Smoking related disease risk, area deprivation and health behaviours

Acknowledgements We thank Professor Luke Vale, Dr Diane Stockton and participants at the Faculty of Public Health conference, Aviemore, Scotland, November 2011 and UK Society for Behavioural Medicine conference, Stirling, Scotland, December 2011 for helpful comments. Funding This work was supported by the Medical Research Council National Preventive Research Initiative Phase 2 [G0701874]; see http://www.npri.org.uk. The Funding Partners relevant to this award are: British Heart Foundation; Cancer Research UK; Department of Health; Diabetes UK; Economic and Social Research Council; Medical Research Council; Research and Development Office for the Northern Ireland Health and Social Services; Chief Scientist Office; Scottish Government Health Directorates; The Stroke Association; Welsh Assembly Government and World Cancer Research Fund. The Health Economics Research Unit is funded by the Chief Scientist Office of the Scottish Government Health and Social Care DirectoratePeer reviewedPostprin

Household Purchasing of Cheap Alcohol : Who Would be Most Affected by Minimum Unit Pricing?

The authors would like to acknowledge Dr Diane Skåtun, Dr Ramses Abul Naga and Dr Damilola Olajide for providing econometric advice on the paper. The comments and suggestions from two anonymous referees from the Nordic Journal of Health Economics were very useful to improving the content of this paper. The data used in this study were from the Rowett Institute of Nutrition and Health (RINH) Kantar data resource. Core funding from the Chief Scientist Office, Scottish Government Health and Social Care Directorates and the University of Aberdeen is gratefully acknowledged.Peer reviewedPublisher PD

The funding of the National Health Service: what is the problem and is social insurance the answer?

Whenever the British National Health Service (NHS) appears to be short of money, the medical, political and proponents of various forms of alternative financing for health care enjoy a resurgence. What would be the economic effects of changing the financial base of the NHS from general taxation to a system of social (or National) insurance? The main effects of such a change can be summarised as first, a regressive redistribution of post-tax income from low earners to the better paid, second, an increase in the supply of labour from low income groups and possibly a reduction in the supply of labour from higher income groups, third, a reduction in aggregate demand and a fall in the demand for labour which may increase unemployment, and, finally, if forward shifting of the tax is assumed, a higher price level. Apart from the tax changes detailed in Section 3, all these effects are qualitative and their precise size will depend on the new tax schedule an the nature of the shifting of the employers’ part of the new tax. As with the proposed Poll tax, the regressive nature of the social insurance system could be mitigated by a progressive tax schedule. However, such a solution would increase the administrative costs of collecting tax revenue and offer no solution to the resolution of the problem of how to achieve a consensus over the level and nature of health care provision. The debate about health care finance leads policy makers into blind alleys. The proper area for policy debate us how, whatever the mix of public and private finance, can efficiency in the use of scarce resources be achieved? To achieve efficiency it is necessary to provide care up to the point where the value of benefits (enhancements in the duration and quality of life) just equals the costs. Unfortunately in all health care systems benefits and costs are unknown and the efficiency of health care provision is impossible to determine. The resolution of such problems would not only be useful in identifying “value for money”, but also whether health care is actually improving the health of citizens.

What can secondary data tell us about household food insecurity in a high-income country context?

In the absence of routinely collected household food insecurity data, this study investigated what could be determined about the nature and prevalence of household food insecurity in Scotland from secondary data. Secondary analysis of the Living Costs and Food Survey (2007–2012) was conducted to calculate weekly food expenditure and its ratio to equivalised income for households below average income (HBAI) and above average income (non-HBAI). Diet Quality Index (DQI) scores were calculated for this survey and the Scottish Health Survey (SHeS, 2008 and 2012). Secondary data provided a partial picture of food insecurity prevalence in Scotland, and a limited picture of differences in diet quality. In 2012, HBAI spent significantly less in absolute terms per week on food and non-alcoholic drinks (£53.85) compared to non-HBAI (£86.73), but proportionately more of their income (29% and 15% respectively). Poorer households were less likely to achieve recommended fruit and vegetable intakes than were more affluent households. The mean DQI score (SHeS data) of HBAI fell between 2008 and 2012, and was significantly lower than the mean score for non-HBAI in 2012. Secondary data are insufficient to generate the robust and comprehensive picture needed to monitor the incidence and prevalence of food insecurity in Scotland.</p

Developing a timeline for evaluating public health nutrition policy interventions: what are the outcomes and when should we expect to see them?

Objective: To develop a timeline for evaluating public health nutrition policy interventions. Design: Concept mapping, a stakeholder-driven approach for developing an evaluation framework to estimate the ‘time to impact’ for policy interventions. The Schools (Health Promotion and Nutrition) (Scotland) Act 2007 was used as the model to develop the evaluation timeline as it had typical characteristics of government policy. Concept mapping requires stakeholders to generate a list of the potential outcomes, sort and rate the outcomes. Multidimensional scaling and hierarchical cluster data analysis were used to develop an anticipated timeline to impact for the policy. Setting: United Kingdom. Subjects: One hundred and eleven stakeholders representing nutrition, public health, medicine, education and catering in a range of sectors: research, policy, local government, National Health Service and schools. Results: Eighty-five possible outcomes were identified and grouped into thirteen clusters describing higher-level themes (e.g. long-term health, food literacy, economics, behaviour, diet, education). Negative and unintended consequences were anticipated relatively soon after implementation of the policy, whereas positive outcomes (e.g. dietary changes, health benefits) were thought likely to take longer to emerge. Stakeholders responsible for implementing the legislation anticipated that it would take longer to observe changes than those from policy or research. Conclusions: Developing an anticipated timeline provides a realistic framework upon which to base an outcome evaluation for policy interventions and identifies positive and negative outcomes as well as considering possible unintended consequences. It offers benefit to both policy makers and researchers in mapping the progress expected towards long-term health goals and outcomes

