Investigating the growing trend of non-drinking among young people; analysis of repeated cross-sectional surveys in England 2005-2015

Changing patterns of health risk in adolescence: implications for health policy

Adolescence is a time of physical, cognitive, social, and emotional development. This period is a very sensitive developmental window; environmental exposures, the development of health behaviours (eg, smoking and physical activity), and illness during adolescence can have implications for lifelong health. In the UK and other high-income countries, the experience of adolescence has changed profoundly over the past 20 years. Smoking, drug use, and alcohol consumption have all been in long-term decline. At the same time, obesity and mental ill health have increased and are now common among adolescents, with new risks (ie, vaping, psychoactive substances, and online harms) emerging. In this Viewpoint, we describe these and related trends in England and the UK. Although previous work has explored these changes in isolation, in this Viewpoint we consider them collectively. We explore what might be driving the changes and consider the implications for practice, policy, and research.

Examining temporal trends in psychological distress and the co-occurrence of common substance use in a population-based sample of grade 7-12 students from 2013 to 2019

PURPOSE

Characterizing trends and correlates of adolescent psychological distress is important due to observed global increases over the last 20 years. Substance use is a commonly discussed correlate, though we lack an understanding about how co-occurrence of these concerns has been changing over time.

METHODS

Data came from repeated, representative, cross-sectional surveys of grade 7-12 students across Ontario, Canada conducted biennially from 2013 to 2019. Poisson regression with robust standard errors was used to examine changes in the joint association between psychological distress (operationalized as Kessler-6 [K6] scores ≥ 13) and substance use over time. Weighted prevalence ratios (PR) and their 99% confidence intervals were estimated, where p < 0.01 denotes statistical significance.

RESULTS

The prevalence of psychological distress doubled between 2013 and 2019, with adjusted increases of about 1.2 times each survey year. This biennial increase did not differ based on sex, perceived social standing, school level, or any substance use. Students using substances consistently reported a higher prevalence of psychological distress (between 1.2 times and 2.7 times higher). There were similarly no differential temporal trends based on substance use for very high distress (K6 ≥ 19) or K6 items explored individually.

CONCLUSION

Psychological distress steeply increased among adolescents and substance use remains important to assess and address alongside distress. However, the magnitude of temporal increases appears to be similar for adolescents reporting and not reporting substance use.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Understanding alcohol use and changes in drinking habits among people with a severe mental illness: a qualitative framework analysis study

Introduction

Individuals with a severe mental illness (SMI) are more likely to drink at harmful levels or abstain. While it is known that drinking patterns change over time, the reasons for this among those with a SMI are unclear. This study aimed to (i) explore the experiences with alcohol, particularly in relation to mental health symptoms, and (ii) how drinking patterns have changed over time, among individuals who have a SMI diagnosis, who either currently drink alcohol or no longer drink.

Methods

One-to-one semi-structured telephone interviews were conducted to address the study aims. Current drinkers' alcohol use was assessed using the Alcohol Use Disorder Identification Test. A framework analysis was used to address the study aims with a specific focus on the differences in the experiences with alcohol use between current and former drinkers.

Results

16 participants were interviewed, and five themes were developed. The analysis highlighted how alcohol was increasingly used to cope with (i) trauma, (ii) SMI-related symptoms, or (iii) stress. Among those with a SMI, non-drinking was facilitated through declines in SMI-related symptoms, previous negative consequences due to alcohol and changing the social environment. Current drinking habits were facilitated through changes in the reasons for drinking and adopting different alcohol moderation techniques.

Discussion

Among those with a SMI diagnosis and who either currently drink alcohol or no longer drink, our findings support the self-medication hypothesis and drinking motives model. However, our findings indicate the need for further development of drinking to cope with a focus on symptoms of a SMI and trauma. Our findings also have implications on specialist alcohol and mental health services, the need to improve individuals' understanding of SMI, and the need to identify reasons for drinking among those with a recent diagnosis of a SMI.

