The monthly ACT ATOD Research eBulletin is a concise summary of newly-published research findings and other research activities of particular relevance to ATOD and allied workers in the ACT.
Its contents cover research on demand reduction, harm reduction and supply reduction; prevention, treatment and law enforcement. ATODA's Research eBulletin is a resource for keeping up-to-date with the evidence base underpinning our ATOD policy and practice.
: Since the mid 1990s there have been calls to make naloxone, a prescription–only medicine in many countries, available to heroin and other opioid users, their peers and family members to prevent overdose deaths.
: In Australia there were calls for a trial of peer naloxone in 2000, yet at the end of that year, heroin availability and harm rapidly declined and a trial did not proceed. In other countries, a number of peer naloxone programs have been successfully implemented. Although a controlled trial had not been conducted, evidence of program implementation demonstrated that trained injecting drug using peers, and others, could successfully administer naloxone to reverse heroin overdose, with few, if any, adverse effects.
: In 2009 Australian drug researchers advocated the broader availability of naloxone for peer administration in cases of opioid overdose. Industrious local advocacy and program development work by a number of stakeholders, notably by the Canberra Alliance for Harm Minimisation and Advocacy (CAHMA), a drug user organisation, contributed to the rollout of Australia’s first prescription naloxone program in the Australian Capital Territory (ACT). Over the subsequent 18 months prescription naloxone programs were commenced in four other Australian states.
: The development of Australia’s first take-home naloxone program in the ACT has been an ‘ice-breaker’ for development of other Australian programs. Issues to be addressed to facilitate future scale-up of naloxone programs concern: scheduling and cost; legal protections for lay administration; prescribing as a barrier to scale-up; intranasal administration; worker administration; and collaboration between key stakeholders.
Reference: Lenton, S, Dietze, P, Olsen, A, Wiggins, N, McDonald, D & Fowlie, C 2014, ‘
To what extent is heroin dependence associated with death, criminal behaviour and depression?
A leading Australian longitudinal cohort study, the Australian Treatment Outcome Study, aims to determine the long-term mortality, remission, criminality and AOD/mental health comorbidity among heroin dependent Australians. Over 600 participants were administered the ATOS structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and mental health between 2001 and 2002, and over 400 completed an 11 year follow-up. By that time ‘63 participants…were deceased. The proportion of participants who reported using heroin in the preceding month decreased significantly from baseline (98.7%) to 36-month follow-up (34.0%...) with further reductions evident between 36-months and 11-years (24.7%). However, one-in-four continued to use heroin at 11-years, and close to one-half (46.6%) were in current treatment. The reduction in current heroin use was accompanied by reductions in risk-taking, crime, and injection-related health problems, and improvements in general physical and mental health. The relationship with treatment exposure was varied. Major depression was consistently associated with poorer outcome’.
Teesson, M, Marel, C, Darke, S, Ross, J, Slade, T, Burns, L, Lynskey, M, Memedovic, S, White, J & Mills, KL 2015,'Long-term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11 year findings from the Australian Treatment Outcome Study
, online ahead of print.
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What are the implications of women's equal right to drink?
The author, from the University of California, San Francisco, reflects upon the implications of the increase, in many countries of the world in recent decades, in women’s economic independence. She ‘…considers how the moral categories of acceptable drinking and drunkenness may have shifted alongside women’s rising economic independence, and looks at evidence on the potential consequences for women’s health and wellbeing.’ She goes on to argue that, ‘…as women have gained economic independence, changes in drinking norms have produced two different kinds of negative unintended consequences for women at high and low extremes of economic spectrum. As liberated women of the middle and upper classes have become more economically equal to men, they have enjoyed the right to drink with less restraint. For them, alongside the equal right to drink has come greater equality in exposure to alcohol-attributable harms, abuse and dependence. I further suggest that, as societies become more liberated, the economic dependency of low-income women is brought into greater question. Under such conditions, women in poverty-particularly those economically dependent on the state, such as welfare mothers-have become subject to more restrictive norms around drinking and intoxication, and more punitive social controls.’
Schmidt, LA 2014, ‘The equal right to drink
’, Drug and Alcohol Review
, vol. 33, no. 6, pp. 581-7.
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What is the current evidence regarding the protective health impacts of low-level alcohol consumption?
