that maintaining therapeutic contact for extended periods of time with individuals with alcohol and other drug disorders appears to promote better long-term outcomes than ‘treatment as usual’, although more studies are needed that compare extended and standard versions of interventions. Achieving good compliance and successful disease management with extended interventions will probably require adaptive protocols in which the intensity of treatment can be adjusted up or down in response to changes in symptoms and functioning over time. Future directions in research on extended interventions were discussed.

Gender differences in the association between substance use and elevated depressive symptoms in a general adolescent population

Abstract: Aims This study explores gender differences in the association between substance use and elevated depressive symptoms in the general adolescent population. Design Cross-sectional self-reported anonymous survey, the 2002/2003 Student Drug Use Survey in the Atlantic Provinces. The sample design was a single-stage cluster sample of randomly selected classes stratified by grade and region. Setting The four Atlantic provinces of Canada. Participants A total of 12 771 students in junior and senior high schools of the public school systems, representing a response rate of about 97%. The average age of participants was 15.2 years. Measurements The measure of elevated depressive symptoms was a 12-item version of the CES-D with three categories of depression risk validated in a companion study. Findings The prevalence of very elevated depressive symptoms was 8.6% in females and 2.6% in males. Alcohol use and cigarette smoking were found to be independent predictors of elevated depressive symptoms in females, but not males; cannabis use was found to be an independent predictor of elevated depressive symptoms in both males and females. Age was found to have a curvilinear relationship with elevated depressive symptoms in females but not in males. The adolescent's academic performance and province of residence were found to be independent risk factors of elevated depressive symptoms among both males and females. About 10.3% of adolescents considered to be potential candidates for needing help reported having received help because they felt depressed. Conclusions The association between depression risk and age, alcohol use, cigarette smoking and cannabis use in the general adolescent population is not straightforward and may differ according to gender. There is unmet need for help for depression among adolescents.

Parental rules and communication: their association with adolescent smoking.

Abstract: Aims To examine the association between parental rules and communication (also referred to as antismoking socialization) and adolescents’ smoking. Design and participants A cross-sectional study including 428 Dutch twoparent families with at least two adolescent children (aged 13‐17 years). Measurements Parents’ and adolescents’ reports on an agreement regarding smoking by adolescents, smoking house rules, parental confidence in preventing their child from smoking, frequency and quality of communication about smoking, and parent’s reactions to smoking experimentation. Findings Compared with fathers and adolescents, mothers reported being more involved in antismoking socialization. There were robust differences in antismoking socialization efforts between smoking and non-smoking parents. Perceived parental influence and frequency and quality of communication about smoking were associated with adolescents’ smoking. The association between antismoking socialization practices and adolescents’ smoking was not moderated by birth order, parents’ smoking or gender of the adolescent. Conclusions Encouraging parents, whether or not they themselves smoke, to discuss smoking-related issues with their children in a constructive and respectful manner is worth exploring as an intervention strategy to prevent young people taking up smoking.

Cut-off levels for breath carbon monoxide as a marker for cigarette smoking.

Abstract: Aims Current clinical studies often use a breath carbon monoxide (BCO) cut-off level of 8 parts per million (p.p.m.) or higher to identify smoking. In this study, the cut-off level of BCO as an indicator of smoking over the past 24 hours was re-examined. Design BCO and self-reported smoking were obtained each weekday for up to 14 weeks in 213 subjects paid to deliver reduced BCO values. Analysis of 12 386 paired values for reported smoking and BCO were analyzed. Findings The 25% quartile, median and 75% quartile values for BCO were 1, 1 and 2 p.p.m. on non-smoking days and 2, 5 and 12 p.p.m. on smoking days, respectively. Receiver-operating characteristic (ROC) analysis indicated that BCO provided high diagnostic accuracy to distinguish between smoking and non-smoking days [area under the curve (AUC) = 0.853, P < 0.0001]. The highest combined sensitivity and specificity was observed at a BCO cut-off level of 3 p.p.m. (sensitivity = 71.5%; specificity = 84.8%). At a BCO cut-off of 8 p.p.m. sensitivity and specificity were 40.6% and 98.2%, respectively, indicating that many smokers would be falsely classified as abstinent. Finally, the percentage of true tests (positive and negative) was highest at a BCO cut-off of 2 p.p.m. (80.2%). Conclusions BCO cut-off levels well below 8 p.p.m and as low as 2–3 p.p.m. may be more useful when it is important to maximize identification of smoking abstinence with a high degree of certainty.