Social disparities in alcohol consumption among Canadian emerging adults

INTRODUCTION

Young adult drinking is a public health priority, but knowledge of socioeconomic status (SES) indicators and alcohol use among emerging adults (EAs; aged 18-29 years) is primarily informed by college samples, populations in their late teens and early twenties and non-Canadian data. We compared the association of three different SES indicators with monthly heavy episodic drinking (HED), less-than-monthly HED, no HED, and no drinking among Canadian EAs.

METHODS

We pooled the 2015 to 2019 waves of the Canadian Community Health Survey to include participants aged 18 to 29 years (n = 29 598). Using multinomial regression, we calculated weighted estimates of alcohol use by education, household income and area-level disadvantage, adjusting for adult roles and sociodemographic characteristics.

RESULTS

Approximately 30% of EAs engaged in monthly HED, whereas 16% did not drink at all in the past year. Compared to those in the lowest household incomes, being in the top income quintile was significantly associated with increased relative odds of monthly HED (e.g. in combined SES model, RRR = 1.21, 95% CI: 1.04-1.39). Higher levels of education, being in higher income quintiles and living in less disadvantaged areas were significantly associated with reduced relative odds of no HED and not drinking. Adjusting for adult roles did not substantially change the associations between SES and alcohol use.

CONCLUSION

Higher SES was associated with HED among EAs, although the magnitude of association was small. Universal prevention measures addressing the affordability, availability and marketing of alcohol could be complemented by interventions targeting EA populations at higher risk of HED.

The social capital penalty paid by teetotallers

Social capital is important and helps protect health and reduce loneliness. Governments worldwide are pursuing policies to reduce the amount of alcohol consumed to protect public health but alcohol consumption remains a prevalent feature of social interaction in the UK. Previous studies have identified a strong relationship between alcohol and social capital which varies in direction depending on the dimension of social capital studied. Using a large nationally representative longitudinal dataset for the UK, we apply an outcome-wide longitudinal design for causal inference, adjusting for covariates, as well as lagged values of outcome and exposure, to investigate if drinking less alcohol or not drinking alcohol at all is related to five binary social capital outcomes: socialising, being active in an organization, feeling lonely, number of close friends, and a bridging social capital score. We use two drinking exposures, binary drinker status, and categorised drinking frequency. We find that not drinking alcohol is negatively associated with socialising. Analysis using the frequency of drinking alcohol exposure finds drinking alcohol monthly or less is negatively associated with being active in an organisation. We find little evidence of any relationship between drinking alcohol and feelings of loneliness, number of friends and bridging social capital. Our results suggest that non-drinkers face barriers to some forms of social capital including socialising, which could be due to alcohol being a social norm in the UK. However, our results also suggest that high-frequency drinkers can reduce their drinking with minimal impact on their social capital. Our findings suggest more needs to be done to make socialising easier for non-drinkers. Furthermore, our findings support the implementation of policies to reduce high-frequency drinking.

Prevalence and Predictors of Poly-Victimization of Adolescents in England and Wales

This study examined the change in the prevalence of adolescent poly-victimization and individual and area predictors of poly-victimization in England and Wales. The national representative longitudinal Offending, Crime and Justice Survey (2003-2006) was analyzed with data from 2,066 adolescents, aged between 10 and 18 years (mean ± SD at Time 1 = 13.08 ± 2.01), using multilevel multinomial logit models. Findings revealed that the majority of the adolescents (41.6%, 48.5%, 54.6%, 61.6%, respectively) did not experience victimization between 2003 and 2006. However, 28.3%, 25.9%, 19.5%, and 14.5% of the adolescents experienced poly-victimization (experiencing more than or equal to two types of victimizations), with a decrease of 13.8% over the 4-year period. Furthermore, some adolescents were consistent poly-victims, meaning they were poly-victims in all years that they participated in the survey. In particular, 3.57% of the adolescents who participated in the four waves of the survey were poly-victims in all years; 7.41% of the adolescents who participated in three of the four waves of the survey were poly-victims in all years; and 25.79% of the adolescents who participated in two of the four waves of the survey were poly-victims in both years. Statistically significant predictors of poly-victimization included having parents who have been in trouble with the police, offending, participating in community-related activities, being a boy, not managing income well, and living in an urban or deprived area. Offending had the greatest impact on poly-victimization. Findings highlight that adolescent poly-victimization in England and Wales decreased between 2003 and 2006 but some adolescents were more likely to experience poly-victimization due to individual, familial, and area characteristics. The findings therefore indicate that a holistic approach is needed to reduce adolescent poly-victimization and suggest that targeting area deprivation should be the priority.

