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BACKGROUND: There is currently no comprehensive legislation protecting non-smokers and children from second-hand smoke (SHS) exposure in private cars at the European Union (EU) level. This study aims to assess smokers' support for smoke-free cars legislation in six EU countries. METHODS: Data come from the EUREST-PLUS ITC Europe Surveys: Wave 1 (2016, n = 6011) and Wave 2 (2018, n = 6027) conducted in Germany, Greece, Hungary, Poland, Romania and Spain. Support for smoke-free cars carrying pre-school children and non-smokers and voluntary implementation of smoke-free cars were assessed among adult smokers. Generalized estimating equations models were used to assess changes in support between waves. RESULTS: In 2018, 96.3% [95% confidence interval (CI) 95.4-97.0%] of the overall sample supported smoke-free legislation for cars carrying pre-school children, representing an increase of 2.4 percentage points in comparison to 2016. Smoke-free legislation for cars transporting non-smokers was supported by 85.2% (95% CI 83.1-87.1%) of smokers' in 2016 and 90.2% (95% CI 88.6-91.7%) in 2018. Among smokers who owned cars, there was a significant 7.2 percentage points increase in voluntary implementation of smoke-free cars carrying children from 2016 (60.7%, 95% CI 57.2-64.0%) to 2018 (67.9%, 95% CI 65.1-70.5%). All sociodemographic groups of smokers reported support higher than 80% in 2018. CONCLUSION: The vast majority of smokers in all six EU countries support smoke-free legislation for cars carrying pre-school children and non-smokers. This almost universal support across countries and sociodemographic groups is a clear indicator of a window of opportunity for the introduction of comprehensive legislation to protect non-smokers and children from SHS exposure in cars.

BACKGROUND: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design. METHODS: Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented). RESULTS: There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands. CONCLUSIONS: Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

Objectives: To establish the level of psychological symptoms and the risk factors for possible decreased mental health among deployed UK maritime forces. Methods: A survey was completed by deployed Royal Navy (RN) personnel which measured the prevalence of common mental disorder (CMD), post-traumatic stress disorder (PTSD) and potential alcohol misuse. Military and operational characteristics were also measured including exposure to potentially traumatic events, problems occurring at home during the deployment, unit cohesion, leadership and morale. Associations between variables of interest were identified using binary logistic regression to generate ORs and 95% CIs adjusted for a range of potential confounding variables. Results: In total, 41.2% (n=572/1387) of respondents reported probable CMD, 7.8% (n=109/1389) probable PTSD and 17.4% (n=242/1387) potentially harmful alcohol use. Lower morale, cohesion, leadership and problems at home were associated with CMD; lower morale, leadership, problems at home and exposure to potentially traumatic events were associated with probable PTSD; working in ships with a smaller crew size was associated with potentially harmful alcohol use. Conclusions: CMD and PTSD were more frequently reported in the maritime environment than during recent land-based deployments. Rates of potentially harmful alcohol use have reduced but remain higher than the wider military. Experiencing problems at home and exposure to potentially traumatic events were associated with experiencing poorer mental health; higher morale, cohesion and better leadership with fewer psychological symptoms.

