When it comes to assessing the impact of e-cigarettes, estimates of device prevalence matter: the BIDI Stick disposable device.

BACKGROUND: While e-cigarettes have been identified as an effective means of tobacco harm reduction, the degree to which these devices will realise their harm reduction potential will be determined in large part by how available these products are to adults who smoke. One of the key factors determining that availability is the regulatory regime around these products. Within the US e-cigarettes have become the most commonly used tobacco product by middle and high school students, with disposable e-cigarettes now the most popular type of device used by youth. In this paper, we report data on the prevalence with which one of the most popular disposable e-cigarettes within the US is being used by youth (aged 13-17) and underage young adults (aged 18-20). METHODS: A cross-sectional online survey of a probability-based sample of 1215 youth (13-17 years) recruited via Ipsos' KnowledgePanel and 3370 young adults aged 18-24, among whom 1125 were aged 18-20, recruited via Ipsos' KnowledgePanel and online consumer research panels. RESULTS: Among youth, 3.50% (95% CI: 2.46-4.83) reported smoking combustible cigarettes in the past 30 days, and 6.73% (95% CI: 5.26-8.48) reported using an e-cigarette in the past 30 days. Among underage young adults, 7.22% (95% CI: 5.24-9.67) reported smoking combustible cigarettes every day or some days, and 15.90% (95% CI: 12.96-19.21) reported using e-cigarettes every day or some days. Despite the scale of e-cigarette use in general among the US youth, only 0.04% (95% CI: 0.00-0.38) of 13-17 years old reported using the BIDI® Stick disposable e-cigarette in the past 30 days. CONCLUSIONS: While disposable e-cigarettes have become the most popular type of e-cigarette used by the US youth, it is likely that the prevalence of use of individual devices varies significantly. There is a need to regularly monitor the use of e-cigarettes by type of device and brand, in order to determine which products have the greatest potential to reduce smoking-related harm among adults who smoke and which products are being used by youth and underage young adults.

The Adult JUUL Switching and Smoking Trajectories (ADJUSST) Study: Methods and Analysis of Loss-to-Follow-up.

Objectives: The Adult JUUL System User Switching and Smoking Trajectories (ADJUSST) study assessed the smoking and JUUL use trajectories of adults who purchased JUUL. In this paper, we describe study methods, characterize the sample, and assesses potential for bias due to loss to follow-up. Methods: We entered 55,414 US adults (≥ age 21) who purchased a JUUL Starter Kit for the first time (online or at retail) in 2018 into a naturalistic, longitudinal observational study, irrespective of baseline smoking status. Participants were invited for follow-ups 1, 2, 3, 6, 9, and 12 months later, focused on assessing past-30-day smoking and JUUL use. Analyses assessed potential bias due to non-response. Results: Over 90% of participants had a history of smoking; 62.8% were past-30-day smokers; 23.3% were former smokers. Participants' average age was 30; 75% were white. Most participants (77.6%) completed some follow-ups; 25% completed all follow-ups. Baseline differences among complete responders (N = 13,729), partial responders (N = 29,252), and complete non-responders (N = 12,433) were small. When recontacted, few 12-month non-responders said their non-response was due to smoking; many reported no past-30-day smoking. Conclusions: The study may elucidate smoking trajectories of adult JUUL users. The potential for bias due to loss to follow-up in ADJUSST was limited.

Harm and Addiction Perceptions of the JUUL E-Cigarette Among Adolescents.