The Growing Trend of Young People Abstaining from Drinking Alcohol: A Literature Review

Background: Youth alcohol use and misuse lead to adverse outcomes. However, the literature has not always associated complete abstinence with better health. Since recent literature indicates an increased proportion of young abstainers, the aim of this paper is to review the studies investigating this upward trend and the factors associated with it, such as socio-demographics, school performance, social life, physical and mental health, and parental influence. Methods: Different databases were searched and appropriated terms were used. Given that the trend has only emerged in recent years, the review was limited to papers published since 2000. A total of 970 papers were returned and 10 were retained for the present review. Results: All papers covered by the review acknowledge the existence of a new significant trend resulting in more young people in developed countries who are choosing to abstain completely from drinking alcohol. They are in good physical and mental health and perform better at school than their drinking peers. The quality of their social life, albeit slightly more limited than that of their drinking peers, appeared to be good. Conclusion: Young alcohol abstainers represent a group situated at the beginning of a continuum of alcohol consumption, they do well and are not very different from light drinkers. Alcohol abstinence at young age does not seem to have any downsides and should therefore be generally advised. To further promote such behavior, measures to encourage parental monitoring and more generous public expenditure on health services and family benefits should be encouraged.

Understanding changes in the locations of drinking occasions in Great Britain: An age-period-cohort analysis of repeat cross-sectional market research data, 2001-2019

INTRODUCTION

The 21st century has seen wide-ranging changes in drinking locations in Great Britain, with on-trade alcohol sales decreasing and off-trade sales increasing. To better understand the underlying time-trends in consumer behaviour, we examine age-period-cohort (APC) effects related to changes in the share of individuals' drinking occasions taking place in: (i) on-trade versus off-trade locations; and (ii) specific on-trade or off-trade locations, that is traditional/community pubs, modern pubs/bars/café bars, nightclubs/late-night venues, restaurants/pub restaurants, social/working men's clubs, golf/other sports clubs/venues, at home (social setting) and at home (non-social setting).

METHODS

Repeat cross-sectional 1-week drinking diary data, collected 2001-2019. APC analysis via negative binomial regression models for each gender (N = 162,296 men, 138,452 women).

RESULTS

A smaller/declining proportion of occasions took place in on-trade compared to off-trade locations. Recent cohorts tended to have a larger share of on-trade occasions than previous cohorts, driven by their larger share of occasions in modern pubs/bars/café bars and nightclubs/late-night venues. Meanwhile, occasions in social/working men's clubs, golf/other sports clubs/venues and traditional/community pubs tended to be popular among older men, but have declined. Finally, the growth of off-trade drinking appears to be driven by a growth of off-trade drinking in non-social settings, in particular by older people/cohorts.

DISCUSSION AND CONCLUSION

Our findings highlight the declining prominence of certain on-trade locations, and increasing prominence of home drinking in non-social settings, within British drinking practices. While rising non-social home drinking is concerning, it is positive from a public health perspective that it does not appear to be shared by recent cohorts.

Prevalence, correlates, and behavioral outcomes of alcohol gifting in China

Introduction

Alcohol gifting is a very common practice in China. However, little is known about the potentially adverse consequences of alcohol gifting. This study aimed to investigate the prevalence of, and factors associated with, alcohol gifting, and explore whether drinking and tobacco use were associated with alcohol gifting.

Methods

Using a cross-sectional multi-stage survey, a sample of 982 household heads from Guangdong Province and 530 household heads from Shaanxi Province was collected online from 30 April to 30 July 2020 in China. Participants completed questionnaires regarding socio-demographic characteristics, social capital, drinking status, and gifting alcohol behavior. Chi-square analysis and multiple logistic regression analysis were used to identify the factors associated with alcohol gifting, and to identify its relationship with alcohol and cigarette use status.