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

Objective To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women

"A Lot of People Are Struggling Privately. They Don’t Know Where to Go or They’re Not Sure of What to Do” : Frontline Service Provider Perspectives of the Nature of Household Food Insecurity in Scotland

Funding: This research was funded by NHS Health Scotland with additional funding support provided for Flora Douglas’ and Stephen Whybrow’s time from the Scottish Government’s RESAS programme. Core support to HERU from the Chief Scientist Office Scottish Government Health and Social Care Directorates and the University of Aberdeen is gratefully acknowledged. Acknowledgments: We would like to acknowledge Bill Gray and Dionne MacKinnon (BG NHS Health Scotland and DMcK, formerly of NHS Health Scotland) for their professional review and support during the project and our study participants for their time and expertise. We are also grateful to the anonymous reviewers of our paper for their time and extremely helpful contributions to this work.Peer reviewedPublisher PD

Health First: An evidence-based alcohol strategy for the UK

Alcohol is taken for granted in the UK today. It is easy to get hold of, increasingly affordable, advertised everywhere and accepted by many as an integral part of daily life. Yet, despite this, the great majority of the population recognise the harm that alcohol causes. They believe that drinking damages health, drives anti social behaviour, harms children and families and creates huge costs for the NHS and the Police. They are right. Every year in the UK, there are thousands of deaths and over a million hospital admissions related to drinking. More than two in five (44%) violent crimes are committed under the influence of alcohol, as are 37% of domesti c violence incidents. One fifth of all violent crime occurs in or near pubs and clubs and 45% of adults avoid town centres at night because of drunken behaviour. The personal, social and economic cost of alcohol has been estimated to be up to &pound;55bn for England and &pound;7.5bn for Scotland. None of this should be taken for granted. The impact of drinking on public health and community safety is so great that radical steps are needed to change our relationship with alcohol. We need to imagine a society where low or no alcohol consumpti on is the norm, drunkenness is socially unacceptable and town centres are safe and welcoming places for everyone to use. Our vision is for a safer, healthier and happier world where the harm caused by alcohol is minimised. This vision is achievable. But only if we tackle the primary drivers of alcohol consumption. The evidence is clear: the most effective way to reduce the harm from alcohol is to reduce the affordability, availability and attractiveness of alcohol products. It is not enough to limit the damage once people are drunk, dependent, ill or dying. We need to intervene earlier in order to reduce consumption across the entire population. The tools are available. The &lsquo;four Ps' of the marketing mix - price, product, promotion and place - are used by alcohol producers and retailers to increase their sales of alcohol. They can also be used by government to reduce alcohol sales, alcohol consumption and alcohol-related harm. Alcohol taxes are an effective public health measure as they raise prices and suppress demand. However, if they do not keep pace with both inflation and incomes, alcohol products will become more affordable over time. This has been the case in the UK. Deep discounting by retailers has also driven down the price of alcohol and encouraged heavy drinkers to maintain dangerous levels of consumption. These problems need to be tackled by a combinati on of more effective fiscal policy and controls on pricing and discounting. Alcohol products are an extraordinary anomaly. Unlike most food products, they are both remarkably harmful and excepti onally lightly regulated. As with other toxic products, the product label ought to communicate the content of the product and the risks of its consumpti on. Regulation should drive out products that appeal to young people while also incentivising the development and sale of lower strength products. The pervasive marketing of alcohol products in the UK is indefensible. Current restrictions are woefully inadequate: children and young people are regularly exposed to alcohol adverti sing in both old and new media. Only a complete ban on all alcohol advertising and sponsorship will make a lasting diff erence. Licensing practice in the UK is out of date. The focus on pubs and bars has allowed shops and supermarkets to become the dominant players in alcohol sales. Consequently, alcohol is now more available than it has ever been. This has driven pre-loading: getting drunk on cheap, shop-bought alcohol before heading out to late-opening night life. Licensing must focus on public health and seek to control the overall availability of alcohol as well as the effects of drunkenness. Beyond these populati on-level approaches, many more targeted measures are needed to reduce alcohol-related harm. Early interventi on by health and social care professionals is an important and underexploited opportunity to prevent problems developing. Stronger drink driving measures are also required. All these measures are needed. Together, they provide a template for an integrated and comprehensive strategy to tackle the harm from alcohol in the UK.Additional co-authors: Gerry McElwee, Dr Kieran Moriarty CBE, Dr Robin Purshouse, Dr Peter Rice, Alison Rogers, George Roycroft , Chit Selvarajah, Don Shenker, Eric Appleby, Dr Nick Sheron, and Colin Shevill

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

Background: Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby. Aim: To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design. Design: Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout. Setting: UK. Participants: The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking. Methods: (1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test. Results: Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A ‘ladder’ logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical ‘ladder’ towards smoking cessation and breastfeeding. Incentive interventions provide opportunity ‘rungs’ to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women’s capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave ‘healthily’ risk them feeling pressurised and failing. To avoid ‘losing face’, women may disengage. Limitations: Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population. Conclusions: Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is importan

Services just for men? Insights from a national study of the well men services pilots.

Men continue to have a lower life expectancy in most countries compared to women. Explanations of this gendered health inequality tend to focus on male risk taking, unhealthy lifestyle choices and resistance to seeking help from health services. In the period 2005-2008 the Scottish Government funded a nationwide community health promotion programme aimed at improving men's health, called Well Men Service Pilots (henceforth WMS)