INTRODUCTION: This study assessed adolescents' harm and addiction perceptions of the highest-selling brand-JUUL-of the most commonly used tobacco product-electronic cigarettes (e-cigarettes)-among adolescents in the United States. METHODS: A cross-sectional online survey assessed use and perceptions of the harmfulness and addictiveness of the JUUL e-cigarette and conventional tobacco cigarettes in a nationally representative sample of 9865 adolescents aged 13-17 years in the United States. Associations between adolescents' harm and addiction perceptions and their use of a JUUL e-cigarette were examined through multinomial logistic regression models. RESULTS: Overall, 6.1% and 9.3% of adolescents believed daily use and occasional use of a JUUL e-cigarette, respectively, would cause them no harm. Around 11.3% believed they would either never experience harm from using a JUUL e-cigarette or they could use a JUUL e-cigarette for at least 20 years before experiencing any harm, and 7.3% believed they would be "very unlikely" to become addicted to using a JUUL e-cigarette. Overall, 39.3% and 29.3% of adolescents perceived the JUUL e-cigarette as "less harmful" and "less addictive" than conventional cigarettes, respectively. Compared to never users of the JUUL e-cigarette, current and former users held significantly lower harm and addiction perceptions of the JUUL e-cigarette on all measures. CONCLUSIONS: The majority of adolescents believed using a JUUL e-cigarette would put them at, at least, some risk for experiencing health problems and addiction. A smaller but significant proportion believed they could use a JUUL e-cigarette without ever being harmed by or becoming addicted to the JUUL e-cigarette. IMPLICATIONS: The study reports adolescents' perceptions of the harmfulness and addictiveness of the highest-selling brand of the most commonly used tobacco product among youth in the United States. Though the majority of adolescents correctly believed that using a JUUL e-cigarette would put them at, at least, some risk for experiencing health problems and addiction, a small proportion believed that using a JUUL e-cigarette would be risk free. Correcting such risk-free perceptions may reduce adolescents' interest in trying and continuing to use JUUL e-cigarettes.

Sources of youth access to JUUL vaping products in the United States.

INTRODUCTION: This study assessed sources of youth access to JUUL vaping products, the highest selling brand of the most commonly used tobacco product among adolescents in the United States. METHODS: A cross-sectional online survey assessed use of JUUL vaping products in a non-probability, nationally representative sample of 9865 adolescents aged 13-17 years in the United States. Past 30-day JUUL users (n = 1537) were asked how they got the JUUL vaping products they had used in the past 30-days. Those who reported having bought JUUL products themselves were asked about the places and people from whom they had bought products. Population-weighted percentages and 95% confidence intervals are reported for each source of access. RESULTS: An estimated 79.6% (95% CI = 77.5-81.6%) of current JUUL users obtained JUUL products from at least one social source (e.g. 'someone bought for me, someone offered to me) in the past 30 days. By comparison, 20.0% [95% CI = 18.0-22.0%) of current users bought JUUL products themselves. Of 1322 youth who reported obtaining JUUL products from at least one source or by buying products themselves in the past 30 days, 77.5% (95% CI = 75.3-79.8%) had obtained JUUL products exclusively from social sources (i.e. they did not buy products directly), 17.2% (95% CI = 15.2-19.3%) obtained JUUL products exclusively by buying the products themselves (i.e. they did not obtain products from any social sources), and 5.2% (95% CI = 4.0-6.4%) had obtained JUUL products both from social sources and from buying the products themselves. Among youth who bought JUUL products themselves, the most common place of purchase was 'a gas station or convenience store' [53.1% (95% CI = 47.5- 58.6%)]. CONCLUSIONS: Youth who are currently using JUUL vaping products obtain these products predominantly through social sources, such as friends and peers. Youth sources of access to JUUL vaping products appear to mirror youth sources of access to other tobacco products. Reducing youth use of JUUL vaping products will require a greater focus on measures that deter or penalize legal-age purchasers who give or sell products to minors.

Factors associated with past 30-day abstinence from cigarette smoking in adult established smokers who used a JUUL vaporizer for 6 months.

BACKGROUND: JUUL is the fastest growing and highest selling brand of e-cigarette/vapor products in the USA. Assessing the effect of JUUL vapor products on adult smokers' use of conventional tobacco cigarettes can help inform the potential population health impact of these products. METHODS: Participants were 15,456 US adult established current smokers aged 21 years who had purchased their first JUUL Starter Kit from a retail store or online within the past 7 days. Online surveys assessed past 30-day use of conventional cigarettes, JUUL vapor products, and other e-cigarettes/vapor products at 3 and 6 months after their first JUUL purchase. Logistic regression models examined factors associated with smokers' odds of self-reporting past 30-day abstinence from cigarette smoking at 6 months. RESULTS: Past 30-day point prevalence abstinence from smoking at 6 months was 31.6% in the intent-to-treat (ITT) sample and 54.0% among those who responded at 6 months (n = 9040; 58.5% of ITT). Consecutive past 30-day smoking abstinence outcomes at 3 and 6 months were reported by 20.3% of the ITT sample and 40.6% of responders to both assessments (n = 7726). Covariate-adjusted odds for reporting past 30-day smoking abstinence at 6 months were significantly higher among primary users of mint- or mango-flavored JUULpods (compared to primary users of Virginia tobacco-flavored JUULpods), exclusive users of JUULpods in characterizing flavors (compared to exclusive users of tobacco-flavored JUULpods), daily users of the JUUL vaporizer (compared to less-than-daily), initial retail purchasers (compared to initial e-commerce purchasers), and those who first purchased a JUUL to help to quit smoking completely. Odds for reporting past 30-day smoking abstinence were significantly lower among those who, at study enrolment, had smoked regularly for ≥ 20 years, smoked ≥ 10 cigarettes per day, and smoked on all 30 of the previous 30 days. CONCLUSIONS: Around one third of enrolled smokers and one half of smokers who responded to a 6-month follow-up reported being past 30-day abstinent from cigarette smoking after using a JUUL vaporizer for 6 months. More frequent use of a JUUL vaporizer and primary use of JUULpods in characterizing flavors, particularly mint and mango, appeared to be important to smokers' chances of quitting. The impact of suspending retail sales of flavored JUULpods on adult smokers' likelihood of quitting should be closely assessed.

