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Background and Aims: Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour., Design: APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys., Setting: England (1972-2019)., Participants: Individuals aged 18-90 years., Measurements: We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years., Findings: Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25., Conclusions: Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25., (© 2021 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Aims: To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions., Design: A controlled, quasi-experimental (difference-in-differences) observational study using negative binomial regression., Setting: Hospitals in all 149 organisational areas in England for the period 2009-2010 to 2015-2016., Participants: 572 545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on International Classification of Diseases 10th Revision (ICD-10) diagnosis codes (37 964 patients in 8 intervention areas and 534 581 in 141 comparison areas)., Intervention and Comparators: Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment and non-re-presentation to treatment in the 12 months following completion., Measurements: Annual counts of hospital admissions, emergency admissions and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin and deprivation., Findings: For 37 245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non-intervention areas (95% CI = 1.049; 1.097). There were an estimated additional 3 352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses., Conclusion: A programme in England from 2012 to 2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions., (© 2021 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Aims: The United Kingdom and Australia have developed highly divergent policy responses to electronic nicotine delivery systems (ENDS). To understand the historical origins of these differences, we describe the history of tobacco control in each country and the key roles played in setting ENDS policy in its early stages by public health regulations and policy networks, anti-smoking organizations, 'vaper' activist networks and advocates of harm reduction policies towards injecting drug use., Methods: We analysed key government reports, policy statements from public health bodies and non-government organizations (e.g. cancer councils and medical organizations) on ENDS; submissions to an Australian parliamentary inquiry; media coverage of policy debates in medical journals; and the history of tobacco control policy in Australia and England. Key discourses about ENDS were identified for each country. These were compared across countries during a multi-day face-to-face meeting, where consensus was reached on the key commonalities and divergences in historical approaches to nicotine policy. This paper focuses on England, as different policy responses were apparent in constituent countries of the United Kingdom, and Scotland in particular., Results: Policymakers in Australia and England differ markedly in the priority that they have given to using ENDS to promote smoking cessation or restricting smokers' access to prevent uptake among young people. In understanding the origins of these divergent responses, we identified the following key differences between the two countries' approaches to nicotine regulation: an influential scientific network that favoured nicotine harm reduction in the United Kingdom and the absence of such a network in Australia; the success of different types of health activism both in England and in Europe in opposing more restrictive policies; and the greater influence on policy in England of the field of illicit drug harm reduction., Conclusions: An understanding of the different policy responses to electronic nicotine delivery systems (ENDS) in England and Australia requires an appreciation of how actors within the different policy structures, scientific networks and activist organizations in each country and region have interpreted the evidence and the priority that policymakers have given to the competing goals of preventing adolescent uptake and encouraging smokers to use ENDS to quit smoking., (© 2021 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background and Aims: Youth alcohol consumption has declined significantly during the past 15 years in many high-income countries, which may have significant public health benefits. However, if the reductions in drinking occur mainly among lighter drinkers who are at lower risk, then rates of alcohol-related harm among young people today and adults in future may not fall in line with consumption. There is conflicting evidence from Swedish school studies, with some suggesting that all young people are drinking less, while others suggest that alcohol consumption among heavier drinkers may be stable or rising while average consumption declines. This paper extends the geographical focus of previous research and examines whether the decline in youth drinking is consistent across the consumption distribution in England., Design: Quantile regression of 15 waves of repeat cross-sectional survey data., Setting: England, 2001-16., Participants: A total of 31 882 schoolchildren (50.7% male) aged 11-15 who responded to the Smoking Drinking and Drug Use among Young People surveys., Measurements: Past-week alcohol consumption in UK units at each fifth percentile of the consumption distribution., Findings: Reductions in alcohol consumption