Background:Youth vaping prevalence varies across countries and may be related to differing regulations/products. The emergence of cheap disposable vapes and high-concentration nicotine salts heightened concerns related to youth's ease of access, dependence and potential health risks. Objectives:We examined youth in England versus Canada and the United States and: how patterns of vaping/smoking varied, given the countries' different regulatory frameworks nicotine and potential toxicant exposure in youth who vape, smoke or do neither in youth who use salt and free-base nicotine respiratory symptom reporting. Design, methods, setting and participants:Objectives 1 and 4: Repeated cross-sectional surveys (International Tobacco Control Youth Tobacco and Vaping Surveys), England, Canada, United States, 2017-22, N = 1355-39,214, 16- to 19-year-olds, or 16- to 29-year-olds, depending on analysis. Objectives 2 and 3: International Tobacco Control Biomarker Sub-Study, England, Canada, United States, 2019-22, 16- to 19-year-olds, N = 364 and England-only Biomarker Sub-Study, 2022-3, 16- to 19-year-olds, N = 201. Past-week users and past 30-day non-users were tested. Interventions:None, comparisons based on vaping/smoking status. Main outcome measures:Objective 1: Vape flavours, nicotine concentration, product types, brands used. Objectives 2 and 3: Urinary biomarkers, normalised for creatinine; tobacco-specific nitrosamine NNK (NNAL); volatile organic compounds (VOCs): acrolein (3HPMA), acrylamide (2CaHEMA), acrylonitrile (2CyEMA), benzene (PhMA), toluene (BzMA), xylene (24MPhMA); nicotine: cotinine, trans-3'-hydroxycotinine (3-HC), total nicotine equivalents. Objective 4: Self-reporting any of 5 past-week respiratory symptoms (e.g. cough and dyspnoea). Results:Objective 1: Usual flavours were unchanged after 2020 United States pod-based vape flavour restrictions. Youth used exempt brands/products. Simultaneously, disposable vape use increased. In England, in 2022, 48% of 16- to 29-year-olds who vaped in past 30 days used Elf Bar brands, mainly for subjective responses (e.g. flavour/taste), rather than quitting smoking. Nicotine concentrations varied cross-country. Objectives 1, 2 and 3: Compared to smoking tobacco (exclusive or alongside vaping), exclusive vaping was associated with: similar nicotine exposure (those using nicotine salts had higher levels of nicotine metabolites vs. free-base/unknown); lower exposure to NNK, acrolein, acrylamide and acrylonitrile, but higher toluene exposure (than dual use). Compared with not vaping/smoking, exclusive vaping was associated with similar exposure to acrolein and acrylonitrile and higher exposure to toluene and acrylamide (past 24-hour sensitivity analysis). Benzene and xylene biomarkers were detected in < 5% of urine samples. Some country-level biomarker differences were observed. Objective 4: Vaping was associated with higher respiratory symptom reporting than not vaping/smoking. Youth who smoked and vaped had higher odds of symptoms than those only vaping. Using fruit, multiple or 'other' flavours was associated with higher odds of symptoms than tobacco flavours. Nicotine salt use was frequently unknown but may be associated with symptoms. Limitations:Recall, misunderstandings and misreporting are possible. A subset of biomarkers was included, not all potential confounders were assessed and categorisation into vaping/smoking groups based on past-week behaviour does not fully account for past smoking exposure. Conclusions:Pod flavour restrictions were ineffective. Youth were increasingly using disposable vapes containing nicotine salts. Those who vape were exposed to lower levels of toxicants than those who smoke, but a few toxicants were higher compared to youth who did not vape/smoke. Self-reported past-week respiratory symptoms were also higher in those who vaped than those not vaping/smoking and were related to flavours. Future work:The rapidly evolving nicotine vape market needs ongoing survey/biomarker research. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR130292.