Capital depreciation: The lack of recovery capital and post-release support for prisoners leaving the Drug Recovery Wings in England and Wales.

BACKGROUND: This article draws on the evaluation of the pilot Drug Recovery Wings (DRWs), which were introduced ten prisons in England and Wales, with the intention of delivering abstinence-focused drug recovery services. The DRW pilots can be seen as representing the extension of the recovery paradigm - so prevalent elsewhere in UK drug policy - to the prison system. This study aimed to provide a detailed account of DRW prisoners' expectations and experiences in the transition from prison to the community and explore the potential for 'doing recovery' in prison and on release. METHODS: In-depth, qualitative interviews were conducted in prison with 61 prisoners across six of the DRWs. Follow-up interviews six months after release were conducted with 21 prisoners and 26 'recovery supports' (people identified as being close to the prisoners). Data from one, other or both sources was available for 36 prisoners. All interviews were fully transcribed and coded. RESULTS: The majority of the 61 had long histories of alcohol and/or opiate dependence, childhood adversity, undiagnosed mental health problems and few educational qualifications. Nonetheless, many had long histories of employment - mostly in manual trades. The majority described themselves as being 'in recovery' at the time of the first interview in prison. While one of the main aims of the DRWs was to support prisoners' recovery journeys into the community, this aspect of their work did not materialize. Professional support at release was largely absent or, where present, ineffectual. Many were released street-homeless or to disordered and threatening hostels and night-shelters. Only three of the 36 were fully abstinent from drink and drugs at time of re-interview, although some had moderated their use. A substantial number had returned to pre-imprisonment levels of use, often with deeply damaging impacts on those around them. DISCUSSION AND CONCLUSIONS: This research suggests a fundamental contradiction between recovery and imprisonment. In large part, imprisonment serves to erode recovery capital while, at the same time, making psychoactive substances readily available. Looking to the future, every effort should be made to divert substance users from imprisonment in the first place. Where that fails, the primary aim should be to reduce the erosion of recovery capital during imprisonment: through family support work, providing proper housing, training and education opportunities and ensuring a graduated reintroduction of prisoners into the community.

Prevalence of Awareness and Use of JUUL E-cigarettes in a National Probability Sample of Adolescents in the United States.

Objective: In this study, we estimate the prevalence of awareness and use of the JUUL e-ciga- rette among adolescents in the United States (US). Methods: We conducted a cross-sectional, self-report online survey between September 21 and October 3, 2018 that assessed awareness and use of JUUL e-cigarettes, other e-cigarettes, and combustible cigarettes in a national prob- ability sample of 1017 US adolescents aged 13-17 years. Results: Approximately 45.5% of adolescents aged 15-17 years and 29.1% of adolescents aged 13-14 years had ever seen or heard of a brand of e-cigarette called 'JUUL'. Among adolescents aged 15-17 years, 7.6% had ever used a JUUL, 4.0% had used a JUUL in the past 30 days, and 0.3% had used a JUUL on 20-30 of the past 30 days. Among adolescents aged 13-14 years, 1.5% had ever used a JUUL, 0.8% had used a JUUL in the past 30 days, and 0.0% had used a JUUL on 20-30 of the past 30 days. Conclusion: In September-October 2018, we estimated that about 39 in 100 US adolescents aged 13-17 years were aware of the JUUL brand of e-cigarette, and about 3 in 100 were estimated to have used a JUUL e-cigarette in the past 30 days. Close to half of all past 30-day e-cigarette use involved use of a JUUL e-cigarette. Present prevalence estimates may be limited to online modes of survey data collection and to the time period in which the data were collected. Findings reinforce the public health importance of acting to reduce youth access to JUUL vaping products, and of rou- tinely monitoring youth awareness and use of specific e-cigarette brands.