occurred at all percentiles of the consumption distribution analysed between 2001 and 2016, but the magnitude of the decline differed across percentiles. The decline in consumption at the 90th percentile [β = -0.21, confidence interval (CI) = -0.24, -0.18] was significantly larger than among either lighter drinkers at the 50th percentile (β = -0.02, CI = -0.02, -0.01) or heavier drinkers at the 95th percentile (β = -0.16, CI = -0.18, -0.13)., Conclusions: Alcohol consumption among young people in England appears to be declining across the consumption distribution, and peaks among heavy drinkers. The magnitude of this decline differs significantly between percentiles of the consumption distribution, with consumption falling proportionally less among the lightest, moderate and very heaviest youth drinkers., (© 2019 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Aims: This paper presents updated prevalence estimates of awareness, ever-use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing., Design, Setting, Participants and Measurements: A cross-sectional analysis of adult (≥ 18 years) current smokers and ex-smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013-17. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs), not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs), not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand; (3) less restrictive policies (LRPs), legal to be sold and marketed with regulations: England, the Netherlands, Republic of Korea, United States; and (4) no regulatory policies (NRPs), Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country-specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily versus non-daily)., Findings: NVP awareness and use were lowest in NRP countries. Generally, ever- and current use of NVPs were lower in MRP countries (ever-use = 7.1-48.9%; current use = 0.3-3.5%) relative to LRP countries (ever-use = 38.9-66.6%; current use = 5.5-17.2%) and RP countries (ever-use = 10.0-62.4%; current use = 1.4-15.5%). NVP use was highest among high-income countries, followed by upper-middle-income countries, and then by lower-middle-income countries., Conclusions: With a few exceptions, awareness and use of nicotine vaping products varied by the strength of national regulations governing nicotine vaping product sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in nicotine vaping products in these countries where smoking populations are predominantly poorer. The higher awareness and use of nicotine vaping products in high income countries with moderately (e.g. Canada, New Zealand) and less (e.g. England, United States) restrictive policies, is likely due to the greater availability and affordability of nicotine vaping products., (© 2019 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background and Aims: E-cigarettes have the potential either to decrease or increase health inequalities, depending on socio-economic differences in their use and effectiveness. This paper estimated the associations between socio-economic status (SES) and e-cigarette use and examined whether these associations changed between 2014 and 2017., Design: A monthly repeat cross-sectional household survey of adults (16+) between January 2014 and December 2017. This time-period was chosen given that the prevalence of e-cigarette use stabilized in England in late 2013., Setting: England., Participants: Participants in the Smoking Toolkit Study, a monthly household survey of smoking and smoking cessation among adults (n = 81 063; mean age = 48.4 years, 49% were women) in England. Subsets included past year smokers (n = 16 232; mean age = 42.8, 46% women), smokers during a quit attempt (n = 5305, mean age = 40.6, 49% women) and long-term ex-smokers (n = 13 562, mean age = 59.3, 44% women)., Measurements: The outcome measure for the analyses was current e-cigarette use. We also included smokers during a quit attempt where use of an e-cigarette during the most recent quit attempt was the outcome measure. Social grade based on occupation was the SES explanatory variable, using the National Readership Survey classification system of AB (higher and intermediate managerial, administrative and professional), C1 (supervisory, clerical and junior managerial, administrative and professional), C2 (skilled manual workers), D (semi-skilled and unskilled manual workers) and E (state pensioners, casual and lowest-grade workers, unemployed with state benefits only). The analyses were stratified by year to assess the changes in these associations over time., Findings: Among past-year smokers, lower SES groups had lower overall odds of e-cigarette use compared with the highest SES group AB (D: odds ratio = 0.53, 95% confidence interval = 0.40-0.71; E: 0.67, 0.50-0.89). These differences in e-cigarette use reduced over time. The use of e-cigarettes during a quit attempt showed no clear temporal or socio-economic patterns. Among long-term ex-smokers, use of e-cigarettes increased from 2014 to 2017 among all groups and use was more likely in SES groups C2 (2.03, 1.08-3.96) and D (2.29, 1.13-4.70) compared with AB., Conclusions: From 2014 to 2017 in England, e-cigarette use was greater among smokers from higher compared with lower socio-economic status (SES) groups, but this difference attenuated over time. Use during a quit attempt was similar throughout SES groups. Use by long-term ex-smokers increased over time among all groups and was consistently more common in lower SES groups., (© 2018 Society for the Study of Addiction.)

