Protocol for the proactive or reactive telephone smoking cessation support (PORTSSS) trial

Background: Telephone quit lines are accessible to many smokers and are used to engage motivated smokers to make quit attempts. Smoking cessation counselling provided via telephone can either be reactive (i.e. primarily involving the provision of evidence-based information), or proactive (i.e. primarily involving repeated, sequenced calls from and interaction with trained cessation counsellors). Some studies have found proactive telephone counselling more effective and this trial will investigate whether or not proactive telephone support for smoking cessation, delivered through the National Health Service (NHS) Smoking Helpline is more effective or cost-effective than reactive support. It will also investigate whether or not providing nicotine replacement therapy (NRT), in addition to telephone counselling, has an adjunctive impact on smoking cessation rates and whether or not this is cost effective. Methods: This will be a parallel group, factorial design RCT, conducted through the English national NHS Smoking Helpline which is run from headquarters in Glasgow. Participants will be smokers who call the helpline from any location in England and who wish to stop smoking. If 644 participants are recruited to four equally-sized trial groups (total sample size = 2576), the trial will have 90% power for detecting a treatment effect (Odds Ratio) of 1.5 for each of the two interventions: i) proactive versus reactive support and ii) the offer of NRT versus no offer. The primary outcome measure for the study is self-reported, prolonged abstinence from smoking for at least six months following an agreed quit date. A concurrent health economic evaluation will investigate the cost effectiveness of the two interventions when delivered via a telephone helpline. Discussion: The PORTSSS trial will provide high quality evidence to determine the most appropriate kind of counselling which should be provided via the NHS Smoking Helpline and also whether or not an additional offer of cost-free NRT is effective and cost effective for smoking cessation. Trial Registration: (clinicaltrials.gov): NCT0077594

Effect of Smoke-Free Legislation on Adult Smoking Behaviour in England in the 18 Months following Implementation

Comprehensive smoke-free legislation covering all enclosed public places and workplaces was implemented in England on 1 July 2007. This study examines the impact of this legislation on smoking prevalence, number of cigarettes smoked and location of smoking, controlling for secular trends through the end of 2008.Repeat cross sectional survey using nationally representative data from the Health Survey for England (HSE). In total there are 54,333 respondents from 2003-2008. Logit and linear regression models were used to examine the effect of the legislation on smoking prevalence and the number of cigarettes smoked daily among continuing smokers which took the underlying trend into account. Our finding suggest that smoking prevalence (current smoker) decreased from 25% in 2003 to 21% in 2008 (AOR = 0.96 per year, 95% CI = 0.95-0.98, P<0.01) and the mean number of cigarettes consumed daily by smokers decreased from 14.1 in 2003 to 13.1 in 2008 (coefficient for time trend = -0.28±0.06 SE cig/day per year, P<0.01). After adjusting for these trends the introduction of smoke-free legislation was not associated with additional reductions in smoking prevalence (AOR = 1.02, 95% CI = 0.94-1.11, P = 0.596) or daily cigarette use in smokers (0.42±0.28 SE; P = 0.142). The percentage of respondents reporting smoking 'at work' and 'inside pubs or bars' decreased significantly from 14% to 2% (p<0.001) and from 34% to 2% (p<0.001), respectively, after the legislation. The percentage reporting smoking 'inside restaurants, cafes, or canteens' decreased significantly from 9% to 1% (p<0.001) and 'inside their home' decreased significantly from 65% to 55% (p<0.01).There is widespread compliance with the smoke-free legislation in England, which has led to large drops in indoor smoking in all venues, including at home. Declines in smoking prevalence and consumption continued along existing trends; they did not accelerate during the 18 months immediately following implementation

Ecosystem Resilience and Threshold Response in the Galápagos Coastal Zone

Background: The Intergovernmental Panel on Climate Change (IPCC) provides a conservative estimate on rates of sea-level rise of 3.8 mm yr⁻¹ at the end of the 21st century, which may have a detrimental effect on ecologically important mangrove ecosystems. Understanding factors influencing the long-term resilience of these communities is critical but poorly understood. We investigate ecological resilience in a coastal mangrove community from the Galápagos Islands over the last 2700 years using three research questions: What are the 'fast and slow' processes operating in the coastal zone? Is there evidence for a threshold response? How can the past inform us about the resilience of the modern system?Methodology/Principal Findings: Palaeoecological methods (AMS radiocarbon dating, stable carbon isotopes (δ13C)) were used to reconstruct sedimentation rates and ecological change over the past 2,700 years at Diablas lagoon, Isabela, Galápagos. Bulk geochemical analysis was also used to determine local environmental changes, and salinity was reconstructed using a diatom transfer function. Changes in relative sea level (RSL) were estimated using a glacio-isostatic adjustment model. Non-linear behaviour was observed in the Diablas mangrove ecosystem as it responded to increased salinities following exposure to tidal inundations. A negative feedback was observed which enabled the mangrove canopy to accrete vertically, but disturbances may have opened up the canopy and contributed to an erosion of resilience over time. A combination of drier climatic conditions and a slight fall in RSL then resulted in a threshold response, from a mangrove community to a microbial mat.Conclusions/Significance: Palaeoecological records can provide important information on the nature of non-linear behaviour by identifying thresholds within ecological systems, and in outlining responses to 'fast and slow' environmental change between alternative stable states. This study highlights the need to incorporate a long-term ecological perspective when designing strategies for maximizing coastal resilience.</p

Prokaryotic and Eukaryotic Community Structure in Field and Cultured Microbialites from the Alkaline Lake Alchichica (Mexico)