Factors associated with past 30-day abstinence from cigarette smoking in a non-probabilistic sample of 15,456 adult established current smokers in the United States who used JUUL vapor products for three months.

BACKGROUND: JUUL is the fastest growing and highest selling brand of e-cigarette/vapor products in the USA. Assessing the effect of JUUL vapor products on adult smokers' use of conventional tobacco cigarettes can help inform the potential population health impact of these products. METHODS: Online surveys assessed past 30-day use of conventional cigarettes, JUUL vapor products, and other e-cigarettes/vapor products, monthly for 3 months, in a non-probabilistic sample of 15,456 US adults (21+ years). Participants were established current smokers of conventional cigarettes and recruited at their first purchase of a JUUL Starter Kit in a retail store or through JUUL's website. Logistic regression models examined factors associated with participants' odds of reporting past 30-day abstinence from cigarette smoking at the 3-months assessment. RESULTS: Past 30-day smoking abstinence at the 3-months assessment was reported by 28.3% of the intent-to-treat (ITT) sample (n = 15,456) and 47.1% of an efficacy subset sample that completed the 3-months assessment (n = 9272). Covariate-adjusted odds for reporting past 30-day smoking abstinence at the 3-months assessment were significantly higher among participants who primarily used Mint or Mango flavored JUULpods (versus Virginia Tobacco flavor) in the past 30 days; exclusively used JUULpods in characterizing flavors (versus tobacco flavors) in the past 30 days; used a JUUL vaporizer on all 30 of the past 30 days; purchased their first JUUL vaporizer in a retail store (versus online); and first purchased a JUUL Starter Kit to help quit smoking completely. Odds for reporting past 30-day smoking abstinence were significantly lower among participants who, at study enrolment, had smoked regularly for ≥ 20 years, smoked ≥ 20 cigarettes per day, and smoked on all 30 of the previous 30 days. CONCLUSIONS: At least 28.3% of adult smokers had quit smoking cigarettes completely after using a JUUL vaporizer for 3 months. More frequent use of a JUUL vaporizer and primary use of JUULpods containing characterizing flavors, particularly Mint and Mango, appears to be important to new JUUL users' chances of quitting smoking. The impact of banning retail sales of flavored JUULpods on adult smokers' likelihood of quitting should be closely assessed.

The Value of Providing Smokers with Free E-Cigarettes: Smoking Reduction and Cessation Associated with the Three-Month Provision to Smokers of a Refillable Tank-Style E-Cigarette.

Despite the uptake of tobacco smoking declining in the United Kingdom (UK), smoking is still the leading cause of preventable poor health and premature death. While improved approaches to smoking cessation are necessary, encouraging and assisting smokers to switch by using substantially less toxic non-tobacco nicotine products may be a possible option. To date, few studies have investigated the rates of smoking cessation and smoking reduction that are associated with the provision of free electronic-cigarettes (e-cigarettes) to smokers. In this exploratory study, the Blu Pro e-cigarette was given to a convenience sample of adult smokers (n = 72) to assist them in reducing and quitting over a 90-day period. The rates of smoking abstinence and daily smoking patterns were assessed at baseline, 30 days, 60 days, and 90 days. The response rate was 87%. After 90 days, the complete abstinence rate was 36.5%, up from 0% at baseline. The frequency of daily smoking reduced from 88.7% to 17.5% (p < 0.001), and the median consumption of cigarettes/day reduced from 15 to five (p < 0.001). The median number of days per month that participants smoked also reduced from 30 to 13 after 90 days (p < 0.001). On the basis of these results, there may be value in smoking cessation services and other services ensuring that smokers are provided with e-cigarettes at zero or minimal costs for at least a short period of time.

Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA.

