Background and aim Stimulating the use of alcohol-free beverages is portrayed as one strategy to reduce excessive alcohol use and alcohol-related harm among students in higher education. This strategy relies on the assumption that students drink alcohol-free to substitute alcohol (i.e. 'substitution effect'), while other possibilities like drinking alcohol-free in addition to alcohol (i.e. 'addition effect') or alcohol-free acting as a step-up to consume (more) alcohol (i.e. 'stepping-stone' effect) have largely been neglected. Consequently, this pre-registered study aimed to examine bi-directional temporal associations between the quantity of alcohol and alcohol-free use among university students (aim 1). Next, these bi-directional temporal associations were examined in subgroups: females vs. males (aim 2) and members vs. non-members of student associations (aim 3).Design Observational study, utilizing wave 2, wave 3 and wave 4 of Radboud University's Healthy Student Life study. Data were collected May-July 2022, 2023 and 2024.Setting The Netherlands.Participants 9951 university students, of which 6790 students had only cross-sectional data, while 2383 and 778 students participated in 2 and 3 surveys, respectively. At wave 2, participants' mean age was 23 (standard deviation = 4.0). 70% were female, 17% were members of a student association, 13% were international students and 57% were enrolled in a bachelor programme.Measurements At all waves, participants self-reported the frequency and quantity of alcohol and alcohol-free beverage consumption, using two (adapted) items of the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C). Additionally, participants self-reported on: gender, student association membership, living situation, relationship status and other substance use. Last, information on biological sex, age, educational programme and (inter)national status was received from the university administrative records. Random Intercept Cross-Lagged Panel Models were used to study reciprocal effects between the quantity of alcohol and alcohol-free use, by decomposing observed scores in between-person differences and within-person dynamics.Results None of the analyses, in the total sample (aim 1; b between 0.02 and 0.03, p between 0.414 and 0.779) or in subgroups (aims 2-3; b between -0.001 and 0.12, p between 0.192 and 0.988), provided support for within-person cross-lagged effects between the quantity of alcohol and alcohol-free use.Summary Among Dutch university students, no evidence was found for substitution or stepping-stone effects of alcohol-free beverages, which (indirectly) suggests that students generally drink alcohol-free as an additive to alcohol, rather than as a substitute or stepping-stone.
Aims To identify heroin overdose and polydrug risk profiles of Australian adults with long-term heroin dependence and assess if psychosocial, treatment, physical and mental health-related covariates were associated with class membership. Design The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS). Setting Sydney, New South Wales, Australia. Participants 615 people with heroin dependence were recruited in 2001-2002, of whom 401 completed the follow-up interview between 2019 and 2021 and were included in this study (mean age: 47.3 years, standard deviation: 7.4; 66% male). Measurements Latent class analysis used indicator variables of heroin use, overdose history and past-month use of alcohol, benzodiazepines, other opioids, cannabis, amphetamines and cocaine. Odds ratios were estimated for covariates associated with class membership using multinomial logistic regression. Covariates included: age, sex, employment, crime, lifetime incarceration, unstable housing, age of first heroin use under 18 years, use of opioid maintenance therapy, naloxone history, trauma, post-traumatic stress disorder diagnosis, Short Form Health Survey-12 scores representing severely poor physical and mental health and depression. All latent class indicator variables and covariates were based on the latest 2019-2021 responses, except for three covariates (age of first heroin use, antisocial personality disorder and borderline personality disorder) where responses from 2001to 2002 were retained. Results Three latent classes were identified: high risk (7%), moderate risk (44%) and low risk (49%) of heroin overdose. The 3-class model had a Log Likelihood of -2133.31 and Entropy of 0.61. The 3-class model had the lowest sample size adjusted-Bayesian information of 601.02 and the bootstrapped likelihood ratio test suggested the 3-class model fit better than the 2-class model (P < 0.05). The high-risk class was defined by high probabilities of a past-year overdose, more than 10 lifetime overdoses, and 44-74% probability of past-month use of heroin, amphetamines, benzodiazepines and other opioids. Individuals in the moderate-and low-risk class were unlikely to have a past-year overdose. The moderate risk class had 30-50% probability of past-month use of heroin, amphetamines, benzodiazepines and other opioids, while the low-risk class had 6-17% probability of past-month use of these substances. Past-month crime, past-month depression and lifetime incarceration were associated with moderate-and high-risk class membership. Current methadone treatment and lifetime trauma were associated with moderate-risk class membership. Summary The Australian Treatment Outcome Study cohort with long-term heroin dependence can be classified into high, moderate and low risk of heroin overdose based on overdose history and polydrug use. People with higher rates of heroin, cannabis, amphetamines, benzodiazepines and other opioid use are more likely to belong to the high-and moderate-risk class.
