Can labelled glasses influence drinking behaviour

 

Imagine you went up to a bar, ordered a large glass of wine and it was served to you in a pint glass. People would look at you funny. The wine might not taste the same. You might not enjoy the drinking experience. We associate wine glasses with drinking wine, whisky glasses with whisky, pint glasses with beer… You get the gist. Often when we go to a pub and ask for a beer, they have a unique glass to serve each brand in. Different shapes and sizes of glasses are associated with specific drinks and many of us may perceive this as adding to the drinking session. Often, branding is displayed on glassware too, in case you’re so drunk during that fifth Guinness you need a reminder of what you’re drinking.

The point here is, from a marketing perspective, the glass is an integral tool which has been described as “integral to the moment of consumption”, suggested to have equal importance to other marketing methods (e.g. product design, sponsorship, packaging). Alcohol research indicates different sizes and shapes impact on drinking rates, yet glasses are not subject to the same scrutiny and control from a public health, harm-reduction perspective as other marketing techniques.

Currently in the UK, alcohol labels with unit guidelines are displayed (if you look hard enough) on alcohol products. A recent study suggested people pay minimal attention to these labels, and that is if they have the chance to be seen. What if you arrive at a house party and your friend pours you a vodka and lemonade? Or you are in a pub and you’re served a pint of draught beer? In addition, if labels in their current form are displayed and noticed they are unlikely to impact on our behaviour; many people lack knowledge of units, with knowledge lowest in those who drink heavily. Even in those who are aware of the concept of a unit, units are often not used to reduce drinking.

For a section of my PhD studies* I decided to investigate the impact of labelled glasses on drinking behaviour, in a population of majority undergraduate students. For my first glass label study I used a pre-existing measurement tool available from the drink charity Drink Wise to see whether glass labels with unit and warning labels, and safe daily guidelines** could reduce consumption compared to a plain glass of the same size and shape. I investigated this in a bar-laboratory with pairs of student social drinkers, to create an environment as close to a ‘typical’ drinking setting as possible. Results indicated the glasses did not influence drinking behaviour, consumption of beer and wine was roughly the same in each group over a 20 minute period.

I conducted focus groups to explore the potential reasons for the lack of differences between groups. The majority of participants stated that they could not relate to, and often did not use units to guide behaviour. Units were described as ‘not being taken too seriously’ anymore, with an emphasis on the message being boring and repetitive. This shows that even when unit labels are displayed and noticed at the moment of consumption, they are unlikely to be utilised to change behaviour, supporting previous research.

Another point raised in these focus groups (by female participants especially) was that calorie information would be more likely to change behaviour than unit information. Calorie information is mandatory on food, but is not required on alcohol products, which doesn’t make a lot of sense.

Appetite research indicates that the provision of calorie information alone has inconsistent effects on eating behaviour, but including exercise information (i.e. you will have to walk for 1 hour to burn off this pint) can be effective in reducing consumption and impacting food choice. In addition, websites/phone apps with drinking reduction tools, often include food equivalent information on their unit calculators (i.e. the calories in this pint equate to half a burger), a form of information that may be particularly useful for individuals who are more sedentary. Therefore, for my next study I investigated glass labels displaying calorie information with the addition of exercise or food equivalent information.

Another point raised in the focus groups was that the glasses were not aesthetically pleasing, and participants emphasised that they would not drink wine out of half pint glasses with ‘childlike’ labels. So for this study I used pint glasses and designed my own labels that were more simplistic (but large enough to be noticed). I investigated these glasses in the bar-lab, but this time I tested participants individually, as I found a very high modelling effect when testing in pairs, supporting research showing the same.

I found that for participants overall, these glass labels did not reduce drinking. However, when I explored this further and separated groups by gender, exercise labels significantly reduced drinking in female participants. This indicates calorie and unit labels alone do not reduce consumption, supporting recent findings by Maynard and colleagues in Bristol, in which displaying this information on a slip of paper also did not influence consumption. However, exercise equivalent labels show promise and this is an area that should definitely be investigated further, along with alternative forms of displaying nutritional information.

Again, I conducted focus groups to gain further insights into these findings. Participants were a lot more accepting of these labelled glasses (compared to the unit glasses used in the previous study) and the majority indicated that they could be effective in reducing drinking. Specifically they emphasised that they found it much easier to relate to and understand information when presented in this form. However, they did make it clear that this may change once in a drinking occasion and that I was ruining their fun. Fair enough. Many students do drink for sociability reasons, or for enhancement, and the majority do mature out of this. It may be that different populations are looking to change and are ready for their fun to be ruined. These types of labels may have increased impact in those who want to cut down, and therefore this form of information warrants further research in a variety of populations.

Another worrying finding from the focus groups was the potential of this type of information in increasing ‘drunkorexia’ behaviours, which I have previously written a blog about (see here). ‘Drunkorexia’ is a non-medical term used to describe diet related behaviours that are related to and used to compensate for the consumption of alcohol and its calories, such as skipping meals and excessively exercising. This does not necessarily mean nutritional information should not be provided as we have a right to know it, but measures to decrease the likelihood of these behaviours should be provided alongside.

To conclude, key findings from these studies were that:

1) Unit information alone is not sufficient for behaviour change. Nutritional information (alongside relatable equivalents) could be useful; participants were accepting of it and there is no reason for it not to be displayed. However, it is not a standalone intervention, and should be provided alongside other harm-reduction methods.

2) Glasses are an accepted and potentially effective method to display this information.

3) Focus group findings suggest that the drinking culture of students and their predetermined intoxication levels are very robust to change.

*Studies currently being written up for publication- contact author for further information.

**Note: previous guidelines (of 2-3 units per day for women and 3-4 units per day for men) as these studies were conducted before new guidelines were introduced.

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Parenting factors associated with adolescent alcohol misuse

Alcohol misuse in young people is a specific focus on the agenda of the World Health Organization (WHO, 2010). Alcohol use is typically initiated in adolescence (WHO, 2010) and carries high levels of risk, such as risk of dependence, physical harms and cognitive impairment (Hall et al., 2016).

Parents have been identified as vital in preventing adolescent alcohol misuse and the identification of key parenting factors is vital in the development of successful interventions.

A narrative systematic review (Ryan et al., 2010) identified a wide range of key parenting factors associated with adolescent alcohol misuse which the current study aimed to update with a comprehensive search strategy and meta-analysis of primary studies.

Alcohol use typically starts in adolescence and can lead to dependence, physical harms and cognitive impairment.

Methods

A total of 131 longitudinal studies were included, with 416 associations. Studies had a minimum follow-up period of one year.

Twelve parenting factors (alcohol specific factors and general factors) and two adolescent alcohol use outcomes were identified (alcohol initiation and levels of later use/misuse).

There were a diversity of methodologies and analyses across studies, meaning not all effect sizes could be extracted and only a subset could be included in the meta-analyses. Meta-analyses were conducted for specific factors when there were at least two independent studies available. Authors used for effect size as it was most commonly reported in studies (rs were interpreted based on Cohen’s guidelines with 0.10 indicating a small effect).

To determine reliability of associations across all studies authors used Stouffer’s method of combining p-values, a technique used when there is a heterogeneity in analytical approaches.