BACKGROUND: Understanding the role that flavors play in the population's use of e-cigarettes and the impact that flavored e-cigarette products have on the population's use of more harmful tobacco products, like conventional cigarettes, has been identified by the US Food and Drug Administration (FDA) as a public health research priority. The purpose of the study was to assess the first e-cigarette flavor and current e-cigarette flavors used by a large non-probabilistic sample of adult frequent users of e-cigarettes in the USA and assess how flavor preferences vary by cigarette smoking status and time since first e-cigarette purchase. METHODS: An online survey assessed the first e-cigarette flavor and current e-cigarette flavors used by a non-probabilistic sample of 20,836 adult frequent e-cigarette users in the USA. Differences in e-cigarette flavor preferences between current smokers, former smokers, and never-smokers and trends in the first flavor used across time of e-cigarette use initiation were assessed. RESULTS: The majority (n = 15,807; 76.4%) of sampled frequent e-cigarette users had completely substituted e-cigarettes for conventional cigarettes-"switchers"-and were currently using rechargeable, refillable vaping devices. Among them, the proportion of first e-cigarette purchases that were fruit-flavored increased from 17.8% of first purchases made before 2011 to 33.5% of first purchases made between June 2015 and June 2016. Tobacco-flavored first purchases almost halved during this time (46.0% pre-2011 to 24.0% between 2015 and 2016). Fruit/fruit beverage (73.9 to 82.9% of sampled users), dessert/pastry (63.5 to 68.5% of sampled users), and candy, chocolate, or sweets (48.7 to 53.4% of sampled users) were the most popular currently used e-cigarette flavors. Tobacco and menthol flavors, the two most popular flavors for initiating e-cigarette use prior to 2013, now rank as the 5th and 6th most popular currently used e-cigarette flavors, respectively. CONCLUSIONS: Adult frequent e-cigarette users in the USA who have completely switched from smoking cigarettes to using e-cigarettes are increasingly likely to have initiated e-cigarette use with non-tobacco flavors and to have transitioned from tobacco to non-tobacco flavors over time. Restricting access to non-tobacco e-cigarette flavors may discourage smokers from attempting to switch to e-cigarettes.

Change and Continuity in Vaping and Smoking by Young People: A Qualitative Case Study of A Friendship Group.

This paper reports a qualitative case study of a small friendship group (n = 8) in Glasgow, Scotland. Interviewed twice at six months apart, these 16 to 17 year olds reported a substantial change in their use of and attitudes towards e-cigarettes and tobacco. At time 1, vaping generated much excitement and interest, with six out of eight individuals having their own vape device. At time 2, only two young people still vaped, with the others no longer professing any interest in continued vaping. The two regular smokers, who had been smoking before they first vaped, now only vaped privately and to reduce their tobacco intake. This small case study illustrates plasticity in the use of these devices; just as young people can move into their use, so too can they move away from them. This small study underscores the importance of differentiating between long-term, frequent, consistent use and more episodic, experimental and infrequent use by young people and for undertaking a measurement of actual e-cigarette use at multiple time points in both quantitative and qualitative studies. In addition, the case study illustrates the powerful impact which peers can have on teenagers use of e-cigarettes.

Advice From Former-Smoking E-Cigarette Users to Current Smokers on How to Use E-Cigarettes as Part of an Attempt to Quit Smoking.

Introduction: Substitution of e-cigarettes for tobacco smoking has the potential to prevent almost all the harm caused by smoking. Identifying strategies that may increase smokers' capability, opportunity and motivation to use e-cigarettes in place of tobacco cigarettes is vital. Former smokers who have successfully used e-cigarettes to quit smoking may be especially well qualified to increase current smokers' interest in switching and ability to switch to e-cigarettes. Methods: A multi-national, self-selected sample of 4192 former smokers who quit smoking by using e-cigarettes were asked, via an online survey, the advice they would offer to smokers who are considering using e-cigarettes to support an attempt to quit smoking. Results: Thematic analysis of participants' qualitative responses identified four emergent themes: (1) Find a combination of vaping device, flavors of e-liquid and nicotine strength that "works for you"; (2) Continuing to smoke for a while after starting to vape is OK; (3) Failure to quit smoking with the use of approved smoking cessation aids before success with e-cigarettes is common; and (4) Awareness of improved health and hygiene since switching to vaping. Conclusions: Experienced vapers who used to smoke appear eager to give smokers advice and practical information about vaping that may assist attempts to switch from smoking to vaping. Encouraging cigarette smokers to interact with experienced vapers in places where vapers themselves once received advice and now give advice about vaping-vape shops and online discussion fora-may have significant potential to help more smokers to switch to e-cigarette use. Implications: This study describes the advice that former-smokers who used e-cigarettes to quit smoking would offer to smokers who are considering using an e-cigarette to support an attempt to quit smoking. Vapers advised smokers to find the right combination of device, flavors and nicotine strength, continue to smoke and vape for a while if they wished, not be deterred by past failed attempts to quit smoking, and expect health to improve after they have switched to vaping. Encouraging smokers to interact with vaping peers in vape shops and in online vaping-dedicated discussion fora may help significantly more smokers switch to vaping.