Cardiovascular Disease (CVD) is one of the leading causes of premature mortality and morbidity in the UK with an estimated cost to the NHS of £14.4 billion. The incidence of CVD is projected to rise due to an ageing population and a high incidence of hypertension and Type 2 diabetes. Both of these conditions are associated with obesity, a condition which is reaching epidemic proportions, and is a modifiable risk factor for CVD. The NHS Health Checks programme is a national programme introduced in 2009 as part of a government programme to reduce avoidable deaths and disability. The main aim of the NHS Health Check is to improve the health and wellbeing of adults aged 40-74 years. It aims to do this through the promotion of earlier awareness, assessment and management of major risk factors and conditions that contribute to premature death and disability. Additionally, it aspires to contributing towards reducing health inequalities in England. NHS Health Checks are mainly delivered in GP practices by nurses or healthcare assistants who usually invite patients by letter. However, the method used to invite patients for an NHS Health Check has been shown to influence their likelihood of attendance. A recent study that explored attendance and method of invite for a Health Check found that verbal and telephone invitations resulted in a greater likelihood of attendance compared to a written letter invitation. This has recently been demonstrated by a GP practice in a deprived area of South Bristol. The practice piloted a telephone invitation method for engaging eligible patients for an NHS Health Check. Community link workers telephoned eligible patients, and if the patient consented, they completed selected aspects of the NHS Health Check by telephone. This was followed by inviting the patient to attend their GP practice for the remaining aspects of the NHS Health Check to be completed. This mainly included the physiological measurements for example blood tests and blood pressure. They found that their rate of ratio of invitations made to attendance for the full Health Check increased from 36%, using a traditional letter invite, to 78% using the telephone invitation method. As a consequence of this success, Bristol City Council (Public Health) identified funding to enable this model to be rolled out to all GP practices within the lowest lower layer super output areas (LSOAs) throughout the City of Bristol. We used a quantitative, quasi-experimental approach, to examine the relationship between attendance, or not for an NHS Health Check and age, gender, Index of Multiple Deprivation (IMD) score and ethnicity. We compared and contrasted the types of patients who attended for an NHS Health Check as a result of the telephone outreach initiative, with those who attended for an NHS Health Check as a result of the more traditional letter invite. We also compared and contrasted attendance for an NHS Health Check during the intervention period, with a similar period, prior to the intervention. To try and contextualise our results we explored and described potential confounding influences that may have encouraged or discouraged uptake of an NHS Health Check over the intervention period. The main aims and objectives of this evaluation were: Aims: • To evaluate the effectiveness of the telephone outreach service versus the standard invitation approach on uptake of NHS Health Checks in GP practices located in the lowest lower super output areas (LSOAs) in the city of Bristol. Objectives •Using practices located in the lowest LSOAs in the City of Bristol, compare the rate of uptake of an NHS Health Check in the target population, in GP practices using the telephone outreach initiative, with the rate of uptake in comparison / control practices who were using the traditional letter invite. •Investigate the relationship in the target population of those who attended or declined an NHS heath check, with age, gender, IMD and ethnicity, in both patients who were invited using the telephone outreach initiative and the traditional letter invite. •To explore other possible influencing factors on the uptake of NHS Health Checks, by the target population, during the study period.

Industry lobbying remains an obstacle to effective health-oriented alcohol policy. In 2013, an increase in excise tax on spirits was announced by the Polish government. This article presents a qualitative analysis of the public debate that ensued on the potential economic, health and social effects of the policy. It focuses on how competing groups, including industry actors, framed their position and sought to dominate the debate. Online archives of five Polish national newspapers, two spirits trade associations, and parliamentary and ministerial archives were searched. A thematic content analysis of the identified sources was conducted. The overall findings were compared with existing research on the framing of the Minimum Unit Pricing (MUP) debate in the UK. A total of 155 sources were analysed. Two main frames were identified: health, and economic. The spirits industry successfully promoted the economic frame in their own publications and in the media. The debate was dominated by arguments about potential growth of the grey market and losses in tax revenue that might result from the excise tax increase. The framing of the debate in Poland differed from the framing of the MUP debate in the United Kingdom. The Polish public health community was unsuccessful in making health considerations a significant element of the alcohol policy debate. The strategies pursued by UK health advocates offer lessons for how to make a more substantial impact on media coverage and promote health-oriented legislation.

Background: Recently, proposals have been made to improve mental health care for UK military veterans. Combat Stress (CS), a veteran's charity, has provided mental health services for veterans since 1919. Since 2003, service users have included veterans from the Iraq and Afghanistan conflicts; however, their pattern of help-seeking has not been evaluated. Aims: To describe the characteristics of the veteran population of the recent Iraq or Afghanistan conflicts who sought help from CS between 2003 and May 2011. Methods: CS Iraq and Afghanistan veteran clinical and welfare records were evaluated. Results: Nine hundred and eighty-eight records were evaluated. The median time for veterans of recent conflicts to seek help from CS since discharge from military service was ~2 years, considerably shorter than the mean time of 14 years previously estimated by CS. Approximately, three-quarters of the veterans receiving a full clinical assessment (n = 114), received a diagnosis of post traumatic stress disorder (PTSD) (n = 87). Approximately half of the clinically assessed veterans self-referred to CS (51%); their most frequent diagnosis was PTSD. Conclusions: Veterans who have served in Iraq and Afghanistan are presenting to Combat Stress sooner, and at a younger age, than veterans of previous conflicts and operations.