Results

Authors categorised factors into one of three categories: factors with a sound convergent evidence base (significant effect sizes and significant Stouffer’s P), factors with a weak evidence base (a significant Stouffer’s P, but the meta-analysis of the subset was non-significant or could not be conducted) and factors with a weak evidence base (insufficient evidence to draw conclusions).

Factors with a sound convergent evidence base:

  • Provision of alcohol had the largest effect size of the parenting factors, with drinking at home and having alcohol easily accessible associated with earlier initiation and higher alcohol use/misuse
  • Favourable paternal attitudes towards alcohol use were associated with early initiation, and both maternal and paternal favourable attitudes were associated with increased alcohol use/misuse
  • Paternal alcohol use was associated with early initiation and both maternal and paternal alcohol use were related to increased alcohol use/misuse
  • High parental monitoring and parent-child relationship quality were associated with delayed alcohol initiation association and reduced alcohol use/misuse
  • High maternal support was associated with delayed alcohol initiation and both high paternal and maternal support were associated with reduced alcohol use/misuse
  • High parental involvement was associated with delayed alcohol initiation and reduced alcohol use/misuse.

Factors with an emerging evidence base:

  • Having parental rules about alcohol use was associated with delayed alcohol initiation and lower levels of alcohol use/misuse, with clear rules having a protective effect
  • Higher levels of family conflict were associated with early alcohol initiation and higher levels of alcohol use/misuse
  • Maternal parental discipline was associated with delayed alcohol initiation, with appropriate discipline having a protective effect.

Factors with a weak evidence base:

  • Alcohol specific communication was not significantly associated with alcohol initiation or reduced levels of alcohol use/misuse
  • There were ambiguous findings for general parent-child communicationand delayed alcohol initiation. A significant association was found between positive general communication between parent and child and alcohol use/misuse.

Moderation effects

Moderation effects were tested when there were at least four associations available with meta-regression analysis (follow-up interval and baseline age) and subgroup analyses (adolescent gender and outcome measure).

Follow-up interval moderated the association for five parenting factors (favourable attitudes towards alcohol use and family conflict on initiation, parental support and parental involvement on later use/misuse and parent child relationship on both initiation and use/misuse), with smaller effect sizes for longer intervals, indicating parenting can have long term influences.

Baseline age moderated the association for three parenting factors (family conflict and parent-child relationship quality on initiation and parental involvement on later use/misuse). Studies with younger children at baseline had smaller effect sizes, although authors suggest this could be an artefact of follow-up interval, as longer follow-ups are likely to recruit children at a younger age.

There was significant moderation by adolescent gender for parent-child relationship quality and parental monitoring, with girls more sensitive in terms of risk for early initiation.

There was a significant moderation by outcome measure in the associations between favourable attitudes towards alcohol and initiation and between parent-child relationship quality and both initiation and levels of later use/misuse. A stronger association was found when frequency/quantity/binge drinking measures were used, rather than onset measures.

Provision of alcohol, favourable attitudes towards alcohol, and maternal/paternal alcohol use were all related to increased alcohol use/misuse in young people.

Discussion

Authors emphasise that the heterogeneity across studies indicates the need for clearly defined and validated measures in future longitudinal research in this area. Overall effect sizes are small (rs = -0.224 to 0.263 and overall only accounting for 1-7% of variance). Authors recommend tailored online programmes to:

Support the translation of the sound evidence base on the various parenting factors examined here into prevention interventions to upskill parents.

Strengths and limitations

Strengths

  • This is a comprehensive review of a wide range of specific parental factors associated with initiation and alcohol use/misuse in adolescents. Where possible, authors have conducted meta-analyses to identify associations, contributing to the literature that to date has only included narrative systematic reviews
  • The division of factors into three categories based on evidence strength is particularly useful for future research and intervention design.

Limitations

  • Meta-analyses could not be conducted for all parenting factors and for those that were conducted they may have been underpowered to detect associations, as some contained as little as two independent studies
  • Due to the inclusion of primary studies that have not been adjusted for covariates (because of heterogeneity across studies), causality cannot be drawn from the associations
  • Findings mainly relate to developed countries and may not be generalisable to other cultures and countries.

Conclusions

This study highlights a set of parental factors that have a small but significant impact on adolescent alcohol use and should be targeted in intervention efforts. Specific factor categories can provide a framework for future research design that lends to systematic analysis.

This study highlights a set of parental factors that have a small but significant impact on adolescent alcohol use and should be targeted in intervention efforts.

Links

Primary paper

Yap MBH, Cheong TWK, Zaravinos-Tsakos F, Lubman DI, Jorm AF. (2017) Modifiable parenting factors associated with adolescent alcohol misuse: a systematic review and meta-analysis of longitudinal studies. Addiction, doi: 10.1111/add.13785.

Other references

Hall WD, Patton G, Stockings E, Weier M, Lynskey M, Morley KI et al. (2016) Why young people’s substance use matters for global health. Lancet Psychiatry 2016; 3: 265–79.

Ryan SM, Jorm AF, Lubman DI. (2010) Parenting factors associated with reduced adolescent alcohol use: a systematic review of longitudinal studies. Aust NZ J Psychiatry 2010; 44:774–83. [PubMed abstract]

World Health Organization. (2010) Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization; 2010.

Eat, drink and be skinny.

As a society, we love to measure our behaviour. Apps that encourage self-monitoring of behaviour have become increasingly popular; how many hours of sleep did you get last night? How many steps have you taken today? How many more bites of that chocolate bar can you have? I’m guilty of it. ‘MyFitnessPal’ and I have had a rocky relationship in the past and at times I admit I’ve been slightly obsessive, tallying up my 20 second walks to kitchen to make tea and counting my walk up the hill with shopping as ‘heavy lifting’. I would be secretly happy when my app told me I hadn’t eaten enough in a day and annoyed when I was 1 calorie over my limit. However, one thing I would never do was enter the calories consumed from alcohol. Why? Because I knew it would ruin all the hard work I had put in with my food. I did try a few times, but my 120 minutes ‘vigorous dancing’ from 12 to 2am wasn’t enough to counteract the 2000 calories (probably an underestimate) I consumed.

Not all of us are as happy lying to ourselves. Recently my research has moved towards using calorie information to reduce drinking and I came across a new term, ‘drunkorexia’. This is a non-medical term which is used to describe diet related behaviours that are related to and used to compensate for the consumption of alcohol and its calories. These behaviours are carried out to avoid weight gain and also to enhance alcohol’s effects. For example, eating low calorie food in smaller amounts and skipping meals before drinking. Also by partaking in excessive exercise, for example in women higher levels of alcohol use are associated with greater exercise fixation and frequency. More extreme behaviours such as purging and using diet pills and laxatives have also been reported. These ‘drunkorexia’ behaviours have been shown to be associated with higher harms from alcohol, drinking on an empty stomach gets you drunk faster which leads to an increase in memory loss, injury and unprotected sex.

This is not a new phenomenon, we have all heard the phrase ‘eating’s cheating’, but in a society that is becoming increasingly obsessed with health it is something that is becoming more common. Our Instagrams are filled with gym bunnies, the ‘#nopainnogainers’, fixated with eating clean and delighting us with streams of photos of kale smoothies, quinoa salads and screenshots of new personal running records. In fact, an eating clean obsession has now been given the term ‘orthorexia’. But our nation still has a drinking problem, and it is worrying to think that such extreme measures are being taken to ensure both intoxication and healthiness are maintained in parallel. Our obsession with being healthy could actually be having the reverse effect, of course moderation is the ideal, but we must remember that sometimes it is OK to drink and eat to excess and not feel guilty.