Why Don't More Smokers Switch to Using E-Cigarettes: The Views of Confirmed Smokers.

Whilst e-cigarettes have been characterised by Public Health England as being around 95% less harmful than combustible tobacco products, only a minority of current smokers (around 16% within the UK) are using these devices. In this paper we report the results of an online survey of 650 smokers in contact with a smokers' rights group in the UK. A total of 91% of the smokers surveyed were smoking on a daily basis. Fifty nine percent reported having used electronic nicotine delivery systems, the majority of whom reported having used e-cigarettes. Those smokers that had not used these devices principally explained this in terms of the pleasure they derived from smoking. The features smokers' liked most about e-cigarette had to do with the range of settings in which they could be used, the lack of an offensive smell associated with their use, the available flavours and the reduced level of harm. The elements which smokers liked least about e-cigarettes had to do with the vaping experience, the technology, the chemical nature of e-liquids and the complex technology that was associated with these devices. If a greater number of smokers are to be encouraged to take up e-cigarettes, it will be necessary not only to convey accurate information on the relative harm of these devices (compared to combustible tobacco products), but to ensure that they are able to be used in a wider range of settings than those within which smoking can currently occur and that the vaping experience more closely resembles the smoking experience.

Conspicuous by their abstinence: The limited engagement of heroin users in English and Welsh Drug Recovery Wings.

BACKGROUND: In recent years, an abstinence-focused, 'recovery' agenda has emerged in UK drug policy, largely in response to the perception that many opioid users had been 'parked indefinitely' on opioid substitution therapy (OST). The introduction of ten pilot 'Drug Recovery Wings' (DRWs) in 2011 represents the application of this recovery agenda to prisons. This paper describes the DRWs' operational models, the place of opiate dependent prisoners within them, and the challenges of delivering 'recovery' in prison. METHODS: In 2013, the implementation and operational models of all ten pilot DRWs were rapidly assessed. Up to three days were spent in each DRW, undertaking semi-structured interviews with a sample of 94 DRW staff and 102 DRW residents. Interviews were fully transcribed, and coded using grounded theory. Findings from the nine adult prisons are presented here. RESULTS: Four types of DRW were identified, distinguished by their size and selection criteria. Strikingly, no mid- or large-sized units regularly supported OST recipients through detoxification. Type A were large units whose residents were mostly on OST with long criminal records and few social or personal resources. Detoxification was rare, and medication reduction slow. Type B's mid-sized DRW was developed as a psychosocial support service for OST clients seeking detoxification. However, staff struggled to find such prisoners, and detoxification again proved rare. Type C DRWs focused on abstinence from all drugs, including OST. Though OST clients were not intentionally excluded, very few applied to these wings. Only Type D DRWs, offering intensive treatment on very small wings, regularly recruited OST recipients into abstinence-focused interventions. CONCLUSION: Prison units wishing to support OST recipients in making greater progress towards abstinence may need to be small, intensive and take a stepped approach based on preparatory motivational work and extensive preparation for release. However, concerns about post-release deaths will remain.

The Impact of Misuse and Diversion of Opioid Substitution Treatment Medicines: Evidence Review and Expert Consensus.

