Sadie Boniface

Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls

BACKGROUND There is uncertainty over whether maternal smoking is associated with birth defects. We conducted the first ever comprehensive systematic review to establish which specific malformations are associated with smoking. METHODS Observational studies published 1959–2010 were identified (Medline), and included if they reported the odds ratio (OR) for having a non-chromosomal birth defect among women who smoked during pregnancy compared with non-smokers. ORs adjusted for potential confounders were extracted (e.g. maternal age and alcohol), otherwise unadjusted estimates were used. One hundred and seventy-two articles were used in the meta-analyses: a total of 173 687 malformed cases and 11 674 332 unaffected controls. RESULTS Significant positive associations with maternal smoking were found for: cardiovascular/heart defects [OR 1.09, 95% confidence interval (CI) 1.02–1.17]; musculoskeletal defects (OR 1.16, 95% CI 1.05–1.27); limb reduction defects (OR 1.26, 95% CI 1.15–1.39); missing/extra digits (OR 1.18, 95% CI 0.99–1.41); clubfoot (OR 1.28, 95% CI 1.10–1.47); craniosynostosis (OR 1.33, 95% CI 1.03–1.73); facial defects (OR 1.19, 95% CI 1.06–1.35); eye defects (OR 1.25, 95% CI 1.11–1.40); orofacial clefts (OR 1.28, 95% CI 1.20–1.36); gastrointestinal defects (OR 1.27, 95% CI 1.18–1.36); gastroschisis (OR 1.50, 95% CI 1.28–1.76); anal atresia (OR 1.20, 95% CI 1.06–1.36); hernia (OR 1.40, 95% CI 1.23–1.59); and undescended testes (OR 1.13, 95% CI 1.02–1.25). There was a reduced risk for hypospadias (OR 0.90, 95% CI 0.85–0.95) and skin defects (OR 0.82, 0.75–0.89). For all defects combined the OR was 1.01 (0.96–1.07), due to including defects with a reduced risk and those with no association (including chromosomal defects). CONCLUSIONS Birth defects that are positively associated with maternal smoking should now be included in public health educational materials to encourage more women to quit before or during pregnancy.

How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario

BACKGROUND This study predicts the implications of under-reporting of alcohol consumption in England for alcohol consumption above Government drinking thresholds. METHODS Two nationally representative samples of private households in England were used: General LiFestyle survey (GLF) and Health Survey for England (HSE) 2008. Participants were 9608 adults with self-reported alcohol consumption on heaviest drinking day in the last week (HSE) and 12 490 adults with self-reported average weekly alcohol consumption (GLF). Alcohol consumption in both surveys was revised to account for under-reporting in three hypothetical scenarios. The prevalence of drinking more than UK Government guidelines of 21/14 (men/women) alcohol units a week, and 4/3 units per day, and the prevalence of binge drinking (>8/6 units) were investigated using logistic regression. RESULTS Among drinkers, mean weekly alcohol intake increases to 20.8 units and mean alcohol intake on heaviest drinking day in the last week increases to 10.6 units. Over one-third of adults are drinking above weekly guidelines and over three-quarters drank above daily limits on their heaviest drinking day in the last week. The revision changes some of the significant predictors of drinking above thresholds. In the revised scenario, women have similar odds to men of binge drinking and higher odds of drinking more than daily limits, compared with lower odds in the original survey. CONCLUSION Revising alcohol consumption assuming equal under-reporting across the population does not have an equal effect on the proportion of adults drinking above weekly or daily thresholds. It is crucial that further research explores the population distribution of under-reporting.