Results

Multiple logistic regression analysis showed that age, gender, household annual income, province, drinking status, and social participation were prominent correlates of both offering and receiving alcohol. Participants who were married, had an education level of junior high school, or had a large social network had higher odds of receiving alcohol. When both alcohol gifting behaviors were included in the models, participants who offered alcohol had 2.15 (95% CI: 1.63–2.85) times higher odds of current drinking than those who didn’t offer alcohol and participants who received alcohol had 1.87 (95% CI: 1.45–2.41) times higher odds of current drinking than those who did not receive alcohol. Those who received alcohol had significantly higher odds of current smoking (AOR = 1.64; 95% CI: 1.25–2.14), while those who offered alcohol had significantly lower odds of current smoking (AOR = 0.71;95% CI:0.53–0.95).

Conclusions

Social participation is an important correlate of alcohol gifting. Alcohol receiving behaviors were significantly associated with both current alcohol and tobacco use. These associations can be used to inform alcohol gifting interventions in China.

Longitudinal assessment of drinking changes during the pandemic: The 2021 COVID-19 follow-up study to the 2019 to 2020 National Alcohol Survey

Background

Surveys of changes in drinking during the COVID‐19 pandemic have primarily relied on retrospective self‐report. Further, most such surveys have not included detailed measures of alcohol use patterns, such as beverage‐specific consumption, nor measures of alcohol use disorder (AUD) symptoms that would allow a comprehensive understanding of changes in alcohol use.

Methods

Data from 1819 completed interviews from the N14C follow‐up survey to the 2019 to 2020 National Alcohol Survey (N14) were conducted between January 30 and March 28, 2021. Questions on alcohol use from the Graduated Frequency series, beverage‐specific quantity and frequency, and DSM‐5 AUD items were asked in both surveys and used to estimate changes from pre‐pandemic drinking to drinking during the pandemic. Analyses focus on changes in these measures over time and comparisons between key subgroups defined by gender, race/ethnicity, and age.

Results

Key findings include particularly large increases in drinking and AUD for African Americans and women, reduced drinking and heavy drinking prevalence among men and White respondents, and a concentration of increased drinking and AUD among respondents aged 35 to 49. Increases in alcohol use were found to be driven particularly by increases in drinking frequency and the consumption of spirits.

Conclusions

Results confirm prior findings of overall increases and subgroup‐specific changes, and importantly, provide detailed information on the patterns of change across major socio‐demographic subgroups. Substantial increases in the prevalence of DSM‐5 moderate to severe AUDs are a novel finding that is of particular concern.

Generational Shifts in Young Adult Cardiovascular Health? Millennials and Generation X in the United States and England

OBJECTIVES

To compare cardiovascular (CV) risks/conditions of Millennials (born 1981-1996) to those of Generation X (Gen X; born 1965-1980) at ages 20-34 years, across 2 countries (United States, England), by gender.

METHODS

Using data from the National Health and Nutrition Examination Survey (United States) and Health Survey for England, we estimated weighted unadjusted and adjusted gender-specific proportions of CV risk factors/conditions, separately for Millennials and Generation X in each country. We also further calculated sex-specific generational differences in CV risk factor/conditions by income tercile and for individuals with normal body weight.

RESULTS

Millennials in the United States were more obese compared to their Gen X counterparts and more likely to have diabetes risk but less likely to smoke or have high cholesterol. Millennials in England had higher diabetes risk but similar or lower rates of other CV risk/conditions compared to their Gen X counterparts. Generational changes could not be fully attributed to increases in obesity or decreases in income.

DISCUSSION

We expected that Millennial CV risk factors/conditions would be worse than those of Gen X, particularly in the United States, because Millennials came of age during the Great Recession and a period of increasing population obesity. Millennials generally fared worse than their Gen X counterparts in terms of obesity and diabetes risk, especially in the United States, but had lower rates of smoking and high cholesterol in both countries. Secular trends of increasing obesity and decreased economic opportunities did not appear to lead to uniform generational differences in CV risk factors.

Declining drinking among adolescents: Are we seeing a denormalisation of drinking and a normalisation of non-drinking?

