Two heads are better than one: Australian tobacco control experts' and mental health change champions' consensus on addressing the problem of high smoking rates among people with mental illness

Building consensus on a set of ENDS-specific pictorial health warnings: a Delphi study among a tobacco control expert panel

BACKGROUND

This study reports on the development of pictorial health warning labels for electronic nicotine delivery system (ENDS) using the Delphi approach with a panel of tobacco control experts. Twenty-four evidence-based ENDS-specific warnings corresponding to three themes (toxicity, health risks and specific harm) were developed and used in the Delphi study.

METHODS

We conducted a three-round online Delphi study among 60 experts (55% female) between June 2022 and April 2023. We balanced the panel in areas of expertise and positions relevant to ENDS (risks, benefits). In round 1, participants rated the warnings on attention, relevance to evidence and perceived effectiveness (harm perception, motivation to quit) and provided suggestions for improvement. In rounds 2 and 3, participants ranked the revised warnings based on importance in each theme. We assessed levels of agreement between participants using interquartile deviations and medians.

RESULTS

Warnings in theme 1, toxicity, received the highest ratings for perceived effectiveness on harm perception and encouraging quitting ENDS (p<0.05). Experts recommended using clear and affirmative text paired with emotion-provoking pictures and avoiding the rare side effects of ENDS. Most of the top-ranked warnings were from theme 3, ENDS-specific harm, pertained to lung damage, dual use of ENDS and cigarettes, nicotine addiction among youth, anti-ENDS industry sentiment and toxicity.

DISCUSSION

This study developed 24 evidence-based ENDS health warning labels using a systematic process that included several rounds of expert panel feedback. These warnings can be used to advance ENDS prevention and tobacco control policies and further target different populations.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Delphi study among international expert panel to develop waterpipe-specific health warning labels

BACKGROUND

Waterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate smoking-related risks and address reduced-harm misperceptions. Therefore, the development of WP-specific HWLs represents a priority for WP control.

METHODS

A panel of experts in WP science developed 28 WP-specific HWLs corresponding to five themes (health risks, addiction, harm to others, WP-specific harm, WP harm compared to cigarettes). Subsequently, a three-round Delphi study was conducted among international expert panel to reach consensus on a set of the most effective HWLs for each theme. Levels of agreement between participants were assessed using interquartile deviations, and the rank between the tied HWLs was based on the median.

RESULTS

Starting with 28 candidate HWLs stratified according to five WP-related themes, our international expert panel reached consensus on the 13 most important WP-specific HWLs. Labels with the highest agreement were related to oral and heart disease, WP's harmful effects on newborn children and the amount of smoke inhaled from WP compared to cigarettes.

CONCLUSION

This study is the first to systematically develop and evaluate potential WP-specific HWLs based on the scientific evidence about WP's harmful effects, scientific understanding of HWL for cigarettes and the opinions of experts in WP science, tobacco control and health communication. The final selected HWLs can be adapted based on the context and policy landscape of the target country and can be further fine-tuned based on feedback from WP smokers and non-smokers.

y-QUIT: Smoking Prevalence, Engagement, and Effectiveness of an Individualized Smoking Cessation Intervention in Youth With Severe Mental Illness

Introduction: Young people with psychosis are six times more likely to be tobacco smokers than their gender- and age-matched peers. Smoking is a major contributor to the 15-year reduced life expectancy among people experiencing severe mental illness (SMI). There is a lack of evidence-supported interventions for smoking cessation among young people with SMI. Material and Methods: The study comprised two phases and aimed to assess (i) the prevalence of smoking among a community sample of young people with psychotic illness or at high risk of developing psychosis; (ii) the proportion who engaged in the intervention; (iii) the proportion who achieved smoking cessation; and (iv) secondary smoking-related outcomes. In phase one, prevalence of smoking was assessed among young people with psychotic illness or at high risk of developing psychosis attending a community-based youth mental health service between 16/5/2017 and 16/11/2017. In phase two, over a 1-year period, individuals identified as smokers were invited to participate in a 12-week tailored smoking cessation intervention program that included pharmacological treatment, motivational interviewing, and behavioral change techniques. Those unwilling to participate in a full intervention were offered a brief intervention. Participants of the full intervention were assessed at baseline and at week 12 endpoint on: daily cigarettes smoked (self-report), exhaled CO, nicotine dependence, readiness to quit, and confidence to quit. Results: In phase one, smoking prevalence was 48.2% (53 of 110) among clients of the youth mental health service. Smokers were significantly more likely to be male (X ² = 6.41 p = 0.009). During phase two, 41 of 61 eligible clients engaged in a smoking cessation intervention (67.2%). Effectiveness: twenty-one clients participated in a full intervention (34.4%), of whom three (14.3%) received a brief intervention initially and during engagement converted to full intervention. Twenty participants (32.8%) received a brief intervention only. Ten participants in the full intervention (47.6%) and five in the brief intervention (25%) dropped out. Six (28.6% of full intervention) reported smoking cessation verified by CO monitoring. Participants who completed the full intervention (n = 9) reduced number of cigarettes smoked, nicotine dependence, and exhaled CO, while readiness to quit and confidence to quit increased. Pharmacotherapy was predominantly combination NRT (n = 18; 85.7%), varenicline (4.8%), oral NRT only (4.8%), or none (4.8%). No adverse events were reported. Conclusion: This pilot real-world study demonstrates that both screening for smoking and offering an effective smoking cessation intervention are achievable in youth experiencing or at risk of psychosis.