Objectives The treatment of tobacco dependence in patients admitted to hospital is a priority for the National Health Service in England. We aimed to conduct an economic analysis of a pilot ‘opt-out’ tobacco dependence treatment intervention adapted from the Ottawa Model of Smoking Cessation.Design Observational cost analysis of an inpatient tobacco dependence treatment intervention, and matched cohort study comparing readmission costs between patients who received the intervention and benchmarked equivalents who did not.Setting 11 acute inpatient wards in a major teaching hospital in London, England.Participants 673 patients who smoked, admitted between 1 July 2020 and 30 June 2021.Interventions The intervention consisted of the systematic identification of smoking status, automatic referral to tobacco dependence advisors, provision of pharmacotherapy and behavioural support throughout the hospital stay and telephone support for 6 months after discharge.Primary and secondary outcome measures The primary outcomes were cost-per-patient, cost-per-quit and incremental cost effectiveness ratio among patients who received the intervention. The secondary outcomes were patient-level readmission costs and bed-days from 6 months after discharge, compared between the intervention group and a group of matched benchmark patients who smoked but did not receive the intervention.Results The total cost of the intervention was £178 105. On the basis of 104 patients who reported not smoking at 6 months, the cost-per-quit was £1712.55, equating to an estimated age-adjusted incremental cost per life year gained of £3325. Among 611 patients who were successfully matched to a benchmark cohort, readmissions for patients in the intervention group cost £492 k less than their benchmark equivalents over 21 months from 1 January 2021 to 30 September 2022 (£266 k vs £758 k), incurred 414 fewer bed days (303 vs 717) and readmitted at a lower rate (5% vs 11%). There were reduced readmission rates and costs among all patients who received the intervention compared with their benchmarked equivalents, regardless of smoking status at 6 months, except among those who opted out.Conclusions A pilot ‘opt-out’ tobacco dependence treatment intervention implemented in an acute hospital setting in London demonstrated value for money through reduced readmission rates and costs among all patients who received it.

INTRODUCTION:In May 2020, the United Kingdom banned menthol as a characteristic flavor in cigarettes. This study aimed to test cigarettes on sale in England in 2021-2022 for menthol and other characterizing flavors, through sensory and chemical testing. AIMS AND METHODS:Assessments were conducted for 20 cigarette brands (16 tests and four reference products). An untrained consumer panel of 50 people who smoked daily were each randomized to smell one of the two blocks of 10 unburnt cigarettes in duplicate (50 assessments per product). Using the Check-All-That-Apply method, participants assessed the presence of 22 odor attributes, including menthol/mint. For each test and reference cigarette, proportions of assessments that identified menthol/mint, "fruity," "confectionary" and "non-tobacco" odors were identified and compared accounting for the within-participant duplicate testing. For each cigarette, the content of 34 flavoring chemicals (16 cooling/minty) was analyzed using gas chromatography-mass spectrometry. RESULTS:Four of the sixteen test cigarette products were more frequently identified by participants as having a menthol/mint odor than reference products and had detectable levels of menthol/mint in the chemical tests. For four other test products, there was some discordance between the chemical and sensory assessments. Sensory testing also identified a fruity odor in six test products and a confectionary odor in one test product. The compounds dihydroxyacetone and triacetin were detected above the LLOQ in all products. CONCLUSIONS:Four cigarette products for sale in England in 2021-2022 appeared non-compliant with the ban on menthol as a characterizing flavor in sensory and chemical tests. IMPLICATIONS:Menthol is known to enhance the appeal of tobacco products, particularly among young people. The subjective nature of determining "characterizing" flavors in tobacco products creates compliance challenges. Our findings suggest that more stringent regulatory policies around flavoring additives used in tobacco products might be necessary. An outright ban on menthol, other minty flavorings, and additives not essential to the manufacturing process could provide clearer guidelines for manufacturers and regulators.