Background: In the United States (US) and Brazil, obesity has emerged as a health epidemic. This article is driven by the following research questions: how did the US and Brazil's federal institutions respond to obesity? And how did these responses affect policy implementation? The aim of this article is therefore to conduct a comparative case study analysis of how these nations' institutions responded in order to determine the key lessons learned. Methods: This study uses primary and secondary qualitative data to substantiate causal arguments and factual claims. Results: Brazil shows that converting preexisting federal agencies working in primary healthcare to emphasize the provision of obesity prevention services can facilitate policy implementation, especially in rural areas. Brazil also reveals the importance of targeting federal grant support to the highest obesity prevalence areas and imposing grant conditionalities, while illustrating how the incorporation of social health movements into the bureaucracy facilitates the early adoption of nutrition and obesity policies. None of these reforms were pursued in the US. Conclusions: Brazil's government has engaged in innovative institutional conversion processes aiding its ability to sustain its centralized influence when implementing obesity policy. The US government's adoption of Brazil's institutional innovations may help to strengthen its policy response.

Background: Social scientists have paid increasing attention to health technology assessment (HTA). This paper provides an overview of existing social scientific literature on HTA, with a focus on sociology and political science and their subfields. Methods: Narrative review of key pieces in English. Results: Three broad themes recur in the emerging social science literature on HTA: the drivers of the establishment and concrete institutional designs of HTA bodies; the effects of institutionalized HTA on pricing and reimbursement systems and the broader society; and the social and political influences on HTA decisions. Conclusion: Social scientists bring a focus on institutions and social actors involved in HTA, using primarily small-N research designs and qualitative methods. They provide valuable critical perspectives on HTA, at times challenging its otherwise unquestioned assumptions. However, they often leave aside questions important to the HTA practitioner community, including the role of culture and values. Closer collaboration could be beneficial to tackle new relevant questions pertaining to HTA.

Background: Informal employment is common in developing countries, including Egypt. This type of employment may have significant consequences on mental health. Objectives: To determine the prevalence and risk factors of common mental disorders and substance abuse among temporary hired hospital cleaners. Methods: A cross-sectional study was conducted on 242 adult temporary cleaners and 209 permanent cleaners working in 4 governmental hospitals in Zagazig City, Sharqia Governorate, Egypt. All participants were invited to complete a structured questionnaire through a semi-structured interview which included the self-reporting questionnaire 20 items (SRQ-20) and the work stress scale. Assessment of drug use included urine-based screening tests for common substances abused. Results: The prevalence of job stress, common mental disorders and substance abuse, particularly tramadol and cannabis (Bango), was significantly higher in the studied temporary cleaners compared to permanent cleaners. Risk factors associated with increased susceptibility of the temporary cleaners to common mental disorders were family history of substance abuse, high crowding index, history of physical illness, low educational level, and smoking; while being unmarried, male sex, family history of mental disorder, age ≥40 years, smoking, and length of service ≥8 years, were associated with substance abuse among the same group. Conclusion: Temporary hired hospital cleaners suffered from impaired mental health more than permanent cleaners. Therefore, expanding the coverage of current laws and occupational safety and health standards to cover workers in the informal sector especially in developing countries is recommended.

Background: The Department of Community Mental Health (DCMH) at RAF Brize Norton runs a regular anxiety management day (AMD) which is a group intervention for regular military personnel who have been diagnosed with anxiety-related disorders. The AMD is a 1 day course for up to 20 participants run by two community mental health nurses based at the DCMH. It contains a combination of psycho-education and generic anxiety management techniques. Aims: To establish whether the AMD is acceptable to full time regular military personnel who have been referred to the DCMH. Methods: The acceptability of the AMD was assessed using a standardized feedback form, which asked about the patient's perception of the quality of the AMD and the course content. Feedback data were collected over a 12 month period between September 2010 and August 2011. Results Clinical and sociodemographic data were available for 91 of the 97 (94%) participants who participated in the AMD over the period from September 2010 to August 2011. Ninety-two per cent (89/97) of participants completed a post course survey immediately after they completed the AMD. Respectively, 95 and 93% considered the format and content of the AMD to be of good quality. Conclusions: The AMD fits well with the stepped care approach of the Improving Access to Psychological Therapies programme and resulted in a good level of patient satisfaction.

Variations in the distribution of power have been used to account for and to advocate different types of doctor-patient relationship. It might be expected that doctors who become patients would have a 'mutual' relationship with their treating doctor. Data from interviews with doctors with a recent illness show that this is not necessarily the case and may not even be doctors' preferred model of doctor-patient relationship for themselves when they become ill. Doctors constitute anomalous patients since they confound two categories generally held to be separate, 'doctor' and 'patient'. This affects the type of medical encounter they have, raising issues of identity and role performance for both patient and treating doctor. Doctor/patients may be in control of the encounter (through choice or default); they may consciously choose or have explicitly ascribed to them the status of 'ordinary patient'; some believe that doctors should be treated as extraordinary patients with particular needs dependent on their insider status as much as their pathology, The negotiation of power in the encounter between doctors and medically qualified patients is problematic but the existence of the power differential in the medical encounter emerges as 'natural' and largely as desirable, since it is linked to the ability and authority to take charge of the disorder which illness represents.