Background and Aims: Estimating 'return on investment' (ROI) from smoking cessation interventions requires reach and effectiveness parameters for interventions for use in economic models such as the EQUIPT ROI tool (http://roi.equipt.eu). This paper describes the derivation of these parameter estimates for England that can be adapted to create ROI models for use by other countries., Methods: Estimates were derived for interventions in terms of their reach and effectiveness in: (1) promoting quit attempts and (2) improving the success of quit attempts (abstinence for at least 12 months). The sources were systematic reviews of efficacy supplemented by individual effectiveness evaluations and national surveys., Findings: Quit attempt rates were estimated to be increased by the following percentages (with reach in parentheses): 20% by tax increases raising the cost of smoking 5% above the cost of living index (100%); 10% by enforced comprehensive indoor public smoking bans (100%); 3% by mass media campaigns achieving 400 gross rating points (100%); 40% by brief opportunistic physician advice (21%); and 110% by use of a licensed nicotine product to reduce cigarette consumption (12%). Quit success rates were estimated to be increased by the following ratios: 60% by single-form nicotine replacement therapy (NRT) (5%); 114% by NRT patch plus a faster-acting NRT (2%);124% by prescribed varenicline (5%); 60% by bupropion (1%); 100% by nortriptyline (0%), 10) 298% by cytisine (0%); 40% by individual face-to-face behavioural support (2%); 37% by telephone support (0.5%); 88% by group behavioural support (1%); 63% by text messaging (0.5%); and 19% by printed self-help materials (1%). There was insufficient evidence to obtain reliable, country-specific estimates for interventions such as websites, smartphone applications and e-cigarettes., Conclusions: Tax increases, indoor smoking bans, brief opportunistic physician advice and use of nicotine replacement therapy (NRT) for smoking reduction can all increase population quit attempt rates. Quit success rates can be increased by provision of NRT, varenicline, bupropion, nortriptyline, cytisine and behavioural support delivered through a variety of modalities. Parameter estimates for the effectiveness and reach of these interventions can contribute to return on investment estimates in support of national or regional policy decisions., (© 2017 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background and Aims: This narrative review aimed to provide a brief overview of five key research 'classics' produced by the innovative and radical thought leader, Professor Michael Anthony Hamilton Russell (1932-2009), drawing upon his other work wherever feasible., Methods: Narrative review. From more than 250 publications, we selected papers we considered seminal texts, published in 1971, 1976, 1978, 1979 and 1991., Results: Russell was among the first researchers to explain that smoking was a dependence disorder caused by the drug nicotine decades before this was recognized formally. He therefore saw quickly the importance of delivering nicotine in a less harmful format as a way of controlling nicotine withdrawal when stopping smoking, first studying nicotine gum. In addition to pharmacotherapies, Russell's research also explored the role of behavioural support, particularly the role of general practitioners (GPs), alone as well as supported by specialist clinics; this research underpinned initiatives in England to reimburse doctors for giving advice to smokers, and to provide a national network of smoking cessation services. Research on nicotine uptake from other delivery systems and routes led Russell to theorize that the speed and dose of delivery impacted upon the effectiveness of a product to act as a substitute for smoking. He commented on the addictiveness of the high nicotine boli delivered in quick succession when smoking cigarettes and argued that alternative recreational nicotine delivery systems would need to be promoted actively to smokers in order for them to compete with cigarettes, a forerunner for contemporary debates on electronic cigarettes., Conclusions: The legacy of Russell's landmark research is seen in present-day nicotine science, policy and discourse., (© 2017 Society for the Study of Addiction.)