In an editorial in the leading journal Addiction
, researchers from Australia and abroad state that ‘The evolving epidemiological literature, including improved methodology for assessing causality in observational studies, is raising doubts about whether moderate alcohol consumption has a protective effect on health’.
They refer to literature that indicates that ‘…the observed protective associations may not be causal is suggested by the diverse and unlikely conditions for which such relationships have been identified (e.g. liver cirrhosis, fetal effects, the common cold). Other emerging evidence is also pointing increasingly to confounding and selection bias as important contributors to the J-shaped alcohol–health curve’. Studies have suggested that ‘…putative biomarkers of coronary heart disease (CHD) found to be improved by low doses of alcohol in experimental studies, including increased high-density lipoprotein cholesterol, reduced C-reactive protein and reduced fibrinogen, may not in fact be causally related to CHD’.
The authors conclude ‘The foundations of the hypothesis for protective effects of low-dose alcohol have now been so undermined that in our opinion the field is due for a major repositioning of the status of moderate alcohol consumption as protective. Because alcohol is a leading cause of health problems, social responsibility demands adoption of the precautionary principle, particularly in the absence of randomized studies…that support any protective effects’.
Chikritzhs, T, Stockwell, T, Naimi, T, Andreasson, S, Dangardt, F & Liang, W 2015, ‘Has the leaning tower of presumed health benefits from “moderate” alcohol use finally collapsed?
, online ahead of print.
Comment: This topic is important for a number of reasons. Professionals providing advice to patients and to the public at large about the health effects of alcohol consumption need to be clear that their advice is soundly based on the evidence. Furthermore, some leading epidemiological studies that have significant impact on alcohol policy continue to treat low-level alcohol consumption as a protective factor for a number of serious health conditions. Accordingly, need to clarify this matter is becoming increasingly important.
How likely is it that the adoption of alcohol policies to discourage binge drinkers from drinking on licensed premises will reduce alcohol-related motor vehicle crashes?
A study conducted in the USA examined how the probability of driving after a binge-drinking episode varies with the location of consumption and type of alcohol consumed, and investigated the relationship between the location of alcohol purchase and the number of alcohol-impaired fatal motor vehicle crashes. The researchers found that ‘…binge-drinkers are significantly more likely to drive after consuming alcohol at establishments that sell alcohol for on-premises consumption, e.g., from bars or restaurants, particularly after drinking beer. Further, per capita sales of alcohol for off-premises consumption are unrelated to the rate of alcohol-impaired fatal motor vehicle crashes. When disaggregating alcohol types, per capita sales of beer for off-premises consumption are negatively associated with the rate of alcohol-impaired fatal motor vehicle crashes. In contrast, total per capita sales of alcohol from all establishments (on- and off-premises) are positively related to the rate of alcohol-impaired fatal motor vehicle crashes and the magnitude of this relationship is strongest for beer sales’. They concluded that ‘…policies that shift consumption away from bars and restaurants could lead to a decline in the number of motor vehicle crashes’.
Cotti, C, Dunn, RA & Tefft, N 2014, ‘Alcohol-impaired motor vehicle crash risk and the location of alcohol purchase
’, Social Science and Medicine
, vol. 108, pp. 201-9.
Comment: It is difficult to know to what extent these findings from the USA are applicable in the Australian context. The matter is important, however, particularly for licensing authorities and for community members and community-based organisations that advocate for evidence-based limits on liquor outlet densities.
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How strong a correlation is there between density of alcohol outlets and domestic violence?
An analysis of the research on the relationship between alcohol policies and intimate partner violence (IPV) examined articles on outlet density, hours and days of sale, and pricing/taxation. The researchers found that ‘Research on outlet density has the most consistent findings, with most studies indicating that higher densities of alcohol outlets are associated with higher rates of IPV. Fewer studies have been conducted on pricing policies and policies restricting hours/days of sale, with most studies suggesting no impact on IPV rates’. The researchers concluded ‘A higher density of alcohol outlets appears to be associated with greater rates of IPV. However, there is limited evidence suggesting that alcohol pricing policies and restrictions on hours and days of sale are associated with IPV outcomes’.