BACKGROUND

In the early 2000s, alcohol use among young people began to decline in many western countries, especially among adolescents (ages between 12-17 years old). These declines have continued steadily over the past two decades, against the backdrop of much smaller declines among the general population.

ARGUMENT

Hypotheses examining individual factors fail adequately to provide the necessary 'big picture' thinking needed to understand declines in adolescent drinking. We use the normalisation thesis to argue that there is strong international evidence for both processes of denormalisation of drinking and normalisation of non-drinking occurring for adolescents in many western countries.

CONCLUSIONS

Research on declining adolescent drinking provides evidence of both denormalisation of alcohol consumption and normalisation of non-drinking. This has implications for enabling policy environments more amenable to regulation and increasing the acceptability of non-drinking in social contexts. Normalisation theory (and its various interpretations) provides a useful multi-dimensional tool for understanding declines in adolescent drinking.

Tracking the decline in Australian adolescent drinking into adulthood

BACKGROUND AND AIMS

Adolescent drinking in Australia (and many other countries) has declined substantially since the early 2000s. This study aimed to test whether these declines have been maintained into adulthood and whether they are consistent across sub-groups defined by sex and socio-economic status.

DESIGN

Quasi-cohorts were constructed from seven repeated waves of cross-sectional household survey data (2001-2019).

SETTING

Australia.

PARTICIPANTS

A total of 20 733 respondents age between 14 and 24 (male: 9492; female: 11 241).

MEASUREMENTS

Participants were grouped into five cohorts based on their birth year (from 1979-1983 to 1999-2003). Three measures of drinking were assessed: any past-year consumption (yes/no), past-year regular risky drinking (12 or more drinking episodes of >40 g of pure alcohol, yes/no) and total volume of alcohol consumed in the past year (in Australian standard drinks, 10 g of alcohol). Socio-economic status was measured based on neighbourhood of residence.

FINDINGS

Drinking declines were consistent across socio-economic groups on all measures and trends were broadly similar for women and men. More recent birth cohorts had significantly lower levels of drinking across all three measures (odds ratios between 0.31 and 0.70 for drinking and risky drinking, coefficients between -0.28 and -0.80 for drinking volume). There were significant interactions between birth cohort and age for past-year drinking and past-year regular risky drinking, with cohort differences diminishing as age increased.

CONCLUSIONS

Lighter drinking adolescent cohorts appear to partly 'catch up' to previous cohorts by early adulthood, but maintain lower levels of drinking and risky drinking up to the age of 24. These ongoing reductions in drinking are spread evenly across socio-economic groups.

Lifestyle factors and obesity in young adults - changes in the 2000s in Finland

AIMS

Young adulthood is a life stage that is vulnerable to detrimental lifestyle changes and excessive weight gain, which may have major effects on health later in life. This study aimed to examine the changes in lifestyle-related factors in the 2000s and sociodemographic differences in lifestyle in Finnish young adults.

METHODS

The study was based on the cross-sectional data from two representative samples of Finnish young adults aged 18-29 years from the Health 2000 Survey (n = 1894; 90% participated) and the FinHealth 2017 Study (n = 1162; 54% participated). Sociodemographic factors, lifestyle choices (smoking, alcohol consumption, intake of vegetables, physical activity), and anthropometrics were self-reported. Weighted prevalence based on predictive margins and odds ratios were analyzed using logistic regression, taking into account the sampling design and non-response.

RESULTS

The prevalence of daily cigarette smoking decreased between the years 2000 and 2017 from 34% to 12% (p < 0.01) and from 23% to 11% (p < 0.01) in men and women, respectively. There was a decline in the prevalence of daily intake of fresh vegetables, especially in men. The prevalence of obesity (BMI ⩾ 30 kg/m²) doubled being 15% in men and 18% in women in 2017. Health-endangering lifestyles, measured by a lifestyle sum score, were more common among young adults with lower education compared to those with higher.

CONCLUSIONS

This study showed both favorable and unfavorable changes in the lifestyles of Finnish young adults in the 2000s. Health-endangering lifestyles were more common among young adults with lower education, suggesting the need for tailored health-promoting actions. Special attention should be given to obesity prevention.