Background: In 1804 Thomas Trotter, a recently retired Physician to the Fleet, published his 'Essay on Drunkenness'. This was the first ever book-length consideration of the phenomenon of alcohol dependence and its treatment., Aims: The aim of this paper is to explore the impact of that treatise on the evolution of relevant ideas over the years that have followed., Methods: A factual analysis of the content of the Essay is the starting-point, followed by an examination of sequential published appraisals on the significance, or lack of significance, of this work., Findings and Conclusions: To the modern reader, Trotter is likely to be seen as prescient, with his assertion that 'the habit of drunkenness is a disease of the mind', setting the scene for two centuries of debate. The literature, however, seems to suggest that Trotter did not, in fact, achieve much impact either on professional opinion or on the emergent temperance movement. It was Benjamin Rush's 1785 pamphlet on 'Ardent Spirits' which achieved iconic status. Rush and Trotter, although in some ways overlapping in their ideas, differed in other respects., (© 2012 The Author. Addiction © 2012 Society for the Study of Addiction.)

Aim:   This paper provides a historical overview of licensing law in Scotland. It seeks to put important contemporary policy developments into their historical context and to draw attention to key themes in licensing policy debates across the United Kingdom., Design:   Based on a survey of statutes, commissions of enquiry and consumption and retail data, this paper draws together historical evidence to present a synopsis of Scottish licensing history., Settings:   The article focuses on Scotland, but also discusses UK-wide licensing policy over a 250-year period., Findings:   Scottish licensing has diverged from licensing in England and Wales and has addressed some historical licensing weaknesses, including problems of accountability, overprovision and systemic oversight regarding off-sales. Distinctive features of current Scottish legislation include public health protection as a statutory licensing objective; local Licensing Forums and Licensing Standards Officers; a requirement for explicit policies on the 'overprovision' of licensed premises; mandatory restrictions on price promotions in the on- and off-trades; and limitations on opening hours for off-licences., Conclusion:   Scotland has developed alcohol policies several times addressing long-standing licensing weaknesses throughout the United Kingdom. Some Scottish alcohol policies have later become the norm in England and Wales., (© 2012 The Author, Addiction © 2012 Society for the Study of Addiction.)

Aims: There is a growing interest in very low rate [fewer than one cigarette per day (CPD)] and light (one to nine CPD) smokers and in some parts of the world their numbers appear to be increasing. This paper examined changes in prevalence over the past 5 years, cessation patterns, and smoking and demographic characteristics of very low rate, light and moderate-to-heavy (10+ CPD) smokers in England., Design: Cross-sectional and longitudinal data from aggregated monthly waves of a household survey: the Smoking Toolkit Study., Setting: England., Participants: A total of 23,245 smokers interviewed between November 2006 and May 2011 and 4147 who provided data at 6-month follow-up., Measurements: We compared the demographic and smoking characteristics between the three groups of smokers at baseline, and the rate of attempts to quit, use of aids to cessation and success of quit attempts at follow-up., Findings: Very low rate smoking remained extremely rare (1.9% of smokers in 2006 to 2.8% in 2011), but light smoking became increasingly common (23.9-32.8%). Compared with moderate-to-heavy smokers, very low rate and light smokers were younger, more often female and from a higher socio-economic background. They were more motivated to quit and enjoyed smoking less. During the 6-month follow-up period, light smokers, but not very low rate smokers, were more likely to attempt to quit than moderate-to-heavy smokers. When they tried to quit, very low rate and light smokers used aids to cessation less than moderate-to-heavy smokers but still used them to a substantial degree: 18%, 31% and 44% used over-the-counter nicotine replacement therapy in their most recent quit attempt for the three types of smoker, respectively. Even very low rate smokers had a substantial failure rate: 65% failed in their most recent quit attempt within 6 months., Conclusions: Very low rate (fewer than one cigarette per day) and light (one to nine cigarettes per day) smokers in England are at least as motivated to quit as heavier smokers. Although they use cessation medication less than heavier smokers and are more likely to succeed, they still use such medication and fail in quit attempts to a substantial degree., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Abstinence from alcohol is a way of life for many American evangelicals, with rates of abstention running at over 70% among some Pentecostal denominations. This paper examines the religious beliefs that, historically, have supported teetotalism. The most notable of these is Christian perfection, a doctrine that originated in 18th-century England, that was then radicalized in America in the early 19th century. Abstinence from alcohol is highest among denominations that make Christian perfection the cornerstone of their teachings, and lowest among those that discount human agency. The paper also argues that 19th-century American evangelicals were by no means committed uniformly to temperance as a way of life, and that this was especially true of the various Methodist churches.