BACKGROUND/AIMS: Opioid substitution treatment (OST) improves outcomes in opioid dependence. However, controlled drugs used in treatment may be misused or diverted, resulting in negative treatment outcomes. This review defines a framework to assess the impact of misuse and diversion. METHODS: A systematic review of published studies of misuse and diversion of OST medicines was completed; this evidence was paired with expert real-world experience to better understand the impact of misuse and diversion on the individual and on society. RESULTS: Direct impact to the individual includes failure to progress in recovery and negative effects on health (overdose, health risks associated with injecting behaviour). Diversion of OST has impacts on a community that is beyond the intended OST recipient. The direct impact includes risk to others (unsupervised use; unintended exposure of children to diverted medication) and drug-related criminal behavior. The indirect impact includes the economic costs of untreated opioid dependence, crime and loss of productivity. CONCLUSION: While treatment for opioid dependence is essential and must be supported, it is vital to reduce misuse and diversion while ensuring the best possible care. Understanding the impact of OST misuse and diversion is key to defining strategies to address these issues.

Tobacco plain packaging: Evidence based policy or public health advocacy?

In December 2012, Australia became the first country to require all tobacco products be sold solely in standardised or 'plain' packaging, bereft of the manufacturers' trademarked branding and colours, although retaining large graphic and text health warnings. Following the publication of Sir Cyril Chantler's review of the evidence on the effects of plain tobacco packaging, the Ministers of the United Kingdom Parliament voted in March 2015 to implement similar legislation. Support for plain packaging derives from the belief that tobacco products sold in plain packs have reduced appeal and so are more likely to deter young people and non-smokers from starting tobacco use, and more likely to motivate smokers to quit and stay quit. This article considers why support for the plain packaging policy has grown among tobacco control researchers, public health advocates and government ministers, and reviews Australian survey data that speak to the possible introductory effect of plain packaging on smoking prevalence within Australia. The article concludes by emphasising the need for more detailed research to be undertaken before judging the capacity of the plain packaging policy to deliver the multitude of positive effects that have been claimed by its most ardent supporters.

Clear rhetoric and blurred reality: the development of a recovery focus in UK drug treatment policy and practice.

This paper looks at the transformation of UK drug treatment policy in the priority that is now being given to recovery. The paper explores the factors that helped shape that transformation and notes that in the main the influences were external to those directly involved in delivering drug treatment (research, politicians, media, think tanks) and that whilst the combined influence of these elements succeeded in reframing policy, it has left the realm of drug treatment service delivery unclear in a number of key areas including: determining how long drug users should remain in treatment; avoiding relapse; relations between professional drug workers and peer supporters; and meeting the diverse needs of drug users including those who are not seeking to become drug free. The paper concludes by considering what kind of initiatives and mechanisms may be needed to ensure a closer alignment between policy and practice within the drug treatment sphere.

Medically assisted recovery from opiate dependence within the context of the UK drug strategy: methadone and Suboxone (buprenorphine-naloxone) patients compared.

The focus of drug policy in the UK has shifted markedly in the past 5 years to move beyond merely emphasising drug abstinence towards maximising individuals' opportunities for recovery. The UK government continues to recognise the prescribing of narcotic medications indicated for opiate dependence as a key element of these individuals' recovery journey. This article describes a small, naturalistic comparison of the efficacy of the two most commonly prescribed opiate substitute medications in the UK--methadone hydrochloride (methadone oral solution) and Suboxone (buprenorphine-naloxone sublingual tablets)--for reducing current heroin users' (n = 34) days of heroin use, and preventing short-term abstainers (n = 37) from relapsing to regular heroin use. All patients had been prescribed either methadone or Suboxone for maintenance for 6 months prior to intake. Results showed that when controlling for a number of patient-level covariates, both methadone and Suboxone significantly reduced current users' days of heroin use between the 90 days prior to intake and at the 8-month follow-up, with Suboxone yielding a significantly larger magnitude reduction in heroin use days than methadone. Methadone and Suboxone were highly and equally effective for preventing relapse to regular heroin use, with all but 3 of 37 (91.9%) patients who were abstinent at intake reporting past 90-day point prevalence heroin abstinence at the 8-month follow-up. Overall, prescribing methadone or Suboxone for eight continuous months was highly effective for initiating abstinence from heroin use, and for converting short-term abstinence to long-term abstinence. However, the study design, which was based on a relatively small sample size and was not able randomise patients to medication and so could not control for the effects of potential prognostic factors inherent within each patient group, means that these conclusions can only be made tentatively. These positive but preliminary indications of the comparative efficacy of methadone and Suboxone for treating opiate dependence now require replication in a well-powered, randomised controlled trial.