The geomicrobiology of crater lake microbialites remains largely unknown despite their evolutionary interest due to their resemblance to some Archaean analogs in the dominance of in situ carbonate precipitation over accretion. Here, we studied the diversity of archaea, bacteria and protists in microbialites of the alkaline Lake Alchichica from both field samples collected along a depth gradient (0–14 m depth) and long-term-maintained laboratory aquaria. Using small subunit (SSU) rRNA gene libraries and fingerprinting methods, we detected a wide diversity of bacteria and protists contrasting with a minor fraction of archaea. Oxygenic photosynthesizers were dominated by cyanobacteria, green algae and diatoms. Cyanobacterial diversity varied with depth, Oscillatoriales dominating shallow and intermediate microbialites and Pleurocapsales the deepest samples. The early-branching Gloeobacterales represented significant proportions in aquaria microbialites. Anoxygenic photosynthesizers were also diverse, comprising members of Alphaproteobacteria and Chloroflexi. Although photosynthetic microorganisms dominated in biomass, heterotrophic lineages were more diverse. We detected members of up to 21 bacterial phyla or candidate divisions, including lineages possibly involved in microbialite formation, such as sulfate-reducing Deltaproteobacteria but also Firmicutes and very diverse taxa likely able to degrade complex polymeric substances, such as Planctomycetales, Bacteroidetes and Verrucomicrobia. Heterotrophic eukaryotes were dominated by Fungi (including members of the basal Rozellida or Cryptomycota), Choanoflagellida, Nucleariida, Amoebozoa, Alveolata and Stramenopiles. The diversity and relative abundance of many eukaryotic lineages suggest an unforeseen role for protists in microbialite ecology. Many lineages from lake microbialites were successfully maintained in aquaria. Interestingly, the diversity detected in aquarium microbialites was higher than in field samples, possibly due to more stable and favorable laboratory conditions. The maintenance of highly diverse natural microbialites in laboratory aquaria holds promise to study the role of different metabolisms in the formation of these structures under controlled conditions

Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation.

Background: Recent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders’ engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England. Methods: The study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the 'intervention’) and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders. Discussion: This interdisciplinary study examines, for the first time, whether and how public health stakeholders involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research

Quantitative Zielvorgaben zur Verringerung der gesundheitlichen Ungleichheit. Lernen von England und anderen westeuropäischen Staaten

In einigen westeurop&auml;ischen Staaten wird schon seit geraumer Zeit versucht, das Ziel &bdquo;Verringerung der gesundheitlichen Ungleichheit&ldquo; so genau wie m&ouml;glich zu definieren. Dabei wird auch vor einer Quantifizierung dieser Zielsetzung nicht zur&uuml;ckgeschreckt. Mit &#39;Quantifizierung&#39; sind hier zahlenm&auml;&szlig;ig fixierte Vorgaben gemeint wie: Die zurzeit vorhandenen Unterschiede in der Mortalit&auml;t zwischen Statusgruppe A und Statusgruppe B sollen in 10 Jahren um 15% kleiner sein. Derartige Vorgaben bergen erhebliche Risiken, aber auch M&ouml;glichkeiten. Die Risiken sind prim&auml;r politischer Natur: Nach Ablauf der gesetzten Frist ist gut zu &uuml;berpr&uuml;fen, wie gut dieses Ziel erreicht worden ist, und auch schon in den Jahren bis zum Ablauf der Frist ist gut zu sehen, ob die Entwicklung in die vorgesehene Richtung geht. Diese &Uuml;berpr&uuml;fung bietet wenig Spielraum f&uuml;r Verschleierungen oder Verharmlosungen. Den Risiken steht jedoch ein wichtiger Vorteil gegen&uuml;ber: Die Planung von Ma&szlig;nahmen kann sehr zielgerichtet erfolgen. Misserfolge k&ouml;nnen zu einer neuen und besseren Ausrichtung der Ma&szlig;nahmen f&uuml;hren. Quasi von selbst stellen sich sehr praxisnahe konkrete Fragen wie z.B.: Welche Ma&szlig;nahme hat welchen Effekt auf die gesundheitliche Ungleichheit? Wer ist f&uuml;r welche Ma&szlig;nahme verantwortlich? Wie k&ouml;nnen diese Ma&szlig;nahmen fachlich und zeitlich koordiniert werden? Wer ist f&uuml;r die Koordination verantwortlich? Wie kann der Erfolg der Ma&szlig;nahmen dadurch abgesichert werden, dass die Personengruppe, deren Gesundheitszustand verbessert werden soll, in die Planung und Durchf&uuml;hrung der Ma&szlig;nahmen eingebunden wird? Wie wirken sich die sozialen und politischen Entwicklungen, die au&szlig;erhalb des geplanten Ma&szlig;nahme-Katalogs liegen (Arbeitsmarkt, Reform der Krankenversicherung etc.) auf die gesundheitliche Ungleichheit aus

Measuring the tail of the dog that doesn't bark in the night: the case of the national evaluation of Choose Life (the national strategy and action plan to prevent suicide in Scotland)

Background Learning about the impact of public health policy presents significant challenges for evaluators. These include the nebulous and organic nature of interventions ensuing from policy directives, the tension between long-term goals and short-term interventions, the appropriateness of establishing control groups, and the problems of providing an economic perspective. An example of contemporary policy that has recently been subject to evaluation is the first phase of the innovative Scottish strategy for suicide prevention (Choose Life). Discussion and summary This paper discusses how challenges, such as those above, were made manifest within this programme. After a brief summary of the overarching approach taken to evaluating the first phase of Choose Life, this paper then offers a set of recommendations for policymakers and evaluators on how learning from a second phase might be augmented. These recommendations are likely to have general resonance across a range of policy evaluations as they move from early planning and implementation to more mature phases