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Our behaviour shouldn’t fall in to either of these extremes, we shouldn’t limit food and excessively exercise to counteract alcohol calories, but neither should we lie to ourselves and ‘MyFitnessPal’. Monitoring alcohol intake should be equally important as monitoring food intake, and it is surprising that no country in the world requires nutritional information or calories on alcohol packaging. Alcohol has an energy value of 7.1 kcal/g, second only to fat. One study showed that for adult alcohol consumers aged 19-64 it accounts for 8.8% of our total energy intake. Although having this information might not make a difference in terms of how much alcohol we consume (I can’t say it does for me), it is information that we should have access to. It seems pretty strange that we are informed of the calories in a can of coke, yet most of us are unaware of the number of calories in an equally as calorific glass of wine. Recent research indicates public support for the inclusion of this information is high, however, the potential for an increase in ‘drunkorexia’ behaviours indicate that measures need to be taken to ensure if the information is provided, it is not used in the wrong way.

 

 

Local alcohol licensing policies associated with reduction in alcohol-related hospital admissions

The hazardous and harmful use of alcohol is a major public health issue. It is estimated that around nine million adults in England drink to potentially harmful levels, and the cost of alcohol misuse to the NHS is around £3.5 billion every year. A further £11 billion per year is spent as a result of alcohol-related crime and £7.3 billion due to lost productivity.

One key strategy concerning alcohol price and availability is licensing, which modifies our drinking environment. Evidence indicates that there is an association between the number of alcohol outlets in neighbourhoods and alcohol-related hospital admissions; therefore restricting the number of alcohol outlets is a potential avenue for reducing alcohol-related harm.

Local authorities have the power to limit both on- and off-trade alcohol outlets. They can refuse individual license applications and they can designate cumulative impact zones (CIZs) to control new alcohol outlets in places where the addition of more would challenge crime prevention and public safety, create a public nuisance or expose children to harm.

In a recent study published in the Journal of Epidemiology and Community Health, authors evaluate whether differences in CIZ implementation and licensing scrutiny by local councils has an impact on population health.

Estimates suggest that alcohol misuse costs the NHS £3.5 billion a year.

Methods

Alcohol licensing data was obtained for 326 lower tier local authorities (LTLAs) in England for the years 2007/2008 and 2011/2012, data from 319 of these local authorities was used in the analyses.

A ‘cumulative licensing intensity score’was developed for each LTLA, this score was divided into four categories; no activity (passive) and 3 levels of intensity (low, medium, high).

Authors looked at the association of licensing intensity with quarterly hospital admission data (standardised for age) with a primary alcohol-related admission for the period 2009-2015. Primary alcohol related admissions are conditions wholly attributable to alcohol, such as alcohol liver disease, ethanol poisoning, malignant neoplasms of the oesophagus and hypertensive diseases. They also controlled for influential factors such as deprivation data, alcohol-related crime rates and population size.

Results

The cumulative licensing intensity score was classified as:

  • Inactive in 43% of authorities
  • Low intensity in 21% of authorities
  • Medium or high in 35% of authorities

Hierarchical growth modelling was used to analyse the data. The inclusion of baseline deprivation, population size and alcohol related crimes in the model explained around 50% of the baseline variability in admission rates between LTLAs. There was no evidence that they could explain changes beyond this over the 2009-2015 period.

The main finding was that the intensity of alcohol policies in LTLAs was associated with larger reductions in alcohol-related hospital admissions. This change in hospital admission rates in the areas with the highest intensity policies was -2% (95% CI -3% to -2%) annually (p=0.05). This is equal to a 5% reduction or 8 fewer alcohol-related admissions per 100,000 people in 2015, compared to if these authorities did not have active policies in place.

In authorities with a medium intensity policy, a non-significant decrease in admission rates of 0.6% annually was found. This is equal to a doubling of reduction in admission rates compared with authorities that were non-active.

Local areas with the most intensive licensing policies saw the biggest reductions in alcohol-related hospital admissions.

Discussion

The results from this study indicate that there is a greater reduction in alcohol-related hospital admissions in local government areas that have more intensive alcohol licensing policies. Active licensing policies are defined by authors as those with CIZs present and more intense scrutiny of license applications.

It is concluded that:

The more intensely alcohol licensing policies are implemented in a local area, the stronger their effect on reduction in alcohol-related hospital admissions.

Strengths and limitations

  • More active policies are often introduced in areas with higher levels of harm. Authors adjusted for this in the models by taking into account confounding variables such as baseline deprivation, population size and alcohol-related crime data.
  • The association does not prove causality. For example, authors emphasise that the drop in admissions could be due to that area adopting other alcohol policies such as late night levies or policies aimed specifically at reducing health harms, such as screening and brief interventions.
  • Authors note that data on accident and emergency department visits was not included in the statistics used. Future research on the impact of licensing on acute societal impacts may help to further explain the data. For example, there may be a larger effect on acute alcohol poisoning or crime, as local policies are often aimed at reducing immediate societal impacts.

Conclusions

This study is the first to demonstrate that in areas with more active licensing policies, there is a greater reduction in alcohol-related hospital admissions. Although conclusions about cause and effect can’t be drawn, the association between the two suggests a population level benefit of policies that restrict licensing.

Should this research inspire Directors of Public Health to consider more active licensing policies?

Links

Primary paper

de Vocht F, Heron J, Angus C, Brennan A, Mooney J, Lock K. et al (2015) Measurable effects of local alcohol licensing policies on population health in England. J Epidemiol Community Health. doi: 10.1136/jech-2015-206040 [Abstract]

Other references

Health Committee. Written evidence from the Department of Health (GAS 01). UK Parliament, 2012. http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/132/132we02.htm#footnote_1 (accessed 26 Aug 2015). http://www.webcitation.org/6b4MqIXYL

PHE. User guide: Local Alcohol Profiles for England 2014 London 2014:23. http://www.lape.org.uk/downloads/LAPE%20User%20Guide_Final.pdf (accessed 26 Aug 2015). http://www.webcitation.org/6b4Nlogai

Public Health England. Alcohol treatment in England 2013-14. London: Public Health England; 2014. http://www.nta.nhs.uk/uploads/adult-alcohol-statistics-2013-14-commentary.pdf

Richardson EA, Hill SE, Mitchell R, et al. Is local alcohol outlet density related to alcohol-related morbidity and mortality in Scottish cities? Health Place. 2015;33:172-80.

– See more at: http://www.nationalelfservice.net/mental-health/substance-misuse/local-alcohol-licensing-policies-associated-with-reduction-in-alcohol-related-hospital-admissions/#sthash.A0siIAFr.dpuf

Dry January = Wet February?

Conflict of interest: Natasha Clarke and Matt Field are at the same institution as Ian Gilmore (University of Liverpool), and all three are members of the UK Centre for Tobacco and Alcohol Studies. Matt Field is also an ‘expert advisor’ for the Dry January campaign. This unpaid role involves providing information and advice to people who are attempting Dry January. 