Kearns, MC, Reidy, DE & Valle, LA 2015, ‘The role of alcohol policies in preventing intimate partner violence: a review of the literature’, Journal of Studies on Alcohol Drugs
, vol. 76, no. 1, pp. 21-30, open access http://www.jsad.com/jsad/article/The_Role_of_Alcohol_Policies_in_Preventing_Intimate_Partner_Violence_A_Rev/5024.html
What does contemporary research tell us about health impacts of smoking by waterpipes?
The leading journal Tobacco Control
is publishing a Special Supplement focusing on waterpipe smoking. In this article, the Supplement’s editor provides an overview of current research and concerns about waterpipes. He points out that the public health community gave little attention to waterpipes until the 1990s when significant increases in tobacco waterpipe use was observed in the Middle East, especially among teenagers and young adults. He points out that ‘This was mostly fuelled by the invention of flavoured and easier-to-use tobacco, a growing café culture in the Middle East, and expanding internet availability and globalisation. As a result, waterpipe use has snowballed globally at the start of the 21st century.’ Referring to key papers in the Special Supplement, the author notes that the "global evolution of this smoking habit has exceeded worst predictions”. In several Middle Eastern nations, the waterpipe has quickly replaced cigarettes as the most popular method of tobacco use among youth, and in several other parts of the world, it is becoming second only to cigarettes. Among US high school students, cigarette use has dropped 33% during the last decade, while use of non-cigarette combustible tobacco products, including waterpipe, has increased by 123%...The seven reviews in this Special Supplement comprehensively document the tremendous progress that has been made during the last decade in understanding waterpipe’s toxicity, epidemiology, addictiveness, health consequences to users and bystanders, and policy implications.’
This is not just a problem in the Middle Eastern nations: ‘Fuelled by misperceptions about its health effects and addictive potential, as well as a mass media environment that emphasises a global youth culture, waterpipe use is seen around the world as a socially acceptable, fashionable, relatively harmless and inexpensive way to relax with friends. These determinants have conspired in extremely lax regulatory environments around the globe to escalate waterpipe use…Even when waterpipe tobacco is specifically mentioned in tobacco control frameworks, guidance is not provided to deal with such issues as the ever-expanding proliferation of producers, advertisers and importers, and the vast array of apparatuses, supplies, tobacco flavours and packaging modes that challenge regulatory efforts. The awkward fit of the WHO’s Framework Convention on Tobacco Control for waterpipe control has been repeatedly emphasised.’
Ward, KD 2015, ‘The waterpipe: an emerging global epidemic in need of action
’, Tobacco Control
, online ahead of print.
What are the health effects of waterpipe smoking?
A review of the literature on the health effects of waterpipe smoking (WPS), part of the Tobacco Control
Special Supplement referred to above, found that ‘WPS acutely leads to increased heart rate, blood pressure, impaired pulmonary function and carbon monoxide intoxication. Chronic bronchitis, emphysema and coronary artery disease are serious complications of long-term use. Lung, gastric and oesophageal cancer are associated with WPS as well as periodontal disease, obstetrical complications, osteoporosis and mental health problems’. The reviewers concluded ‘Contrary to the widely held misconception, WPS is associated with a variety of adverse short-term and long-term health effects that should reinforce the need for stronger regulation’.
El-Zaatari, ZM, Chami, HA & Zaatari, GS 2015, ‘Health effects associated with waterpipe smoking’, Tobacco Control
, online ahead of print, open access http://tobaccocontrol.bmj.com/content/early/2015/02/09/tobaccocontrol-2014-051907.abstract
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Is there anything that Australia can learn from New Zealand's attempt to legalise new psychoactive substances?
Ross Bell, the Executive Director of the New Zealand Drug Foundation and a speaker at ATODA’s 2014 Annual Conference
, wrote in New Scientist
: ‘Hailed as a better way than prohibition, there is much to learn from New Zealand’s stalled attempt to legalise new highs’.
‘Just 18 months ago, New Zealand was the talk of the world’s drug law reformers. It had set up a system to allow new recreational drugs to gain official approval and be sold legally. Moreover, it had won sweeping parliamentary support for this – the Psychoactive Substances Act was passed with a solitary vote against. It seemed that a government had finally taken the bold step towards ending prohibition.
And yet now it is far from clear that the law will ever be used to approve a drug. A panicky government amendment may have made it unworkable. What happened has lessons for others seeking a better way than the failed “war” on drugs to minimise the problems related to psychoactive substances.’