Aim: The goals of this paper are to evaluate whether drinking practices among peers mediates the relationship between a low level of response (LR) to alcohol and a person's heavier drinking and alcohol-related problems in 12-14-year-olds., Design: Correlations and structural equation models (SEM) were used to test a hypothesized model of the relationships among key variables in adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC), a longitudinal birth cohort study in Bristol, England., Participants: These included 688 boys (40.4%) and girls who were offspring of the pregnant women who had been selected as ALSPAC participants in 1991 and 1992. The offspring were interviewed at about age 13 years, and those who had ever consumed a full drink completed the Self-Report of the Effects of Alcohol (SRE) questionnaire indicating the number of drinks required for up to four effects early in their drinking histories. A higher number of drinks required for effects indicated a low LR per drink consumed., Findings: The SEM explained 58% of the variance of the alcohol pattern, and had good fit characteristics. A low LR was related to heavier drinking and more alcohol problems both directly and as mediated partially by drinking in peers. The model performed well across the narrow age range, and applied equally well in boys and girls., Conclusions: The perceived drinking practices of peers is a potentially important mediator of how a low LR to alcohol relates to drinking practices during early adolescence. The findings may be useful in developing approaches to prevent heavier drinking in this young group.

Background: Cessation services were instructed to make special attempts to attract smokers from three 'priority groups': those who were young, pregnant and economically disadvantaged. Progress with attracting priority groups was not assessed formally, but services were set monitored targets to encourage throughput of smokers. Initial research suggests that services have been successful in attracting smokers who live in disadvantaged areas. This paper investigates how smoking cessation services responded to targets and instructions to attract priority groups and discusses the relative impact these on service development., Objectives: To describe how monitored throughput targets influenced the development of smoking cessation services, including attracting priority groups. To describe the range of priority groups that smoking cessation services targeted, methods used and reported progress with this., Methods: Postal surveys of English smoking cessation coordinators conducted in April 2001 and April 2002. Seventy-eight qualitative, semistructured interviews with cessation service staff in two former English health regions conducted in autumn 2001 and 1 year later., Findings: A total of 69.3% of coordinators responded to the first survey (79% to the second survey). In the first survey 91% reported targeting priority groups (100% in the second survey). The proportions (second survey in brackets) who reported targeting the different priority groups were: pregnant women 86% (99%), economically disadvantaged 79% (100%) and young smokers 20% (75%). Interviews showed that coordinators gave the greatest priority to reaching monitored targets as they came under pressure to achieve these. Service staff were generally unclear about how to attract priority groups and developing strategies for this was hindered by the need to meet throughput targets. Locating services in poor areas was thought to attract economically disadvantaged smokers and specialist staff were being appointed to work with pregnant smokers, but otherwise there was little evidence of active strategies for attracting priority groups being applied in practice., Conclusions: Monitored targets for smoker throughput ensured that services quickly began to treat smokers, but this rapid implementation diverted service staff from devising methods for attracting priority group smokers. Coordinators found reaching priority groups challenging and, particularly in the case of young smokers, would have appreciated clear instructions for this aspect of service implementation. Those implementing services in other countries should consider whether similar targets would be helpful to stimulate service development within their health systems.