‘Dry January’ is an Alcohol Concern campaign, supported by Public Health England, in which people commit to a month of complete abstinence from alcohol. As the number of people taking part increases, it is important that participants are aware of the potential benefits and unintended consequences of having 31 days off the booze.

In a recent head-to-head BMJ article (Hamilton & Gilmore, 2016), Ian Hamilton and Ian Gilmore debate the claim that ‘Dry January’ may be doing more harm than good; just because the campaign is popular, this does not necessarily mean that taking a month off alcohol is a good thing. Ian Hamilton claims we do not know enough about such campaigns and is concerned that it has not been rigorously evaluated, whereas Ian Gilmore highlights that it provides an opportunity to reflect on one’s drinking behaviour, and points out evidence that is suggestive of beneficial effects on health and wellbeing.

Is it possible that ‘Dry January’ may be doing more harm than good?

Who should take part?

Ian Hamilton’s first criticism is that ‘Dry January’ does not clearly define its target audience. It is suggested that the campaign may only attract low-risk drinkers who would find it easy to be abstinent for a month. However, a recent study that investigated those participating in Dry January found that their average score on the Alcohol Use Disorders Identification Test (AUDIT) was 12, which is above the cut-off score for hazardous drinking (8). Furthermore, promotional material for the campaign makes it clear that participation is open to anyone who wants to examine their relationship with alcohol.

Dry January = Wet February?

Another criticism is that the campaign may confuse people about what constitutes ‘safe’ drinking. In the context of recently revised government guidelines (DH, 2016) – no more than 14 units per week – it could be confusing to imply that a month of continuous abstinence could mitigate the harmful effects of excessive drinking for the rest of the year. Wouldn’t it be better to send out a consistent message that people should drink within the government guidelines throughout the year? However, Alcohol Concern do make it clear that people should try to reduce their alcohol consumption throughout the year, whether they do Dry January or not. Furthermore, there is evidence to suggest that taking part in ‘Dry January’ can result in a longer term reduction in drinking: Public Health England’s evaluation of those who took part in 2015 showed that 67% of participants had a sustained drop in their alcohol consumption after 6 months, and 8% had decided to stay dry.

Recent research by de Visser and colleagues (2015) adds to these findings, a questionnaire was given to 3,791 people who took part in the campaign and the study found that 71% of those made it through the month without drinking. A 6-month follow-up assessment revealed significant reductions in alcohol consumption and hazardous drinking, even in those who did not abstain for the month. A limitation of this study is the very high drop-out rate, as only 23% completed the follow-up questionnaire. Participants completing the follow-up may have been more likely to continue their long-term change in drinking habits compared to those who did not provide follow-up data; therefore these results must be interpreted carefully.

Interestingly, this study also found improvements in Drinking Refusal Self-Efficacy (an individual’s self-perceived capacity to refuse alcohol) that resulted from taking part. Such consequences of participation in the campaign need further research, as it suggests a potential mechanism through which taking part may lead to sustained reductions in drinking.

Higher quality evaluations of Dry January are needed before we can be sure of its impact.

Short-term benefits

Even if it does not lead to long-term reductions in drinking, a month off drinking can still have benefits in the short-term. One small scale study showed that abstaining for a month prompted reductions in liver fat, blood glucose and blood cholesterol alongside self-reported benefits such as a higher quality of sleep and improved concentration. However, larger scale studies, with appropriate control conditions (e.g. drinking within government guidelines through the month), are needed to investigate the benefits of abstinence more thoroughly.

Heavy drinkers

Another criticism of the ‘Dry January’ campaign is that abrupt abstinence could be harmful in people who are physically dependent on alcohol. This is a group who need expert help when quitting drinking, and a safe management of withdrawal from alcohol. However, the campaign is aimed at social drinkers rather than dependent drinkers, and Alcohol Concern are very clear that Dry January is not a medical detox plan for those who are alcohol dependent”, and heavy drinkers should consult their GP before starting. If ‘Dry January’ can prompt dependent drinkers to seek out professional help, that can’t be a bad thing.

Dry January is aimed at social drinkers, not dependent drinkers.

Conclusions

This head-to-head article raises some important issues. Ideally, the majority of alcohol consumers should stick to the government guidelines throughout the year, and alcohol dependent individuals who want to abstain should seek professional help. But this is easier said than done, and campaigns like Dry January may play an important role when it comes to encouraging people to rethink their relationship with alcohol.

The available research, although limited, suggests some short-term and long-term benefits of taking part, although better quality evidence is certainly needed.

Links

Primary paper

Hamilton I, Gilmore I. (2016) Could campaigns like Dry January do more harm than good?

Other references

DH (2016) Health risks from alcohol: new guidelines. Department of Health, 8 Jan 2016

PHE (2016) Annual report and accounts 2014/15 (PDF). Public Health England, 15 Jul 2015.

– See more at: http://www.nationalelfservice.net/mental-health/substance-misuse/dry-january-wet-february/#sthash.eQ7tl8IY.dpuf

Does parental drinking influence children’s drinking?

Alcohol consumption accounts for approximately 19% of DALYs (defined by WHO as one lost year of “healthy” life) and 27% of premature deaths amongst young people in high income countries (Toumbourou et al, 2007).
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There are many studies examining the effects of prenatal alcohol exposure and the possible side effects on children living with parents with serious and long term alcohol problems, but little is known about how children may be affected by more normative patterns of drinking (e.g. drinking at lower risk levels and binge drinking).

Systematic reviews of prospective cohort studies offer the highest quality observational evidence for the assessment of the true consequences of parental drinking for development of alcohol use and related problems in young people. This is because cohort studies can determine the time order of exposure and outcome and rule out reverse causality.

The current study aimed to review whether and to what extent prospective cohort studies in the general population provide evidence for the true effects of parental drinking on their children’s alcohol use and problems, and to assess the quality of the evidence in terms of their capacity to draw causal inferences. It builds on a recent scoping review (Rossow et al, 2015) that identified 99 cohort studies of parental drinking and adverse outcomes in children.

Methods

A total of 21 studies were included, encompassing 26,354 families or parent-child dyads. As multiple study reports were based on the same cohorts, 16 distinct cohorts were identified and used in the analysis.

Studies were designated as having increased ability to show causality if they had:

  1. A theory driven approach and analysis
  2. Analytic rigor
  3. Minimisation of sources of bias

The parental drinking exposure measure varied between studies with regard to type of drinking behaviour, age of exposure, relationship to outcomes and whose drinking behaviour was measured.

In 16 studies the outcome was one or several measures of drinking behaviour, in 5 studies the outcome was an alcohol-related problem (either as a single outcome or in addition to the drinking behaviour measure).

In 13 studies the outcome was obtained in teenage years, in 7 the outcome measure was obtained in young adulthood and in one study at the age of 10.

Due to this heterogeneity and a lack of data appropriate for meta-analysis authors undertook a narrative synthesis of study findings and risk of bias.