The article goes on to describe the New Zealand innovations, the implementation problems and possible future steps.
Bell, R 2015, ‘War on drugs: the Kiwi comedown has lessons for all, New Scientist
, no. 3003, open access http://www.newscientist.com/article/mg22530030.200-war-on-drugs-the-kiwi-comedown-has-lessons-for-all.html#.VLMFsXtRRZp
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What does the evidence show about cannabis for treating chronic non-cancer pain?
The Pain and Opioids IN Treatment (POINT) study included 1,514 people in Australia who had been prescribed pharmaceutical opioids for chronic non-cancer pain (CNCP). Data on cannabis use, ICD-10 cannabis use disorder and cannabis use for pain were collected. The researchers explored associations between demographic, pain and other patient characteristics and cannabis use for pain. They found that ‘One in six (16%) had used cannabis for pain relief, 6% in the previous month. A quarter reported that they would use it for pain relief if they had access. Those using cannabis for pain on average were younger, reported greater pain severity, greater interference from and poorer coping with pain, and more days out of role in the past year. They had been prescribed opioids for longer, were on higher opioid doses, and were more likely to be non-adherent with their opioid use. Those using cannabis for pain had higher pain interference after controlling for reported pain severity. Almost half (43%) of the sample had ever used cannabis for recreational purposes, and 12% of the entire cohort met criteria for an ICD-10 cannabis use disorder’. They conclude ‘ Cannabis use for pain relief purposes appears common among people living with chronic non-cancer pain, and users report greater pain relief in combination with opioids than when opioids are used alone’.
The researchers comment that ‘In Australia, as in many countries, there is no regulatory framework for medicinal cannabinoid use. This means that cannabis use is effectively marginalised from any discussion or consideration of treatment strategies, despite being used by perhaps one in eight people living with CNCP. Health practitioners need a better understanding the potential harms and benefits of cannabis use among patients they may be treating for CNCP’.
Degenhardt, L, Lintzeris, N, Campbell, G, Bruno, R, Cohen, M, Farrell, M & Hall, WD 2015, ‘Experience of adjunctive cannabis use for chronic non-cancer pain: findings from the Pain and Opioids IN Treatment (POINT) study’
, Drug and Alcohol Dependence
, vol. 147, pp. 144-50.
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How likely is it that smoking marijuana will cause lung damage?
A study conducted in the USA aimed to determine the association between recent and long-term marijuana smoke exposure and lung function and symptoms of respiratory health in a large cohort of U.S. adults, using data from in the 2007-2008 and 2009-2010 National Health and Nutrition Examination Survey cycles. In the combined 2007-2010 cohorts, 59.1% had used marijuana at least once in their lifetime and 12.2% had used in the past month. The researchers found that recent marijuana use was associated with symptoms of airway inflammation, but that moderate lifetime use was not associated with clinically significant changes in measures of lung function. They concluded ‘In a large cross-section of U.S. adults, lifetime marijuana use up to 20 joint-years is not associated with adverse changes in…lung health’.
Kempker, JA, Honig, EG & Martin, GS 2014,’Effects of marijuana exposure on expiratory airflow: a study of adults who participated in the U.S. National Health and Nutrition Examination Study
’, Annals of the American Thoracic Society
, online ahead of print.
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What has the Cochrane Collaboration discovered about electronic cigarettes for smoking cessation and reduction?
A recently-published Cochrane Collaboration review of randomised controlled trials aimed to find out whether electronic cigarettes (ECs) help smokers stop or cut down on their smoking, and whether it is safe to use ECs to do this. The reviewers reported that ‘Combined results from two studies, involving over 600 people, showed that using an EC containing nicotine increased the chances of stopping smoking long-term compared to using an EC without nicotine. Using an EC with nicotine also helped more smokers reduce the amount they smoked by at least half compared to using an EC without nicotine. We could not determine if EC was better than a nicotine patch in helping people stop smoking because the number of participants in the study was low. More studies are needed to evaluate this effect. This study showed that people who used EC were more likely to cut down the amount they smoked by at least half than people using a patch. The other studies were of lower quality, but they supported these findings. There was no evidence that using EC at the same time as using regular cigarettes made people less likely to quit smoking. None of the studies found that smokers who used EC short-term (for 2 years or less) had an increased health risk compared to smokers who did not use EC’.