Background: This paper describes how smoking treatment services in England were delivered beyond the initial set-up phase and explores key factors affecting their development. Services were expected to treat smokers in line with the evidence-base and were issued with government guidance regarding the type of interventions that should be offered. One factor complicating this was the issue of service funding. Funding was initially issued for a 3-year period and although this was extended on two occasions, these extensions were both announced close to the end of funding periods., Objectives: To critically assess key elements in the delivery of the English cessation services, including the nature of treatments offered and the impact of short-term funding on staffing., Methods: A national postal survey of smoking cessation coordinators in April 2002. Semi-structured interviews with 50 smoking cessation staff in two health regions in autumn 2001, followed by further interviews with 28 staff in the same areas in the autumn of 2002., Results: Treatment was delivered in a wide range of venues, ranging from primary care to local authority-owned premises such as town halls and libraries. Most services offered both one-to-one and group support, although interviewees reported an increase in demand for one-to-one support from clients. Pharmacotherapies were used widely; by 2002, 99% of coordinators reported that their advisers recommended nicotine replacement therapy (NRT) to clients, and 95% bupropion. However, prior to April 2001 bupropion was available on prescription, but NRT was not and this variable access to pharmacotherapies posed problems for services. Coordinators reported that the short-term nature of funding made recruiting and retaining staff difficult and interviews revealed that they believed a longer period of protected funding was required for services to demonstrate their effectiveness., Conclusions: As English smoking treatment services developed, lessons were learned that could inform the development of services in other health systems. First, early guidance from government can encourage services to adhere to evidence-based treatment. Secondly, treatment needs to be accessible to smokers and thus there must be a flexible approach to implementation at local level. Thirdly, the availability of nicotine addiction and behavioural therapies should be coordinated to minimize barriers and maximize uptake. Finally, fixed-term funding can exacerbate staff recruitment and retention difficulties and countries establishing treatment services need to consider carefully the initial funding period that is required for stable services to become established within their health systems.

In 1998 the UK government published a White Paper on tobacco which set out the development of smoking cessation treatment services across England. This paper presents a detailed analysis of the events leading up to the inclusion of smoking cessation treatment services within the White Paper, and the background to the evaluation of those services, the results of which are the subject of the remaining papers in this supplement.

This paper summarizes and discusses the key findings of the evaluation of the English smoking treatment services, which were established in 1999 as part of the English National Health Service. Within 4 years these services existed throughout the country and were working at full capacity, a total of pound 76 million having been spent on them over this period, excluding medication costs. In the fourth year almost 235,000 people attended treatment and set a quit date, and the total budget, including medications, was approximately pound 50 million. At the end of the fourth year the government allocated pound 138 million for the services for the period April 2003-March 2006. The CO-validated 4-week abstinence rate was 53%, the validated 52-week abstinence rate was 15%, and the relapse rate from 4 to 52 weeks was 75%. There was no sex difference in cessation rates at long-term follow-up. The cessation results and relapse rate from weeks 4 to 52 are consistent with results from published studies, including clinical trials. The estimated cost per life-year saved was pound 684 and the figure is even lower if the potential future health care cost savings are taken into account at pound 438 per life-year saved. This compares with the benchmark of pound 20,000 per life-year saved, which the National Institute for Clinical Excellence (NICE) is using to recommend new health care interventions in the National Health Service. The services were also succeeding in reaching disadvantaged smokers. However, there have been problems, and other health care systems considering an initiative of this kind should: set national training standards and increase training capacity before launching the services; standardize the provision of pharmaceutical treatments and make them as accessible as possible before launching the services; and give the services at least 5 years of central funding to allow them to become well established. Monitoring is extremely important but should not be so much of a burden that it detracts from developing a quality service and although cessation targets can be helpful, care needs to be taken that they are reasonable and do not promote throughput at the expense of quality.