"Drunk People Are on a Different Level": A Qualitative Study of Reflections From Students About Transitioning and Adapting to United Kingdom University as a Person Who Drinks Little or No Alcohol

BACKGROUND

Though sobriety in young people is on the rise, students who drink little or no alcohol may experience social exclusion at University, impacting well-being. We aim to understand the social experiences of United Kingdom (UK) undergraduate students who drink little or no alcohol.

METHODS

A mixed-methods study using semi-structured, one-to-one interviews and the 24-Item Social Provisions Scale and Flourishing Scale with 15 undergraduate students who drink little or no alcohol. Descriptive statistics are presented for quantitative data and thematic analysis for qualitative.

RESULTS

Eight main themes and four subthemes were generated from thematic analysis summarised in two sections 'views of drinkers from non-drinkers' and 'how peer pressure feels and how people deal with it.' The initial transition to University represented a challenge, where participants struggled to find their 'true' friends. However, students generally had high levels of social provision, well-being and enjoyed close friendships with fewer casual acquaintances. All students experienced some kind of peer pressure (of a varying extremity) and developed coping strategies when in social situations involving alcohol. Fear of missing out on the 'typical' University experience heightened self-imposed expectations to drink. Despite participants acknowledging their counter-normative behaviour, some felt they were subject to stigmatisation by drinkers, doubting their non-drinker status, causing feelings of exclusion or being 'boring.' Their desire to 'be like everyone else' exposed some insight into the negative stereotypes of sobriety, including frustration behind alcohol's status elevation.

CONCLUSION

Students adopt strategies to minimise peer pressure and to fit in. Future research should interrogate drinkers' perceptions of their sober peers to deepen understanding, better break down 'us and them,' and mitigate future expectations within the University drinking culture.

Incidence, Mortality and Survival in Young People with Co-Occurring Mental Disorders and Substance Use: A Retrospective Linked Routine Data Study in Wales

INTRODUCTION

Mental disorder (MD) and substance use (SUD) are associated with poorer than average health and greater mortality. We analysed routine primary care (WLGP) and inpatient admission (PEDW) data to estimate incidence of co-occurring (CC) MD and SUD, and to estimate all-cause mortality and survival with CC, in children and young people in Wales, UK.

METHODS

A retrospective population-based electronic cohort study using data from the Secure Anonymised Information Linkage (SAIL) Databank. Participants were 958,603 individuals aged 11-25 between 2008 and 2017. We estimated first ever incidence of CC, plotted Kaplan-Meier survival curves and carried out Cox regression to estimate hazard ratios (HR) for risk of death by condition group (CC; MD or SUD only; NC).

RESULTS

Higher incidence of CC in WLGP and PEDW was associated with male sex, older age and greater deprivation. Male to female IRRs (95% CI) were 1.18 (1.12-1.24) in WLGP and 1.17 (1.10-1.24) in PEDW, oldest to youngest IRRs were 24.80 (21.20-29.40) in WLGP and 4.50 (4.08-4.98) in PEDW and most to least deprived IRRs were 3.28 (3.00-3.58) in WLGP and 2.59 (2.36-2.84) in PEDW. Incidence in WLGP significantly decreased between 2008 and 2017 (IRR = 0.88, 95% CI 0.78-0.99); the greatest reduction occurred in the most deprived quintile (IRR 0.67, 95% CI 0.54-0.82). Incidence of hospital admissions remained stable (IRR = 0.95, 95% CI 0.84-1.08). Risk of death was significantly higher for CC compared with NC (HR = 8.7, 95% CI 7.5-10.0).

CONCLUSION

Male sex, older age and greater deprivation were associated with higher CC incidence, although the gap between WIMD quintiles has decreased. CC was associated with greater risk of death. Mental health and substance misuse services should be provided in ways that remove barriers, and are acceptable and accessible to all, particularly those at greatest risk, or who are less likely to engage.

Associations between social media usage and alcohol use among youths and young adults: findings from Understanding Society

BACKGROUND AND AIMS

Given the decline in alcohol consumption and rise in technological use among young people, there is a need to investigate whether technology use might influence how young people drink. This study explores how social media use and changes in social media use over time could affect alcohol use among youths.