Introduction: In 2017, the New Zealand Government signalled its intent to legalise the widespread sale of Electronic Nicotine Delivery Systems (ENDS), which many New Zealand retailers have actually sold for several years. Although ENDS uptake may reduce the harm smokers face, it requires them to adopt an entirely new practice; we therefore explored how effectively existing non-specialist tobacco retailers could advise and support potential quitters. Methods: Using in-depth interviews with 18 tobacco retailers (prior to legislative change), we explored knowledge of ENDS, attitudes towards selling ENDS and supporting customers' cessation attempts, perceptions of ENDS' risks and benefits, and views on the proposed legislation. Results: Participants generally had poor knowledge of ENDS products and provided either no advice or gave incorrect information to customers. They believed that the main benefit consumers would realise from using ENDS rather than tobacco would be cost savings; relatively, few saw ENDS as smoking cessation devices. Those who stocked ENDS did so despite reporting very low customer demand, and saw tobacco as more important to their business than ENDS, citing higher repeat business, ancillary sales and rebates. Participants typically supported liberalising ENDS availability, though several expressed concerns about potential youth uptake. Conclusions: Tobacco retailers' limited understanding of ENDS, and the higher value they placed on tobacco, suggests they may have little capacity or inclination to support ENDS users to quit smoking. Licensing schemes for both ENDS and smoked tobacco could simultaneously reduce supply of smoked tobacco while requiring ENDS retailers to meet minimum knowledge standards.

Background: Cigarette butts are ubiquitous litter items, causing major environmental damage and imposing significant clean-up costs. Tobacco companies frame smokers as both the cause of this problem and the source of its solution. However, an extended producer responsibility perspective challenges this view and holds tobacco companies to account for the full life cycle costs of tobacco product waste (TPW). Methods: Using an online cross-sectional survey of 396 New Zealand smokers and 414 non-smokers, we estimated awareness of TPW, attribution of responsibility for TPW and support for interventions to reduce TPW. Descriptive analyses and logistic regression models examined associations between demographic attributes and smoking behaviours, and perceptions of TPW and potential solutions to this problem. Results: Most respondents saw butt litter as toxic to the environment and held smokers primarily responsible for creating TPW. However, when knowledge of butt non-biodegradability increased, so too did the proportion holding tobacco companies responsible for TPW. Changes to product design, fines for littering and expanded smoke-free spaces were considered most likely to reduce TPW. Smokers and non-smokers held different views on measures to address TPW, with smokers favouring more educative approaches and non-smokers more restrictive policies. Conclusions: Strategies to increase awareness of tobacco companies' role in creating TPW could foster political support for producer responsibility measures that require the industry to manage TPW. Nevertheless, policy measures should continue to foster smoking cessation and decrease uptake, as reducing smoking prevalence presents the best long-term solution to addressing TPW.

Background Reality television shows are popular with children and young adults; inclusion of tobacco imagery in these programmes is likely to cause smoking in these groups. Series 3 of the UK reality show Love Island, broadcast in 2017, attracted widespread media criticism for high levels of smoking depicted. We have quantified this tobacco content and estimated the UK population exposure to generic and branded tobacco imagery generated by the show. Methods We used 1-min interval coding to quantify actual or implied tobacco use, tobacco paraphernalia or branding, in alternate episodes of series 3 of Love Island, and Census data and viewing figures from Kantar Media to estimate gross and per capita tobacco impressions. Results We coded 21 episodes comprising 1001 min of content. Tobacco imagery occurred in 204 (20%) intervals; the frequency of appearances fell significantly after media criticism. An identifiable cigarette brand, Lucky Strike Double Click, appeared in 16 intervals. The 21 episodes delivered an estimated 559 million gross tobacco impressions to the UK population, predominantly to women, including 47 million to children aged <16 and 44 million gross impressions of Lucky Strike branding, including 4 million to children <16. Conclusion Despite advertising legislation and broadcasting regulations intended to protect children from smoking imagery in UK television, series 3 of Love Island delivered millions of general and branded tobacco impressions both to children and adults in the UK. More stringent controls on tobacco content in television programmes are urgently needed.

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.