Drinking pattern is more strongly associated with under-reporting of alcohol consumption than socio-demographic factors: evidence from a mixed-methods study

BackgroundUnder-reporting of alcohol consumption is widespread; surveys typically capture 40-60% of alcohol sales. However the population distribution of under-reporting is not well understood.MethodsMixed-methods study to identify factors associated with under-reporting, using the nationally-representative Health Survey for England (HSE) 2011 (overall response rate 66%). Comparison of retrospective computer-assisted personal interview and seven-day drinking diary (n = 3,774 adults 18+, 50% women, diary response rate 69%) to identify factors associated with diary responses exceeding those of the interview using multivariable linear regression for three outcomes: drinking days in the week recorded, volume consumed on heaviest drinking day in the week recorded, and weekly alcohol consumption. Qualitative semi-structured interviews (n = 10) explored reasons for under-reporting in further detail.ResultsNumber of drinking days was slightly greater in the diary than the interview (P < 0.001). Reported consumption was higher in the diary than in the interview for heaviest drinking day in the week recorded (0.7 units greater among men, 1.2 units among women, P < 0.001), and weekly alcohol consumption in women only (1.1 units among women, P = 0.003). Participants who drank more frequently, more heavily, and had a more varied drinking pattern with respect to the types of drink consumed or choice of drinking venues had a larger difference between their diary week and their interview week.The qualitative interviews identified having a non-routine drinking pattern, self-perception as a non-frequent drinker, and usually tracking drinking using experiential approaches as linked to more drinking being reported in the diary than the retrospective interview.ConclusionsHeavy drinking and non-routine drinking patterns may be associated with greater under-reporting of alcohol consumption. Estimates of drinking above recommended levels are likely to be disproportionately under-estimated.

Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports

Abstract Objective To use the relation between cigarette consumption and cardiovascular disease to quantify the risk of coronary heart disease and stroke for light smoking (one to five cigarettes/day). Design Systematic review and meta-analysis. Data sources Medline 1946 to May 2015, with manual searches of references. Eligibility criteria for selecting studies Prospective cohort studies with at least 50 events, reporting hazard ratios or relative risks (both hereafter referred to as relative risk) compared with never smokers or age specific incidence in relation to risk of coronary heart disease or stroke. Data extraction/synthesis MOOSE guidelines were followed. For each study, the relative risk was estimated for smoking one, five, or 20 cigarettes per day by using regression modelling between risk and cigarette consumption. Relative risks were adjusted for at least age and often additional confounders. The main measure was the excess relative risk for smoking one cigarette per day (RR1_per_day−1) expressed as a proportion of that for smoking 20 cigarettes per day (RR20_per_day−1), expected to be about 5% assuming a linear relation between risk and consumption (as seen with lung cancer). The relative risks for one, five, and 20 cigarettes per day were also pooled across all studies in a random effects meta-analysis. Separate analyses were done for each combination of sex and disorder. Results The meta-analysis included 55 publications containing 141 cohort studies. Among men, the pooled relative risk for coronary heart disease was 1.48 for smoking one cigarette per day and 2.04 for 20 cigarettes per day, using all studies, but 1.74 and 2.27 among studies in which the relative risk had been adjusted for multiple confounders. Among women, the pooled relative risks were 1.57 and 2.84 for one and 20 cigarettes per day (or 2.19 and 3.95 using relative risks adjusted for multiple factors). Men who smoked one cigarette per day had 46% of the excess relative risk for smoking 20 cigarettes per day (53% using relative risks adjusted for multiple factors), and women had 31% of the excess risk (38% using relative risks adjusted for multiple factors). For stroke, the pooled relative risks for men were 1.25 and 1.64 for smoking one or 20 cigarettes per day (1.30 and 1.56 using relative risks adjusted for multiple factors). In women, the pooled relative risks were 1.31 and 2.16 for smoking one or 20 cigarettes per day (1.46 and 2.42 using relative risks adjusted for multiple factors). The excess risk for stroke associated with one cigarette per day (in relation to 20 cigarettes per day) was 41% for men and 34% for women (or 64% and 36% using relative risks adjusted for multiple factors). Relative risks were generally higher among women than men. Conclusions Smoking only about one cigarette per day carries a risk of developing coronary heart disease and stroke much greater than expected: around half that for people who smoke 20 per day. No safe level of smoking exists for cardiovascular disease. Smokers should aim to quit instead of cutting down to significantly reduce their risk of these two common major disorders.