Background Alcohol Use Disorder is associated with suicide and suicide attempts, and addiction treatment services have a role in suicide prevention. We aimed to identify risk factors for suicide attempt among a cohort of community-based alcohol treatment service users. Methods Linked data from 4415 adults accessing secondary addiction services for alcohol treatment between 2006 and 2019 in London, UK, were used to identify risk factors for suicide attempt. Cox proportional hazards regression estimated the relative increase or decrease in hazard associated with each risk factor on a composite outcome event; death by suicide or contact with emergency psychiatric care within one year of starting treatment. Findings There were 468 (10.5%) crisis care contact events, and <10 suicide deaths. After adjustment, factors associated with increased hazard of crisis care contact or death by suicide were history of suicide attempt (HR 1.83[1.43-2.33]), poor mental health (HR 1.81[1.41-2.32]), current suicidal ideation (HR 1.65[1.18-2.31]), use of drugs other than cocaine, cannabis and opiates (HR 1.41[1.02-1.95]), female sex (HR 1.34[1.10-1.65]) and social isolation (HR 1.24[1.02 - 1.51]). Factors associated with reduced hazard of crisis care contact or death by suicide were alcohol abstinence (HR 0.51[0.31-0.83], ref>30 units), drinking 1-15 units (HR 0.64[0.49-0.85], ref>30 units), Black ethnicity (HR 0.61[0.45-0.83]) and living with children (HR 0.74[0.56-0.99]). Interpretation The identified risk factors for suicide attempt can help risk formulation and safety planning among patients accessing alcohol treatment services. Funding National Institute for Health Research Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by a PhD studentship from King's College London (JR), and used data provided by the Clinical Record Interactive Search (CRIS) platform funded and developed by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, and a joint infrastructure grant from Guy's and St Thomas' Charity and the Maudsley Charity (grant number BRC-2011-10035). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for the study was granted via the Oxford C Research Ethics Committee, reference (18/SC/0372), which covers all uses of CRIS as an anonymised database for secondary analysis. Specific approval from the CRIS oversight committee was granted under Project 20-030 'The impact of alcohol treatment on suicidal crisis and use of emergency psychiatric care'. All patient identifiable information was removed prior to use by the CRIS application. All data remained within the NHS firewall during analysis. Frequencies fewer than 10 are suppressed in this manuscript as per CRIS guidelines. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The ethical approval to access CRIS data (Oxfordshire Research Ethics Committee C (18/SC/0372)) requires the data to be stored behind an NHS firewall with access governed by a patient-led oversight committee. For this reason, the data cannot be made available in the manuscript, Supporting Information files or a public repository. However, subject to approval from the oversight committee, data access for research purposes is encouraged. Further information is available from cris.administrator@slam.nhs.uk.

Background The National Health Service in England aims to implement tobacco dependency treatment services in all hospitals by 2024. We aimed to assess the uptake of a new service, adapted from the Ottawa Model of Smoking Cessation, and its impact on 6-month quit rates and readmission or death at 1-year follow-up. Methods We conducted a pragmatic service evaluation of a tobacco dependency service implemented among 2067 patients who smoked who were admitted to 2 acute hospitals in London, England, over a 12-month period from July 2020. The intervention consisted of the systematic identification of smoking status, automatic referral to tobacco dependence specialists, provision of pharmacotherapy and behavioural support throughout the hospital stay, and telephone support for 6 months after discharge. The outcomes were (i) patient acceptance of the intervention during admission, (ii) quit success at 6 months after discharge, (iii) death, or (iv) readmission up to 1 year following discharge. Multivariable logistic regression was used to estimate the impact of a range of clinical and demographic variables on these outcomes. Results The majority (79.4%) of patients accepted support at the first assessment. Six months after discharge, 35.1% of successfully contacted patients reported having quit smoking. After adjustment, odds of accepting support were 51–61% higher among patients of all non-White ethnicity groups, relative to White patients, but patients of Mixed, Asian, or Other ethnicities had decreased odds of quit success (adjusted odds ratio (AOR) = 0.32, 95%CI = 0.15–0.66). Decreased odds of accepting support were associated with a diagnosis of cardiovascular disease or diabetes; however, diabetes was associated with increased odds of quit success (AOR = 1.88, 95%CI = 1.17–3.04). Intention to make a quit attempt was associated with a threefold increase in odds of quit success, and 60% lower odds of death, compared to patients who did not intend to quit. A mental health diagnosis was associated with an 84% increase in the odds of dying within 12 months. Conclusions The overall quit rates were similar to results from Ottawa models implemented elsewhere, although outcomes varied by site. Outcomes also varied according to patient demographics and diagnoses, suggesting personalised and culturally tailored interventions may be needed to optimise quit success.