Results

  • The majority of the studies (19 out of 21) reported at least one positive association between parental drinking and offspring’s alcohol-related outcome.
  • The majority of the studies lacked an explicit theoretical conceptualisation of their research aims and none had a strong capacity for causal inference.
  • Four studies showed some capacity for causal inference. All four of these studies found some evidence that parental drinking predicted drinking behaviour in offspring.
  • Three of these studies had clear theory-driven analyses and looked at specific mediation mechanisms; specifically parenting practices, alcohol specific communication and poor inhibitory control in offspring.
  • There were direct effects of paternal but not maternal drinking (Mares et al;, 2011), no mediation effect of poor inhibitory control in offspring (Pears et al., 2008) and a mediation effect of parental monitoring and discipline, which was stronger in early than late adolescence (Latendresse et al., 2007).
  • It was noted that the lack of findings for maternal drinking and inhibitory control mediation effects could be due to poor statistical power in the studies.

Discussion

Nearly all cohort studies included in this review found that parental drinking predicts drinking behaviour in offspring. However, authors emphasise that consistency alone does not indicate a causal relationship, especially as there were mixed findings regarding the impact of maternal and paternal drinking, a lack of identification and control for relevant confounding factors and small data sets. An aim of this review was to evaluate the extent studies showed capacity for causal inferences, and overall it was found that there was a sparse use of theory driven analyses.

Limitations

Limitations identified in the review were the lack of standardisation of measurement in the literature, possible self-report bias for the exposure and outcome measures in the studies and publication bias.

Due to the lack of data appropriate for meta-analysis, authors undertook a narrative synthesis of the included studies. This type of analysis was deemed appropriate for the data, however it does not use techniques as reliable and rigorous as meta-analyses, therefore there is an increased potential for bias. This limitation is addressed in the review and authors emphasise that they have made their process of analysis as transparent as possible.

Conclusions

This is the first systematic review of cohort studies that investigates the capacity of specific studies to indicate causal relationships. This is necessary with cohort studies as confounding is a threat to their validity, where the outcome of interest is affected by other factors as well as the exposure of interest.

Authors conclude that more well-designed theory driven cohort studies are urgently needed so that from a “harms to others” framework interventions can be developed to prevent inter-generational alcohol problems.

The evidence does not yet show a causal link between parental drinking and children's drinking.

Links

Primary paper

Rossow, I., Keating, P., Felix, L., & McCambridge, J. (2015). Does parental drinking influence children’s drinking? A systematic review of prospective cohort studiesAddiction, doi:10.1111/add.13097.

Other references

Latendresse, S., Rose, R., Viken, R., Pulkkinen, L., Kaprio, J. & Dick, D. (2008) Parenting mechanisms in links between parents’ and adolescents’ alcohol use behaviors. Alcoholism: Clinical and Experimental Research, 32, 322-30

Mares, S., van der Vorst, H., Engels, R. & Lichtwarck-Aschoff, A (2011). Parental alcohol use, alcohol-related problems, and alcohol-specific attitudes, alcohol-specific communication, and adolescent excessive alcohol use and alcohol-related problems: An indirect path model. Addictive Behaviors. 36, 209-16.

Pears, K., Capaldi, D. & Owen, L. (2007)  Substance use risk across three generations: the roles of parent discipline practices and inhibitory control. Psychology of Addictive Behaviors. 21, 373

Rossow, I., Felix, L., Keating, P. & McCambridge, J. (2015)Parental drinking and adverse outcomes in children – a scoping review of cohort studies. Drug and Alcohol Review.; in press

Toumbourou, J., Stockwell, T., Neighbors, C., Marlatt, G., Sturge, J. & Rehm, J. (2007) Interventions to reduce harm associated with adolescent substance use. The Lancet,. 369, 1391-401.

 

 

 

The limitations of limits: understanding the usefulness of alcohol guidelines

One of the main problems with conducting alcohol research is my amazingly accurate knowledge of the current drinking guidelines. Obviously this is not a problem for my PhD work, for that it’s quite helpful, and it would probably be detrimental to my work if I didn’t possess this knowledge. However, it’s becomes an issue when I go to the pub on a Friday, have two pints and realise I’m over my daily limit for alcohol units already (and I’ve usually only been out an hour). This is a problem because it means I’m very aware of my unit intake, but this awareness doesn’t make me want to drink less (well maybe beforehand, but not after two pints), it just makes me feel incredibly guilty (again not at the time, but when I wake up the next morning with the obligatory sore head). Add this realization of my unit intake, to the knowledge of the amount of calories in a pint, and add that to the calories in the pizza I HAD to get on the way home and I’m at a level of guilt that only a Bloody Mary can fix.

You may well be reading this thinking: what is a unit of alcohol?! Units were introduced in 1987 and in the UK one unit equates to 8g of pure alcohol, which is roughly the amount we can metabolise in one hour. Current guidelines suggest that men should not drink more than 3-4 units of alcohol a day and women no more than 2-3 units, with at least 48 hours of abstinence after a heavy drinking session. These guidelines are in place to make consumption easily quantifiable across different drinks and so that people can monitor their drinking, as the harms caused by alcohol and its addictive effects are directly related to the amount of alcohol that is consumed. However, to do this we need to be able to understand them and this can be difficult, especially as the size of a unit varies from country to country (e.g. in the US their units are nearly double ours) and there is variability in %ABV from drink to drink, so pour sizes of units vary.

Despite units as a measure of alcohol existing for almost 30 years, they have never quite caught on. In 2009 90% of respondents had heard of calculating consumption in units but only 13% kept a check on the number of units they drank. Despite many of us not using units, research shows we do use other methods to keep track of our drinking, for example in one study young drinkers were interviewed at the beginning of their night, and despite most of them over the safe daily guideline limits, they still discussed using personal guidelines to keep within their desired level, producing a ‘controlled loss of control’. Methods these drinkers discussed included making sure you’re not drinking on an empty stomach (we all remember the days of ‘eating’s cheating’) or drinking less on certain occasions, such as work drinks, where it is maybe not as acceptable to make a complete tit of yourself as it is at your birthday party.

Support for this comes from a very recent study by Lovatt and colleagues, which used focus groups to discuss existing guidelines with drinkers. The study found that most thought existing guidelines were unrealistic, particularly for individuals who were drinking with the aim of intoxication. Drinking was focussed around pleasure and sociability, and there was a view that current guidelines do not account for this. Furthermore participants emphasised that if they were to monitor their drinking, it was more likely to be in number of drinks or containers, or with their own ‘limits’ based on subjective experiences.

Another reason identified in this study for the unrealistic view of unit guidelines was because many of us (especially young adult drinkers) drink heavily one or two nights a week, therefore daily guidelines are seen as irrelevant (and no, unfortunately as handy as it would be, being tee-total Monday to Thursday doesn’t allow you that Friday binge). A recent BBC programme showed a month long experiment with two twin doctors. One twin drinking the recommended daily guidelines (3 to 4 units a day) spread out over all seven days, and the other twin drinking all of these (21 units) in one day, once a week. This was a good programme, mainly for the hilarious footage of the interaction between one very drunk person and one very sober person, which for some reason was made even funnier by the fact they were identical.

But it was also quite eye-opening, as one twin was drinking the daily ‘allowed’ guidelines, yet both men showed signs of ill-health and organ inflammation, not just the binge-drinking twin. This suggests that binge or no binge, alcohol is bad for you, and it is worrying that in this individual drinking the recommended guidelines still caused damage. The current alcohol consumption guidelines are now under review, but I imagine if the UK guidelines were reduced or we were told we should stop drinking all together we would either laugh, cry, or move to a country with higher drinking guidelines!