Background and aims Long-term strong opioid use for chronic non-malignant pain (CNMP) represents a significant public health challenge, associated with reduced health-related quality of life (HRQoL) and increased mortality. The Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) trial demonstrated that a multicomponent intervention supporting opioid withdrawal in people with CNMP successfully reduced opioid consumption compared with best usual care (BUC), without adversely affecting perceived pain levels. This study aimed to assess the value-for-money of the strategies tested in the I-WOTCH trial, from the perspective of the United Kingdom National Health Service (NHS) and Personal and Social Services.Design, setting and participants Within-trial cost-consequence (CCA) and model-based cost-effectiveness analyses (CEA), over one year and lifetime horizons, respectively. Data were sourced from the I-WOTCH trial, which recruited 608 participants from 191 primary care centres in England between May 2017 and January 2019 and followed them up for up to 12 months. Participants received either BUC or 3 group sessions (lasting one day each) led by a trained intervention nurse and by a lay person with CNMP and lived experience with opioid tapering. These sessions, designed to develop self-management skills, were supplemented by ongoing one-to-one support from nursing and lay personnel during follow-up. We used a probabilistic state-transition model to predict expected quality-adjusted life years (QALYs) and costs (in UK ) pound of each strategy over the lifetime of an individual. Model input parameters were derived mostly from the I-WOTCH trial. Opioid-related excess mortality and fracture rates were extracted from the literature.Measurements Individual-level healthcare resource use and generic HRQoL [measured using the EuroQOL five dimensions questionnaire (Equation 5D)] were collected at baseline, 4, 8 and 12 months, and analysed to estimate total costs and health consequences for the I-WOTCH and BUC groups.Findings I-WOTCH had higher costs and similar HRQoL outcomes compared with BUC at 12 months. When accounting for long-term reductions in mortality and morbidity from decreased exposure to strong opioids, our long-term model predicted I-WOTCH to yield higher costs and higher QALYs than BUC over the patient's lifetime, resulting in a base case incremental cost-effectiveness ratio of 29 pound 543/QALY (2019 prices). Results were sensitive to structural assumptions in the model (i.e. cohort starting age, treatment effect weaning rate). Our probabilistic sensitivity analysis found I-WOTCH to have a 50% probability of being cost-effective compared with BUC for willingness-to-pay thresholds ranging between 0 and 100 pound 000/QALY.Conclusions The Improving the Wellbeing of people with Opioid Treated CHronic pain intervention supporting opioid withdrawal in people with chronic non-malignant pain appears to be cost-effective on average, but further research is warranted to reduce current levels of decision uncertainty.
Background and Aim Nicotine pouches are novel products with rapid global sales growth. Our aim was to explore use and perceptions of nicotine pouches among adolescents in Latin America.Design Cross-sectional school surveys between March and August 2025.Setting Sixteen cities, four each in Argentina, Guatemala, Mexico and Peru.Participants Adolescents aged 12-17 years (n = 12 785).Measurements Use of, and susceptibility to, nicotine pouches, through survey questions about frequency of use, brands and flavours used, access, and harm compared to cigarettes and e-cigarettes.Results Self-reported ever use was 6.0%, highest in Peru (9.1%) and lowest in Argentina (3.2%). Ever use was higher among males, those with higher family affluence scores, and those who had ever vaped or smoked tobacco. The rate of current (past 30 day) nicotine pouch use was 2.4%. Those reporting current use typically used pouches infrequently (1-3 days in the last month). The most commonly used brands were Velo (24.4%) and Zyn (18.1%), with pouches most likely to be given to them by someone (26.3%) or giving someone else money to buy them (15.8%). Fruit (20.3%) and mint/menthol (17.3%) were the most common flavours reported. More than one-third of the sample indicated that nicotine pouches were more harmful (somewhat/a lot) than cigarettes (38.7%) and e-cigarettes (36.7%).Summary Nicotine pouch use among adolescents in four Latin American countries appears to be relatively uncommon but higher than in previous youth surveys. Access to nicotine pouches appears to be largely informal, fruit and mint/menthol flavours are most common, and many adolescents appear uncertain about harm compared with cigarettes and e-cigarettes.
Abstract Aims This study aimed to evaluate the restrictiveness of formal alcohol policies in eight Eastern European Union countries from 1995 to 2023 using a quantitative alcohol policy score and to analyse how variations in policy restrictiveness were associated with changes in total adult per capita alcohol consumption (APC) and alcohol‐attributable disease burden. Design Longitudinal observational study based on cross‐national comparisons over a 29‐year period (1995–2023). Setting Bulgaria, Croatia, Czechia, Hungary, Poland, Romania, Slovakia and Slovenia. Participants/cases The units of the analyses were countries ( n = 8) and years ( n = 29). Measurements Annual data on statutory alcohol regulations were collected from national legal documents and scored using a modified Bridging the Gap (BtG‐M) scale, where higher scores indicate more restrictive alcohol policies. Total APC data, a sum of recorded and unrecorded minus tourist consumption, were obtained from the World Health Organization. Alcohol‐attributable disease burden was measured as age‐standardized rates of years of life lost (YLLs), years lived with disability (YLDs), disability‐adjusted life‐years (DALYs) and deaths per 100 000 population attributable to high alcohol use, based on estimates from the 2023 Global Burden of Disease Study (GBD). Results All countries displayed relatively low levels of formal policy restrictiveness, with BtG‐M scores concentrated in the lower half of the scale. At the start of the study, Poland, Slovakia and Czechia showed the highest restrictiveness, while Croatia and Slovenia the lowest. By 2023, BtG‐M scores converged upwards, with Poland and Slovenia recording the highest and Bulgaria and Croatia the lowest restrictiveness levels. Linear mixed‐effects models indicated inverse association between policy restrictiveness and alcohol‐attributable disease burden, particularly mortality; however, the associations were complex: BtG‐M scores were negatively correlated with alcohol consumption and disease burden estimates in Croatia, Czechia, Romania and Slovenia, but not in the other four countries. Summary This study presents the first comprehensive longitudinal analysis of the relationship between formal alcohol policy restrictiveness and alcohol‐attributable disease burden across eight Eastern European Union countries from 1995 to 2023. We found a complex relationship: in countries that strengthened alcohol policies (Croatia, Czechia, Romania and Slovenia), greater policy restrictiveness was associated with lower alcohol consumption and related harm. In the remaining countries (Bulgaria, Hungary, Poland and Slovakia), this relationship was not clearly observed, regardless of overall restrictiveness levels.