Aims: Prescribing nicotine replacement therapy (NRT) or bupropion for smoking cessation is of considerable importance to public health but little is known about prescribing practices. This paper examines general practitioners' (GPs') prescribing patterns in Britain where these drugs are reimbursed. The results have implications for other health-care systems considering introducing reimbursement., Design, Participants and Setting: Postal survey conducted in 2002 of a random sample of 1088 GPs in England and Wales, of whom 642 (59%) responded., Measures: Number of requests GPs reported having received from patients for NRT and bupropion over the past month, the number of prescriptions they reported issuing and ratings of attitudes to these medications., Findings: GPs reported receiving an average of 4.3 requests for NRT and 1.9 for bupropion in the previous month. They reported issuing 3.5 prescriptions for NRT and 1.2 for bupropion. Almost all GPs accepted that NRT (95%) and bupropion (97%) should be reimbursable on National Health Service (NHS) prescription. However, a significant minority of those who received requests for prescriptions did not issue any (8% for NRT and 26% for bupropion). This was related to whether they thought these products should be available on NHS prescription for both NRT and bupropion (OR = 0.66, P < 0.05), which in turn was related to beliefs about whether smokers should have to pay for treatment themselves, the cost-effectiveness of NRT/bupropion and the low priority they would give NRT/bupropion in the drug budget. For bupropion, concern about side-effects independently predicted not prescribing [odds ratio (OR) = 1.46, P < 0.03]., Conclusion: In the British health-care system, which has a well-established system for technology assessment and professionally endorsed guidelines, a significant minority of GPs decline all patient requests for stop-smoking medicines.

Aims: To investigate the ways in which pre-teenage children anticipate and deal with the offer of drugs., Design: A qualitative study based on semi-structured interviews with 10-12-year-old schoolchildren., Setting: The cities of Glasgow (Scotland) and Newcastle (England), UK., Participants: A sample of 216 pre-teenage children. Forty-three had used drugs on at least one occasion, 42 had been offered but had not used drugs and 131 had neither used drugs nor been offered them. Most of the results reported in the paper relate to the experiences of the 42 children who had declined the offer of drugs., Findings: While children who had not been exposed to drug offers expressed a high degree of confidence in their ability to deal with them, those who had actually had to cope with such offers experienced a variety of difficulties. The ease with which an offer could be declined appeared to depend upon two main factors: who was making the offer and the context in which it was being made. According to the children, offers from people with whom they had a close relationship and those in which pressure or encouragement were involved were particularly difficult to deal with., Conclusions: The paper concludes that there is a need to equip young people better with the interpersonal tools they require to deal with the various situations they are likely to encounter in which drugs may be offered. It is suggested that a broadly based life skills approach to drug education may provide the best way of helping young people to deal with these situations.

Objectives: The aim of this study was to explore in detail the relationship between various social aspects of young people's lives and substance use and differences in the degree of influence exerted by the different social factors as a function of age. Design, setting, participants. The study was a survey of pupils aged 11-16 in a stratified sample of five English schools. Data from 4516 participants were obtained in relation to their cigarette, alcohol and illicit drug use and their contact with the police, perceived academic achievements and future expectations, religious beliefs, family structure, the importance of family versus peer opinions and suspension from school., Measures: Cumulative, age-specific preferences of substance misuse were compared. Logistic regression was used to rank the various risk factors., Results: Substantial differences were found between substance users and non-users and the various risk factors being examined. For example, of those who had only been in trouble with the police, 18.8% used illegal drugs compared with 1.6% of those who had not had a police contact and who had no other risk factors. Many of these relationships were age-sensitive. For instance, the negative relationship between belief in God and illicit drug use became stronger as age increased (non-believers: y = 8.1886x - 9.16 R(2) = 0.9484; believers: y = 5.1514x - 8.08 R(2) = 0.9247). These results suggest that, within this sample of English adolescents, there was a strong relationship between substance use and the social factors examined. Although there were differences depending upon whether cigarette, alcohol or illicit drug use was being modelled, logistic regression indicated that the social factors could be ranked in the following order of importance: concurrent use of the second and third substances, having been in trouble with the police, perceived poor academic performance and low future academic expectations, a lack of religious belief, coming from a non-intact family, favouring peer over family opinion and having been suspended from school. Many of these relationships were age-sensitive with substance use peaking at age 15., Conclusion: The models and relationships presented in this paper show that a constellation of behaviours are related to adolescent substance use. Also demonstrated is that behaviours cannot be considered in isolation, but need to be examined from an holistic or biopsychosocial standpoint. These relationships are complex and future research should consider not only causality of adolescent substance use, but also of the aetiology of the satellite behaviours.