It is a confusing picture; if our UK guidelines are reduced then the gap between them and our subjective guidelines will be bigger, potentially making them even less likely to be used by the general public. Lovatt and colleagues emphasised that aspects such as social dimensions should also be taken into account in the development of guidelines and in the Government’s 2012 Alcohol Strategy responses to anti-social behaviour and binge drinking were priorities as well as tackling long-term health risks. Of course guidelines based on health risks are vital and should definitely exist, and they are particularly useful when people are trying hard to cut down. However, with the guidelines being so far removed from our current drinking culture, it’s not surprising they are often (purposefully) ignored.

Pharmacotherapy for anxiety and comorbid alcohol use disorders

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Anxiety disorders frequently co-occur with alcohol dependence. Diagnosis of alcohol dependence is approximately two to four times more likely in individuals diagnosed with anxiety disorders (Hasin et al., 2007). The co-occurrence of these disorders has been associated with more severe symptoms, higher rates of relapse and a corresponding increase in using mental health services (Kessler, 1996).

Certain forms of psychotherapy, such as cognitive behaviour therapy (CBT) might be limited by comorbid alcohol dependency. In contrast, behavioural programmes designed for treating alcohol dependence may not reduce anxiety. Therefore the consideration of pharmacotherapy as a treatment option is suggested.

Some drugs show promise in the treatment of anxiety and comorbid alcohol dependence:

  • Selective serotonin re-uptake inhibitors (SSRIs) are used in the treatment of anxiety disorders and there is some evidence for favourable outcomes in those with less severe alcohol dependence (Pettinati, 2000).
  • Naltrexone (an opioid receptor antagonist) is a drug used for relapse prevention in alcohol disorders which shows some promise with post-traumatic stress disorder (PTSD) (Lubin, 2002).

However, the picture is not a straightforward one and evidence for the use of drugs is mixed. The expert view is that treatment strategies that combine medication with psychotherapy will be most effective, but again support for the usefulness of this combination is not clear.

In the current literature there are a number of shortcomings and the authors of a recent Cochrane review (Ipser et al, 2015) emphasise a systematic review and meta-analysis is needed to quantify the extent of this.

People diagnosed with anxiety disorders are 2-4 times more likely to also be diagnosed with alcohol dependence.

Methods

The Cochrane reviewers searched for all randomised controlled trials (RCTs) for treating anxiety disorders with comorbid alcohol use disorders (according to DSM-III, DSM-IV OR DSM-IV-TR criteria). All medication interventions in which the drug was administered to treat anxiety disorders were eligible for inclusion.

Primary outcomes were clinical treatment response (assessed by the Clinical Global Impressions- Improvement scale (CGI-I)), the reduction of symptom severity and the acceptability of medication. Secondary outcomes were scores on rating scales for disorders other than the primary anxiety disorder; such as abstinence and reduction of alcohol use and reduction of comorbid symptoms of depression.

Results

Five RCTs were eligible for inclusion in the review, with a sample size of 290 participants. Four trials assessed the efficacy of sertraline or paroxetine (selective serotonin re-uptake inhibitors (SSRIs)) and one trial investigated the efficacy of buspirone (5-hydroxytryptamine (5-HT) partial agonist). Interventions varied in duration from eight to 24 weeks, and the sample was mostly male (70%).

Primary outcomes

  • There was preliminary support for the efficacy of paroxetine in improving clinical response in people with social anxiety disorder (SAD) (RR (risk ratio) = 2.23, 95% CI (confidence interval) = 1.13 to 4.41). More than twice as many people with SAD responded to paroxetine (57.6%) than placebo (25.85%) after a mean of 12 weeks of treatment.
  • Study investigators reported that buspirone was superior to placebo in reducing the severity of anxiety symptoms over 12 weeks.
  • No evidence of efficacy in reducing anxiety was observed for paroxetine (mean difference (MD) =14.70, 95% CI = -33.00 to 3.60) and sertraline.
  • There was no evidence that the severity of anxiety disorder symptoms were reduced after treatment with medication. The one exception was busprione, but evidence of reporting bias in this study was emphasised by authors.
  • There was high evidence of attrition in the studies (43.1%) and high frequencies of sexual dysfunction were reported with SSRIs.

Secondary outcomes

  • There were few effects on drinking outcomes reported.
  • There was no evidence for a reduction in symptoms of depression.
  • There was no data on quality of life or functional disability.

You've heard this clarion call before in the woodland: more large and rigorous RCTs needed!

Discussion

This Cochrane review concluded that the evidence base for pharmacotherapy for treating comorbid alcohol use disorders and anxiety is inconclusive.

Authors were unable to retrieve sufficient data to address the majority of initially identified outcomes of interest and although there was a response to the SSRI paroxetine reported, the evidence was of very low quality. Evidence quality was assessed by authors using GRADE (based on design limitations, indirectness of evidence, inconsistency and imprecision of results and a high probability of publication bias).

Limitations

Further problems with the included studies are highlighted in the review:

  • Most studies restricted their inclusion to those without other substance use disorders, despite a high degree of comorbidity between drugs and alcohol in a ‘real life’ sample.
  • The sample was majority male, limiting the strength of applicability of conclusions to a female population.
  • Selective reporting of outcomes may have also biased conclusions; this was particularly the case in the buspirone study (Tollefson et al., 1992).
  • The high attrition rate observed in the studies (43.1%) is a cause for concern. This may mean biased outcomes if drop-outs were due to intervention components, but also because of the small sample sizes in the study, the likeliness that medication effects will be detected is decreased.
  • The presence of possible sources of bias could not be tested formally due to the small number of studies.

Conclusion

Good quality evidence is seriously lacking. Few rigorously designed RCTs were identified assessing the effectiveness of medication in people with comorbid anxiety and alcohol use disorders. The Cochrane reviewers stress that there is an urgent need for additional controlled pharmacotherapy trials in this population.

Research evidence on effectiveness of medication in treating anxiety disorders and comorbid alcohol use disorders is of a very low quality.

Links

Primary paper

Ipser JC, Wilson D, Akindipe TO, Sager C, Stein DJ. Pharmacotherapy for anxiety and comorbid alcohol use disorders. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD007505. DOI: 10.1002/14651858.CD007505.pub2.

Other references

Hasin, D., Stinson F., Ogburn, E. & Grant, B. (2007) Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 64, 830–42. [PubMed abstract]

Kessler, R., Nelson, C., McGonagle K., Edlund, M., Frank R. & Leaf P (1996) The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization (PDF). American Journal of Orthopsychiatry, 66, 17–31.

Lubin, G., Weizman, A., Shmushkevitz, M. & Valevski, A. (2002) Short-term treatment of post-traumatic stress disorder with naltrexone: an open-label preliminary study. Human Psychopharmacology, 17, 181–5. [PubMed abstract]

Pettinati, H., Volpicelli, J., Kranzler, H., Luck, G., Rukstalis, M. & Cnaan, A. (2000) Sertraline treatment for alcohol dependence: interactive effects of medication and alcoholic subtype. Alcoholism, Clinical and Experimental Research, 24, 1041–9. [PubMed abstract]

Tollefson, G., Montague-Clouse, J. & Tollefson, S. (1992) Treatment of comorbid generalized anxiety in a recently detoxified alcoholic population with a selective serotonergic drug (buspirone). Journal of Clinical Psychopharmacology, 12, 19–26. [PubMed abstract]

– See more at: http://www.nationalelfservice.net/mental-health/anxiety-disorder/pharmacotherapy-for-anxiety-and-comorbid-alcohol-use-disorders/#sthash.cGTJ2vfD.dpuf

Varenicline and the risk of neuropsychiatric adverse events and death

I have recently started blogging for The Mental Elf website. Here is my first post on the drug Varenicline for smoking cessation, and the risk of neuropsychiatric adverse events and death. Click here for the original blog.