Background Electronic health records (EHRs) could identify long-term health effects of nicotine vaping. We characterised the extent to which vaping is recorded in primary care EHRs in the UK, on a population level. Methods We performed descriptive analysis of Clinical Practice Research Datalink (CPRD), primary care electronic health records of 25% of the UK population (~ 16 million patients). Patients aged ≥ 18 years whose vaping status was recorded using medical codes between 2006 and 2022 were identified. We reported the frequency of vaping codes; their distribution by patient age, gender, and ethnicity; trends in vaping recording over time (including interrupted time series analyses); and transitions in patient smoking status. Results Seven medical codes indicated current or former vaping, from 150,114 patients. When their vaping status was first recorded, mean patient age was 50.2 years (standard deviation: 15.0), 52.4% were female, and 82.1% were White. Of those recorded as currently vaping, almost all (98.9%) had records of their prior smoking status: 55.0% had been smoking, 38.3% had stopped smoking, 5.6% had never smoked. Of those who were smoking prior to being recorded as vaping, more than a year after the vaping record, over a third (34.2%) were still smoking, under a quarter (23.7%) quit smoking, 1.7% received a ‘never smoked’ status, and there was no smoking status for 40.4%. The ‘e-cigarette or vaping product use-associated lung injury’ (EVALI) outbreak was significantly associated with a declining trend in new records of current vaping between September 2019 and March 2020; and an immediate significant increase in new records of former vaping, followed by a declining trend. Conclusions Few patients are being asked about vaping. Most who vape had smoked, and many quit smoking after starting vaping. To enable electronic health records to provide stronger evidence on health effects, we recommend improved completeness, accuracy and consistency.

Despite associations between alcohol use and suicidal acts, little research measures prognoses of alcohol-using patients treated by Crisis Resolution Teams (CRTs), an intensive community-based intervention. We estimated the association of alcohol use amongst patients accepted following suicidal acts or ideation in four London-based Crisis Resolution Teams, with death-by-any-cause or recontact with crisis care. We analysed the electronic health records of 1615 CRT patients accepted following suicidal acts or ideation over 38 months, following STROBE guidelines. Using logistic regression we estimated the association of alcohol use (indicated by risk-assessment, AUDIT, or ICD-10 diagnosis) with death-or-recontact at (i) 30-days and (ii) 1-year after treatment start, adjusted for age, sex, ethnicity, psychiatric diagnosis, and severity of need. Hazardous, harmful, or dependent drinking was identified in 270 cases at baseline (16.7%); 73 (4.5%) were alcohol dependent. By 1-year, 622 patients (38.5%) had recontacted crisis care or died. After adjustment, alcohol use at a hazardous, harmful, or dependent level was not associated with increased odds of death-or-recontact at 30-days (AOR 1.17, 95%CI 0.73, 1.88) or 1-year (AOR 1.17, 95%CI 0.85, 1.60). Patients with hazardous, harmful, and dependent alcohol use are a small proportion of CRT patients, despite being more commonly encountered in emergency settings from which patients may be referred to CRTs, indicating a potential gap in provision. Those who are included in CRTs are not at increased risk of death-or-recontact within 1 year of treatment, suggesting that their inclusion can work, at least in a sample with predominantly hazardous or harmful alcohol use.

Communication is an essential component for social interaction and personal growth. Communication is simply sharing information from one person to another. Four pillars of effective communication are Listening, Speaking, Reading and Writing. The article focuses on the basics of communication. It tries to delve deep into the various aspects of the communication process. Developing the LSRW skills would help one to enrich the overall quality of their lives. This article assists the readers to get acquaintance with the skills which are the key for building a better communication.