Robbie, H, Bullen, C, Hartmann-Boyce, J & Hajek, P 2014, ‘Electronic cigarettes for smoking cessation and reduction’, Cochrane Database Syst Rev
, vol. 2, no. 12, p. CD010216, open access http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010216.pub2/abstract
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What is the evidence about the disease burden of electronic nicotine delivery systems compared with tobacco cigarettes?
A comparison of the potential disease burden presented by tobacco cigarette (TC) smoke with that of electronic nicotine delivery systems/electronic cigarette (EC) vapour reviewed clinical studies that measured inhaled components, comparing the chemicals and carcinogens produced by vapour versus smoke. The researchers found that ‘Studies show that EC vapors contain far less carcinogenic particles than TC smoke. Whereas ECs have the ability to reach peak serum cotinine/nicotine levels comparable to that of TCs, ECs do not cause an increase in total white blood cell count; thus, ECs have the potential to lower the risk of atherosclerosis and systemic inflammation. Use of ECs has been shown to improve indoor air quality in a home exposed to TC smoke. This reduces secondhand smoke exposure, thus having the potential to decrease respiratory illness/asthma, middle-ear disease, sudden infant death syndrome, and more. However, some studies claim that propylene glycol (PG) vapor can induce respiratory irritation and increase chances for asthma. To minimize risks, EC manufacturers are replacing PG with distilled water and glycerin for vapor production’.
The researchers point to some negative aspects of the use of electronic cigarettes: ‘ECs have received negative attention for several valid reasons. A major concern is that current TC smokers will use ECs to cope in nonsmoking environments and will continue smoking TC in smoking-designated areas; something known as dual use. Another concern is that ECs could become an attractive starter product for young nonsmokers who were initially turned off by the consequences of TC…. Furthermore, many criticize the fruit-flavored and other appetizing flavors of EC cartridges, claiming that this is an attractant for young nonsmokers. There is also concern that ECs may become the reason that many smokers forego traditional cessation methods that have a history of effectiveness. Furthermore, several studies have presented data indicating the challenge of effective EC vaping. This means that many users have difficulty extracting the nicotine from the EC device’. In spite of these negative aspects, the researchers conclude: ‘ Based on the comparison of the chemical analysis of EC and TC carcinogenic profiles and association with health-indicating parameters, ECs impart a lower potential disease burden than conventional TCs’.
Oh, AY & Kacker, A 2014, ‘Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes? Review on E-cigarette vapor versus tobacco smoke’
, vol. 124, no. 12, pp. 2702-6.
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How effective are financial incentives to help pregnant smokers to quit
A randomized controlled parallel group trial in a large health board area with a materially deprived, inner city population in the west of Scotland assessed the efficacy of a financial incentive added to routine specialist pregnancy stop-smoking services versus routine care to help pregnant smokers quit. The participants were 612 self-reported pregnant smokers in Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control. The control group received routine care, which was the offer of a face-to-face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date; then another £50 if at four weeks’ post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks’ gestation.
The research team found that ‘Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%)’, leading them to conclude that ‘Smoking in pregnancy remains a leading preventable cause of maternal and neonatal ill health and death in the United Kingdom and in most other developed countries. Existing interventions are not highly effective. This study provides substantial evidence of a promising and potentially cost effective new intervention to add to present health service support. The findings can serve as the basis for future research to include other UK centres and other healthcare systems’.
Tappin, D, Bauld, L, Purves, D, Boyd, K, Sinclair, L, MacAskill, S, McKell, J, Friel, B, McConnachie, A, de Caestecker, L, Tannahill, C, Radley, A & Coleman, T 2015, ‘Financial incentives for smoking cessation in pregnancy: randomised controlled trial’, BMJ (British Medical Journal)
, vol. 350, online ahead of print, open access http://www.bmj.com/content/350/bmj.h134
Comment: This study applies the well-established approach of contingency management to help create behavioural change. Interestingly, upon publication it received a significant amount of media attention with much of it negative, commentators arguing the public fund should not be used to ‘bribe’ women to stop smoking. The positive findings here are encouraging, particularly as clinicians and researchers struggle to identify the most appropriate strategies to assist the last 10% of smokers to quit.