Actual and Perceived Units of Alcohol in a Self-Defined “Usual Glass” of Alcoholic Drinks in England

Background Several studies have found participants pour more than 1 standard drink or unit as their usual glass. This is the first study to measure actual and perceived amounts of alcohol in a self-defined usual glass of wines and spirits in the general population. Methods Participants were a convenience sample of adults who drink alcohol or who pour drinks for other people (n = 283, 54% women) at 6 sites in South East England. The survey was face to face and comprised a self-completion questionnaire and pouring task. Estimation accuracy, categorised as correct (±0.5 units), underestimate (>0.5 units), or overestimate (>0.5 units) was the main outcome. Results The mean number of units poured was 1.90 (SD 0.80; n = 264) for wine and 1.93 (SD 0.78; n = 201) for spirits. The amount of alcohol in a self-defined usual glass was estimated in 440 glasses (248 wine and 192 spirits). Overestimation took place in 42% glasses of spirit poured and 29% glasses of wine poured, and underestimation in 17 and 19%, respectively. Multinomial logistic regression found volume poured to be significantly associated with underestimating both wines and spirits, and additionally for wine only, belonging to a non-white ethnic group and being unemployed or retired. Not having a university degree was significantly associated with overestimating both drink types. Conclusions This study is the first in the general population and did not identify systematic underestimation of the amount of alcohol in a self-defined usual glass. Underestimation is significantly associated with volume poured for both drink types; therefore, advocating pouring smaller glasses could reduce underestimation of alcohol consumption.

Assessment of Non-Response Bias in Estimates of Alcohol Consumption: Applying the Continuum of Resistance Model in a General Population Survey in England

Background Previous studies have shown heavier drinkers are less likely to respond to surveys and require extended efforts to recruit. This study applies the continuum of resistance model to explore how survey estimates of alcohol consumption may be affected by non-response bias in three consecutive years of a general population survey in England. Methods Using the Health Survey for England (HSE) survey years 2011–13, number of contact attempts (1–6 and 7+) were explored by socio-demographic and drinking characteristics. The odds of drinking more than various thresholds were modelled using logistic regression. Assuming that non-participants were similar to those who were difficult to contact (the continuum of resistance model), the effect of non-response on measures of drinking was investigated. Results In the fully-adjusted regression model, women who required 7+ calls were significantly more likely to drink more than the UK Government’s recommended daily limit (OR 1.19, 95% CI 1.06–1.33, P = 0.003) and to engage in heavy episodic drinking (OR 1.23, 95% CI 1.07–1.42, P = 0.004), however this was not significant in men in the fully-adjusted model. When the continuum of resistance model was applied, there was an increase in average weekly alcohol consumption of 1.8 units among men (a 12.6% relative increase), and an increase of 1.5 units among women (a 20.5% relative increase). There was also an increase in the prevalence of heavy episodic drinking of 2.5% among men (an 12.0% relative increase) and of 2.0% among women (a 15.8% relative increase), although other measures of drinking were less affected. Conclusion Overall alcohol consumption and the prevalence of heavy episodic drinking were higher among HSE participants who required more extended efforts to contact. The continuum of resistance model suggests non-response bias does affect survey estimates of alcohol consumption.

Evidence for the effectiveness of minimum pricing of alcohol: a systematic review and assessment using the Bradford Hill criteria for causality

Objectives To assess the evidence for price-based alcohol policy interventions to determine whether minimum unit pricing (MUP) is likely to be effective. Design Systematic review and assessment of studies according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, against the Bradford Hill criteria for causality. Three electronic databases were searched from inception to February 2017. Additional articles were found through hand searching and grey literature searches. Criteria for selecting studies We included any study design that reported on the effect of price-based interventions on alcohol consumption or alcohol-related morbidity, mortality and wider harms. Studies reporting on the effects of taxation or affordability and studies that only investigated price elasticity of demand were beyond the scope of this review. Studies with any conflict of interest were excluded. All studies were appraised for methodological quality. Results Of 517 studies assessed, 33 studies were included: 26 peer-reviewed research studies and seven from the grey literature. All nine of the Bradford Hill criteria were met, although different types of study satisfied different criteria. For example, modelling studies complied with the consistency and specificity criteria, time series analyses demonstrated the temporality and experiment criteria, and the analogy criterion was fulfilled by comparing the findings with the wider literature on taxation and affordability. Conclusions Overall, the Bradford Hill criteria for causality were satisfied. There was very little evidence that minimum alcohol prices are not associated with consumption or subsequent harms. However the overall quality of the evidence was variable, a large proportion of the evidence base has been produced by a small number of research teams, and the quantitative uncertainty in many estimates or forecasts is often poorly communicated outside the academic literature. Nonetheless, price-based alcohol policy interventions such as MUP are likely to reduce alcohol consumption, alcohol-related morbidity and mortality.