In this paper the relationship between sharing behaviour and needle-exchange attendance is examined. Data from three studies of drug misuse carried out consecutively from 1989 to 1993 in the north-west of England are compared. Samples differed in their drug preferences. Analyses of sharing injecting equipment comparing exchange attenders and non-attenders revealed different patterns in each of the studies. Among opiate injectors no differences were observed in the proportions using others' injecting equipment, but attenders not in treatment were more likely to pass on their used equipment. This was attributed to uneven patterns of availability in the early days of exchange provision. Primary amphetamine users attending a needle exchange shared less than non-attenders, although overall levels of sharing were higher. Frequency of sharing was lowest in the third study of polydrug users but proportions sharing were similar to the opiate users. There was no effect of exchange attendance on sharing. Multiple logistic regressions identified other important predictors in these studies, e.g. treatment status, an injecting partner and injecting friends. Interpretations of the relationship between exchanges and sharing should take account of local availability of sterile equipment and the characteristics of exchange clientele.

Injecting drugs in the streets and other public places is increasingly common in many cities and large towns in the United Kingdom. It is a practice rarely open to view, but the evidence is there in the used needles and syringes left in stairwells of flats, shop doorways, public toilets and other areas where exposure can be avoided. Although it is a development with serious implications for public health, it has received little research attention. This paper reports the factors associated with street injecting from 56 polydrug users who regularly injected in public places. It reveals that they were more likely to be severely drug dependent with associated health problems. A high proportion were homeless. Their drug-related and sexual risk behaviour have implications for the acquisition and transmission of disease.

This paper gives a comparison of the approach of the US courts and of the Solicitor's Disciplinary Tribunal in England to disciplinary proceedings concerning lawyers suffering from alcohol dependence and/or depression. A richer case law in the USA indicates a more sophisticated approach, higher standards as to evidence and better support systems for lawyers in recovery. Useful lessons could be learned from the American experience and the experience of doctors and dentists by English lawyers.

This paper examines the connection between medical research and temperance from the point of view of the Anglican temperance movement in three periods: (1) 1830-55, when Anglican clergymen resisted teetotalism in favour of moderation, in keeping with accepted medical opinion; (2) 1855-73, when a minority of Anglican teetotal clergymen attempted unsuccessfully to convert the Anglican Church to teetotalism and prohibition, as the medical profession in theory, but not always in practice, discouraged excessive therapeutic reliance on alcohol; and (3) 1873-1914, when the prestigious Church of England Temperance Society, with a dual basis, promoted teetotalism among the majority but affirmed the legitimacy of moderate drinking among the British medical and social elite.

Similarities in the trends of the number of offences and the level of alcohol consumption are often used as evidence as a link between alcohol and many forms of criminal activity. However, such crude correlations may be misleading as they neither take account of other factors that might be important, not assist the understanding of the causal links between alcohol and crime. In this paper, the role that economic models may play in furthering the understanding of the potential links between alcohol and crime are explored. A complete model is presented which allows for complex interactions between alcohol, crime and the criminal justice system. Results from testing this model with time series data (1960-88) for England and Wales for different types of crime are discussed in detail. Data defined by standard regions and for the years 1980 to 1988 were also compiled and a summary of the results discussed. The argument that alcohol consumption may be one of the determinants of a wide range of crimes receives some support and is also found that alcohol consumption may affect the probability of detection for some types of crime.