Smoking is the leading cause of preventable morbidity and premature death in the UK and internationally (Peto et al., 2000) and costs the National Health Service around £5 billion annually, therefore smoking cessation aids are important for those wishing to quit.The most clinically effective drug for short term abstinence in smoking cessation is Varenicline (Cahill et al., 2013), which was licensed in the UK in 2006. Concerns about the drug’s neuropsychiatric safety led to issued warnings from the Medicines and Healthcare Products Regulatory Agency (MHRA) in 2008 (MHRA, 2008) and in 2009 the United States Food and Drug Administration (FDA) has required the black box warning (the strongest safety warning) to the labelling of varenicline (FDA, 2009).

A recent meta-analysis (Gibbons & Mann, 2013) found no evidence of an increased risk of depression, suicide or non-fatal self-harm (see Fluharty, 2014). However, a criticism raised was that this study was sponsored by industry and there is evidence that industry sponsored trials may report outcomes favourable to the study sponsor (Etter et al., 2007).

To provide a comprehensive evaluation Thomas and colleagues (2015) conducted a systematic review and meta-analysis to determine the risk of neuropsychiatric adverse events and death in all published randomised placebo controlled trials of varenicline.

Methods

Authors sought randomised placebo controlled trials of any duration of varenicline at the maximum dose (1mg twice daily) in smokers and non-smokers.

Primary outcome measures were neuropsychiatric adverse events including:

  • Suicide
  • Attempted suicide
  • Suicidal ideation
  • Depression

Secondary outcomes included other neuropsychiatric outcomes (abnormal dreams, aggression, anxiety, fatigue, insomnia, irritability, sleep disorders, somnolence) and death.

Results

The meta-analysis included 39 studies, totalling 10,761 patients, with 5,817 patients prescribed a dose of 1mg of varenicline twice daily and 5,844 prescribed placebo. The duration of treatment ranged from one week to 52 weeks.

Primary outcomes

  • Two people died by suicide (both in varenicline arms) and four attempted to do so (two in the varenicline arms and two in the placebo)
  • There was no evidence of an increased risk of:
    • Suicide or suicide attempt (OR = 1.67, 95% CI = 0.33 to 8.57; p = 0.54)
    • Suicidal ideation (OR = 0.58, 95% CI 0.28 to 1.20; p = 0.14)
    • Depression (OR = 0.96, CI 95% 0.75 to 1.22; p = 0.74)
    • Death (OR = 1.05, CI 95% 0.47 to 2.38; p = 0.9)

Secondary outcomes

  • There was no evidence of an increased risk of:
    • Irritability (OR = 0.98, 95% CI = 0.81 to 1.17; p = 0.79)
    • Aggression (OR = 0.91, 95% CI = 0.52 to 1.59; p = 0.75)
    • Somnolence (OR = 1.23, 95% CI = 0.94 to 1.62; p = 0.13)
  • Varenicline was associated with an increased risk of:
    • Sleep disorders (OR = 01.63, 95% CI = 1.29 to 2.07; p < 0.001)
    • Insomnia (OR = 1.56, 95% CI = 1.36 to 1.78; p < 0.001)
    • Abnormal dreams (OR = 2.38, 95% CI = 2.05 to 2.77; p < 0.001)
    • Fatigue (OR = 1.28, 95% CI = 1.06 to 1.55; p = 0.01)
  • There was some evidence of a reduced risk of:
    • Anxiety (OR = 0.75, 95% CI = 0.61 to 0.93; p = 0.008)
  • There was no evidence of a variation in the side effects of depression and suicidal ideation by age group, gender, ethnic origin, presence or absence of psychiatric illness, smoking status and whether the trial was industry sponsored or not.

The review

Discussion

This review finds no increased risk of suicide or attempted suicide, suicidal ideation, depression or death in those treated with varenicline; these results are consistent with a previous meta-analysis (Gibbons & Mann, 2013).

Authors conclude that the health benefits of varenicline for smoking cessation outweigh the risks for suicidal behaviour which they describe as currently unproved. They state:

“The reduction in varenicline prescribing in the UK should be as much a cause for concern to clinicians, regulatory agencies, and policy makers as the unfounded fears regarding varenicline’s association with suicidal behaviour.”

Limitations

The study has some limitations. The authors emphasise that due to the small number of suicides and attempted suicides (n=6) major adverse effects for this outcome can’t be ruled out.

A recent editorial (Harrison-Woolrych, 2015) describes the reasons for the possible disconnect between the findings of meta-analyses and ‘real life’ evidence from case reports showing associations with the drug and mental health side effects (e.g. Harrison-Woolrych & Ashton, 2011). The strict inclusion and exclusion criteria in randomised controlled trials means history of psychiatric illness is often an exclusion criteria, for example in the current meta-analysis, 61.3% of all participants had no history of psychiatric illness. Therefore those in randomised controlled trials might have a lower risk of psychiatric effects than those stopping smoking in real life.

A third of the studies included in the meta-analysis included a majority of men, and it’s been shown that women are over-represented in the group who experience psychiatric events (Harrison-Woolrych & Ashton, 2011). Other aspects of clinical trials that could explain differences in findings compared to case reports are that they often include the recommended 12 weeks of treatment, whereas in real life treatment periods vary. Furthermore the close monitoring in such trials could reduce the risk for adverse events (Harrison-Woolrych, 2015).

Conclusions

The author’s conclusion that that the concerns around suicide are unfounded should be taken carefully. Given the small number of suicide and attempted suicides (n=6), major adverse events for this outcome cannot be ruled out.

Further research is needed to determine whether different smoking populations (e.g., those with existing psychiatric disorders) are more vulnerable to the potential varenicline-associated risks.

The reviewers urge caution and call for further relevant studies before we draw any hard conclusions about the neuropsychiatric safety of varenicline

Links

Primary study

Thomas, K. H., Martin, R. M., Knipe, D. W., Higgins, J. P. T., & Gunnell, D. (2015). Risk of neuropsychiatric adverse events associated with varenicline: systematic review and meta-analysis. BMJ, 350:h1109 doi: http://dx.doi.org/10.1136/bmj.h1109

Other references

Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329. DOI: 10.1002/14651858.CD009329.pub2.

Etter, J. F., Burri, M., & Stapleton, J. (2007). The impact of pharmaceutical company funding on results of randomized trials of nicotine replacement therapy for smoking cessation: a meta-analysis. Addiction, 102, 815-822. doi: 10.1111/j.1360-0443.2007.01822.x [PubMed abstract]

Fluharty, M. Varenicline, smoking cessation and neuropsychiatric adverse events. The Mental Elf, 17 Feb 2014

Gibbons, R. D., & Mann, J. J. (2013). Varenicline, smoking cessation, and neuropsychiatric adverse events (PDF). Am J Psychiatry, 170, 1460-1467. doi: 10.1176/appi.ajp.2013.12121599

Harrison-Woolrych, M. & Ashton, J. (2011) Psychiatric adverse events associated with varenicline: an intensive postmarketing prospective cohort study in New Zealand. Drug Saf, 34, 763-72 [PubMed abstract]

Harrison-Woolrych, M. (2015). Mental health effects of varenicline. BMJ, 350:h1168.