INTRODUCTION:Despite the association of alcohol use with recurrent suicidal acts, individuals attempting suicide after drinking alcohol face barriers accessing crisis care following emergency assessment, demonstrated by higher odds of inpatient admission for those whose suicide attempt did not feature alcohol. This disparity may be due to suicidality dissipating more rapidly after a suicide attempt involving alcohol. We investigated the effect of acute alcohol use and ongoing suicidality on onward care decisions after emergency assessment.METHODS:We analysed electronic health records of 650 suicidal adults detained under Section 136 of the Mental Health Act (1983, amended 2007) for up to 36 h at a London psychiatric emergency care centre. We used logistic regression to estimate the association of acute alcohol use and ongoing suicidality (including their interaction) with admission to psychiatric hospital.RESULTS:Fifteen percent of previously intoxicated detainees expressed suicidal intent at detention end, compared to 24% of detainees who had not used alcohol prior to detention. Compared to those who were not previously intoxicated and not suicidal at detention end, acute alcohol use was associated with reduced odds of admission amongst those no longer suicidal (AOR 0.4, 95% CI 0.2, 0.6). Where suicidality persisted, odds of admission rose; however, the magnitude of increase when in combination with prior alcohol use (AOR 3.6, 95% CI 1.9, 7.1) was under half that of when alcohol was not involved (AOR 8.2, 95% CI 3.5, 19.1).DISCUSSION AND CONCLUSIONS:Acute alcohol use is associated with transient suicidality, but this only partially accounts for disparities in care following suicide attempts.

Background: Alcohol use is a multidimensional risk factor for suicidal behaviour. However, suicide prevention strategies often take `one-size-fits-all' approaches to alcohol use, reflecting an evidence base built on unidimensional measures. Latent Class Analysis can use a range of measures to differentiate distinct patterns of alcohol using behaviour and their associated risks. Methods: We analysed Electronic Health Record data from 650 suicidal adults detained for up to 36 h using police powers (Section 136 of the Mental Health Act 1983, amended 2007) to facilitate psychiatric assessment at a Health-Based Place of Safety, a dedicated emergency psychiatric care centre in London, UK. We conducted a Latent Class Analysis of alcohol using behaviours at first detention, and used multivariable logistic regression to estimate the association of each identified latent class with subsequent death or recontact with emergency psychiatric care over a median follow-up of 490 days, adjusting for sex, age and past-year psychiatric diagnosis. Results: Three classes of alcohol use were identified: low risk drinkers, heavy episodic drinkers and dependent drinkers. The dependent drinking class had twice the odds of death or recontact with emergency psychiatric care as the low risk drinking class (OR 2.32, 95 %CI 1.62-3.32, p < 0.001). Conversely, the heavy episodic drinking class was associated with lower odds of death or recontact than the low risk drinking class (OR 0.66, 95 %CI 0.53 0.81, p < 0.001). Conclusions: The risk of adverse outcomes after a suicide attempt are not uniform for different alcohol use classes. Clinical assessment and suicide prevention efforts should be tailored accordingly.

Abstract Background Substance use and psychiatric illness, particularly psychotic disorders, contribute to violence in emergency healthcare settings. However, there is limited research regarding the relationship between specific substances, psychotic symptoms and violent behaviour in such settings. We investigated the interaction between recent cannabinoid and stimulant use, and acute psychotic symptoms, in relation to violent behaviour in a British emergency healthcare setting. Methods We used electronic medical records from detentions of 1089 individuals under Section 136 of the UK Mental Health Act (1983 amended 2007), an emergency police power used to detain people for 24–36 h for psychiatric assessment. The relationship between recent cannabinoids and/or stimulant use, psychotic symptoms, and violent behaviour, was estimated using logistic regression. Findings There was evidence of recent alcohol or drug use in 64.5% of detentions. Violent incidents occurred in 12.6% of detentions. Psychotic symptoms increased the odds of violence by 4.0 [95% confidence intervals (CI) 2.2–7.4; p < 0.0001]. Cannabinoid use combined with psychotic symptoms increased the odds of violence further [odds ratios (OR) 7.1, 95% CI 3.7–13.6; p < 0.0001]. Recent use of cannabinoids with stimulants but without psychotic symptoms was also associated with increased odds of violence (OR 3.3, 95% CI 1.4–7.9; p < 0.0001). Interpretation In the emergency setting, patients who have recently used cannabinoids and exhibit psychotic symptoms are at higher risk of violent behaviour. Those who have used both stimulants and cannabinoids without psychotic symptoms may also be at increased risk. De-escalation protocols in emergency healthcare settings should account explicitly for substance use.