Academic careers: what do early career researchers think?

ARE YOUNG RESEARCHERS GETTING A FAIR DEAL? Early career researchers (ECRs) are often anecdotally described as facing major challenges. These challenges reportedly include lack of job security, too few opportunities to carve out their own interests, fighting to survive in competitive institutions and being perceived as resources rather than as people. These issues have attracted increasing attention in scientific circles and now also in the media. In response to these concerns, the SSM ECR Subcommittee conducted an ECR members’ survey in early 2015 to obtain views on a range of issues. We had 65 responses (response rate 50.7%) of whom approximately three-quarters were female, and a third were based in London. Responses clustered around three main themes: job instability, limited opportunities to develop an academic career and lack of mentoring.

PS06 Finding the Missing Units: Identifying Under-Reporting of Alcohol Consumption in England

Background Alcohol sales coverage (reported consumption as a percentage of total sales) is typically 40–60%. This study explores how accidental under-estimation of alcohol in drinks poured at home might contribute to low sales coverage. Methods 283 drinking adults (16+) completed a face-to-face survey comprising a questionnaire and pouring task on 12 occasions at six sites in and near London in summer 2011. Actual and perceived number of units poured in a ‘usual glass’ of wines and spirits is explored by demographic and social factors. Results There were 283 participants (54% women) who completed the questionnaire and pouring task. The 283 participants poured a total of 465 glasses of wine and spirits. 52% wine estimates and 42% spirit estimates were within 0.5 units of their actual value. More participants over-estimated the amount of alcohol they had poured than under-estimated. Multinomial logistic regression found significant risk factors for under-estimating wine were increasing volume of wine poured (RRR 1.02 95% CI 1.01–1.02, P<0.0001), belonging to a non-white ethnicity (RRR 3.88, 1.65–9.16, P=0.002), and being unemployed or retired (RRR 4.30, 1.08–17.07, P=0.038). Only the volume of spirits poured was a significant predictor of under-estimating spirits (RRR 1.04, 1.01–1.06, P=0.003). For both wines and spirits, not having a degree was significantly associated with an increased risk of over-estimating the amount of alcohol poured. Conclusion As participants were more likely to over-estimate than under-estimate, this survey is not able to explain low sales coverage as a product of accidental under-estimation of the amount of alcohol poured drinks drunk at home. A future qualitative study will explore how recall accuracy may contribute to low sales coverage.

Prevalence of Hazardous Drinking Among UK 18–35 Year Olds; the Impact of a Revision to the AUDIT Cut Score

AIM Most published research utilizes an AUDIT score of >8 as the threshold for hazardous drinking. Recent research suggests that this limit should be amended for younger drinkers (aged 18-35 years). This study aimed to explore the effect of a revision to AUDIT cut scores. METHOD Applying Foxcroft et al.s [(2015) Accuracy of Alcohol Use Disorders Identification Test for detecting problem drinking in 18-35 year-olds in England: method comparison study. Alcohol Alcohol 50, 244-50] suggested cut off scores of nine for males and four for females to the most recent Adult Psychiatric Morbidity Survey (2007) data. RESULTS This more than doubles the prevalence of female hazardous drinkers, and significantly increases the overall rate for that age group when compared with the standard threshold of >8. CONCLUSION The prevalence of hazardous drinking among females ages 18-30 may be significantly higher than current estimates.