US Food and Drug Administration (FDA) (2009) black box warning: Information for healthcare professionals: varenicline (marketed as Chantix) and bupropion (marketed as Zyban, Wellbutrin, and generics). Silver Spring, Md, FDA.

Medicines and Healthcare Products Regulatory Agency (MHRA) (2008). Varenicline: adverse psychiatric reactions, including depression. Drug Safety Update, 2, 2–3.

Peto R, Darby S, Deo H, Silcocks P, Whitley E, Doll R. (2000). Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies. BMJ, 321: 323.

All women want for Christmas is Baileys

In the lead up to Christmas a new advert appeared on Spotify. It was a lady, and she said “Tonight’s gonna be all about us, here’s to my girls. Toast the girls with Baileys this Christmas”. As a huge Baileys fan I was disappointed, and not just because the advert interrupted my incredible music taste. It was because I thought, what if the boys want to toast with Baileys, or me and my girls want to toast with pints of Stella? The TV advert is pretty terrible too:

According to the global content creations director of Diageo this new Baileys campaign “marks the next phase in our exciting journey to re-ignite the true essence of the Baileys brand by celebrating the brilliant spirit of women”. An advert made by women, with an all-female agency team, female production team and with the background music by an all-female band. Apparently the advert shines the “light on the insight that women bring out the brilliance in each other” and “expresses that particular magic you feel when you’re with your best girlfriends”. I’m not sure Baileys is necessary to show our magic and brilliance, in fact I think Diageo is using our magic and brilliance to market a beverage. I also don’t mind if men want to celebrate their magic and brilliance too. I have plenty of male friends who share the love of the drink and would be quite offended that they’re not invited to the female Baileys party.

Over the last few decades, women have been drinking more than they ever used to, and recent statistics show over half of women interviewed drank alcohol in the previous week, and young people (aged 16-24) are most likely to have drunk heavily at least once during the week. This being equally likely for both men and women. The matching of women’s drinking to men has been linked by some to the UK’s “ladette” culture, a ladette being “a young woman who behaves in a boisterously assertive or crude manner and engages in heavy drinking sessions.” If you can’t picture a boisterous, crude, heavy drinking female feel free to google search for some delightful images. Personally I don’t like the idea that we consume greater amounts just to be more like our male counterparts, but regardless of the cause, we are drinking more.

The alcohol industry never miss a trick, and adapt their strategies to appeal to women. In 2005 2.2% of products in the liquors and alcohol sector were aimed at women (compared with 1.1% for men). In a recent publication by Alcohol Concern it was posited that the drinks industry have taken advantage of women’s’ consumption of alcohol by three main routes:

  1. Concepts of female camaraderie and fun with friends
  2. Appeal of comfort and luxury
  3. Attempts to create and promote products that appeal particularly to women in terms of design and packaging- or being light- lower in calories, less alcoholic, less gassy

Quotes from the industry were included in the document, for the new chocolate Baileys it was stated that:

“Two things above all else lay at the heart of Bailey’s historic success: first, the perception that it was the choice of modern, aspiring, progressive women, achieved through the great marketing campaigns of old; second, we had brilliant, groundbreaking innovation at a product level.” Diageo, 2009

Another drink linked to female drinking is Lambrini. In fact my female flatmate received a bottle of Lambrini this year as her “shit” secret santa gift (Yes, that is what happens now, gone are the days of gifts we like..). Would this have been the shit drink of choice for a guy? It’s doubtful, I imagine it may have been a bottle of Frosty Jacks.

Apparently, “Lambrini is the perfect social lubricant – a light, easy to drink, affordable (wannabe wine) that gets their nights out or in off to a good start. They’ll drink bucket loads of the stuff and still manage to last the duration…Drinking starts early! Early afternoon at the weekend or straight after work Monday to Friday, meeting your girly mates and getting on it is the only way forward.” Lambrini creative brief, 2005

Additionally Baileys sponsored the prize for female fiction and Lambrini sponsors Cheeky Bingo, as “Cheeky players love to get together, have fun and chat online, just like Lambrini girls”. I’m sure a diet of Baileys really gets the creative juices flowing (I don’t think this is too dissimilar from sports sponsorship, where the link gives the impression that our favourite teetotal sports players are regularly sipping whisky and downing pints). I’m also not sure sitting at my computer playing online Bingo and chatting to people I don’t know with a bottle of Lambrini is my ideal evening of fun.

So what are the dangers of the advertisements and branding that appeal solely to women, and why shouldn’t women be matching men’s consumption of alcohol? Well this may be one occasion where gender equality should not be fought for. Gender differences in body structure and chemistry mean that women absorb more alcohol, and take longer to metabolise it. Thus when drinking equal amounts, women will have higher blood alcohol levels and the effects will occur more quickly and last longer.

The risk of cirrhosis and other alcohol-related liver diseases is higher for women than men, research suggests that women are more vulnerable than men to the brain damaging effects of excessive alcohol use, with damage appearing after shorter periods of excessive drinking. Women have the additional danger of increased risk of miscarriage, stillbirth and premature delivery with excessive drinking in and around pregnancy. There is also the risk of foetal alcohol syndrome in the baby; growth, mental and physical problems that occur when an expecting mother drinks alcohol. Furthermore, the risk of breast cancer also increases as alcohol use increases and ridiculously the alcohol industry have managed to cash in on this. Heineken introduced a beer to appeal to women called “Wieckse Rose”, the advertisement for this aimed to increase the awareness of breast cancer. How can you increase awareness by selling something contributing to the disease?! It’s like introducing a new brand of cigarette with the aim of increasing awareness of lung cancer, or cakes to raise the awareness of diabetes.

You may be thinking, this is all well and good, but both men and women are constantly subjected to alcohol advertising anyway, so what’s the problem with gender specific marketing too? One issue could be the marketing of specific drinks to women that appeal because they have lower calories. For example, Skinnygirl, the liquor brand in the US. It’s clever marketing as it gives the impression of a “healthier” alcoholic drink. The idea is that by steering away from calorific beer and wine, towards drinks such as clear spirits and light cocktails one can still be within the day’s calorie count. However, spirits contain a higher alcohol concentration. Diet goal may be reached, but daily unit consumption exceeded.

We can’t deny that different drinks appeal to different genders, or at least they are marketed that way. And yes, it’s probably true that women consumed more Baileys this Christmas than men. But a thought-provoking question is whether we would like ‘feminine’ drinks so much if they were marketed towards men? Would we make the same choices if we hadn’t seen the adverts? Understanding the motives behind the intelligent and dangerous marketing by the alcoholic drinks industry definitely makes one less naïve to the methods used. I’d like to say that in protest, to defy what is expected by the industry from myself and my gender, that I will only drink real ales, dip Yorkies in my bourbon and order whiskey on the rocks in future. But unfortunately I am way too attached to Baileys, and I’m desperate to try all these new flavours they’re bringing out.