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To what extent are family and social problems associated with co-occurring substance use and post-traumatic stress disorder?
Abstract: Objective: Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and post-traumatic stress disorder (PTSD).
Method: A secondary analysis was conducted using data collected from a randomised controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms and social problems were assessed. Longitudinal outcomes were analysed.
Results: At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use and psychiatric severity at follow-up.
Conclusions: For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.
Saunders, EC, McLeman, BM, McGovern, MP, Xie, H, Lambert-Harris, C & Meier, A 2015, ‘The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD’, Journal of Substance Use, online ahead of print.
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To what extent is there an urgent need for voices for integrity in public policy making?
In an editorial in the Australian and New Zealand Journal of Public Health, Boyd Swinburn and Michael Moore refer to Nicky Hager’s recent book Dirty Politics which ‘exposed an apparent systemic approach being used by the tobacco, alcohol and processed food industries in New Zealand to attack prominent public health advocates’. The authors argue that ‘Society needs strong voices to promote public health and the integrity of policy-making processes. This is especially critical given the dominant paradigm of market-based solutions and the increasing conversion by transnational corporations of their economic power into political power…In October 2014, Professor Mike Daube, Director of the Public Health Advocacy Institute of Western Australia and President of the Australian Council on Smoking and Health, came under sustained attack using exaggeration, distortion and fabrication deliberately targeting his credibility. The Slater-style attacks, in this case, started with a sustained effort from a ‘shock jock’ on a commercial radio station and were then picked up by some mainstream media. It seems the original Big Tobacco “handbook of dirty tricks” to undermine public health has been adopted and enriched by other “disease vectors”, Big Alcohol and Big Junk Food.’
They concluded as follows:
‘Voices and actions are needed from public health scientists and practitioners, including:
- building active membership to strengthen existing population health organisations
- building active coalitions of individuals and organisations
- ensuring that public health positions are based on sound evidence and ethics
- taking personal and group action such as writing to MPs, and responding on blogs and in newspapers
- challenging governments that try to gag advocacy activities of community groups, scientists, and health professionals
- protecting freedoms of speech as far as possible in personal contracts
- being vigilant in exposing conflicts of interest in policy-making processes, within government advisory or governance structures, and in the voices that oppose sound, evidence-informed public policy.
‘Strong public health invariably means being effective politically. Politics that is dominated by the interests of big business invariably means weak public health. It is time to reclaim the integrity and strength in public health that is being rapidly eroded. We urgently need many more voices and actions on behalf of the public’s health.’
Swinburn, B & Moore, M 2014, ‘Urgently needed: voices for integrity in public policy making’, Australian and New Zealand Journal of Public Health, vol. 38, no. 6, p. 505.
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Dillon, P 2015, Water pipes, ‘bongs’ and ‘hookahs’: what does the evidence say about harms?, NCPIC Bulletin Series no. 19, National Drug and Alcohol Research Centre, Sydney.
European Monitoring Centre for Drugs and Drug Addiction 2014, Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone, EMCDDA, Lisbon, http://www.emcdda.europa.eu/publications/emcdda-papers/naloxone-effectiveness.
Hepatitis Australia 2015, Liver cancer records worst ‘death-to-incidence ratio’ – new analysis Hepatitis Australia, viewed 04 February 2015, http://www.hepatitisaustralia.com/newsarticles/liver-cancer-records-worst-death-to-incidence-ratio-new-analysis/3/2/2015.
Munton, T, Wedlock, E & Gomersall, A 2014, The role of social and human capital in recovery from drug and alcohol addiction, HRB Drug and Alcohol Evidence Review 1, Health Research Board, Dublin, http://www.hrb.ie/publications/hrb-publication/publications//663/.
Royal College of Obstetricians and Gynaecologists 2015, Alcohol and pregnancy, RCOG, London, https://www.rcog.org.uk/en/patients/patient-leaflets/alcohol-and-pregnancy/.
This patient information leaflet provides advice about the effects of drinking alcohol during pregnancy.
Transform Drug Policy Foundation 2014, Drug policy in Sweden: a repressive approach that increases harm, Transform, [Bristol, UK], http://www.tdpf.org.uk/resources/publications/drug-policy-sweden-repressive-approach-increases-harm.
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