DESIGN

The UK Household Longitudinal Study (Understanding Society).

SETTING

United Kingdom.

PARTICIPANTS

Participants aged 10-15 (n = 4093) and 16-19 (n = 2689) from the youth and main survey interviewed in 2011-13, and followed-up in 2014-16 (aged 10-15 n = 2588, aged 16-19 n = 1057).

MEASUREMENTS

Self-reported social media usage on an average day (no profile/non-daily/less than an hour/1-3/4+ hours use), drinking frequency (never/one to three times/weekly) and binge drinking frequency (never/one to two/three/more than three times) in the past month. Covariates included sex, age, educational status, household income, urban/rural, number of friends and life satisfaction.

FINDINGS

Among 10-15-year-olds, compared with those who used social media for less than an hour, those with no profile [odds ratio (OR) = 0.41, 95% confidence interval (CI) = 0.25-0.67] and non-daily users (OR = 0.49, 95% CI = 0.33-0.72) had a lower risk of drinking at least monthly, whereas those with 1-3 hours' use (OR = 1.44, 95% CI = 1.14-1.81) and 4+ hours' use (OR = 2.08, 1.47-2.95) had a greater risk. Among participants aged 16-19, a lower risk of binge drinking three or more times per month was found for those with no profile [relative risk ratios (RRR) = 0.29, 95% CI = 0.17-0.48] and a higher risk for those with 4+ hours' use (RRR = 1.47, 95% CI = 1.03-2.09). Longitudinally, among 10-15-year-olds, those who had increased their social media usage versus no change were more likely to have increased their drinking frequency (OR = 1.89, 95% CI = 1.45-2.46). Some social media use at baseline (rather than none) was predictive of increased drink and binge drinking frequency over time among youths and young adults.

CONCLUSIONS

Heavier social media use was associated with more frequent alcohol consumption among young people in the United Kingdom.

Outcomes of adults who received liver transplant as young children

BACKGROUND

Patient and graft survival 20-years after pediatric liver transplantation (pLT) are excellent. In children, attainment of normal growth, education and social adaptation to be an independent adult are equally important. This is particularly relevant for children who receive liver transplant at a young age, where infantile-onset liver disease, surgery and immunosuppression can adversely affect growth and neurodevelopment. The aim of this study was to evaluate the long-term physical and psychosocial outcomes of pLT recipients with normal graft function. We coin the term 'meaningful survival'.

METHODS

We performed a cross-sectional study of pLT recipients who received transplants between 1985 and 2004. A 20-year evaluation of physical health (growth, renal function), mental wellbeing and social outcomes (substance abuse, adherence, education, employment) was performed. All patients included were considered to have normal graft function.

FINDINGS

Eighty-four patients met study criteria. Median age at transplantation was 1.3 years (IQR 0·7-3·3 years), with median duration of follow-up of 20.2 years (18·0-23·5). At median of 20-years, 19 patients (23%) had chronic renal dysfunction and 3 patients (4%) had a BMI of >30 (mean 20·4). Evaluation of long-term psychosocial outcomes demonstrated 22 patients (26%) with mental health disorders. Substance abuse was lower than national average. 62 patients (74%) were in education, employment or training. Overall, only 26% of our cohort achieved a composite outcome of 'meaningful survival'.

INTERPRETATION

This is the largest reported long-term study of biopsychosocial outcomes of pLT recipients with normal liver biochemistry, with follow-up upon completion of physical growth and senior school education. Importantly, despite normal liver function, many patients did not demonstrate 'meaningful survival'. We must refocus our efforts towards better understanding the long-term outcomes of children. A 'meaningful survival' rather than mere survival should be our goal.

FUNDING

None.

Trends in generalised anxiety disorders and symptoms in primary care: UK population-based cohort study

BACKGROUND

Generalised anxiety disorder and symptoms are associated with poor physical, emotional and social functioning and frequent primary and acute care visits. We investigated recent temporal trends in anxiety and related mental illness in UK general practice.

AIMS

The aims of this analysis are to examine temporal changes in recording of generalised anxiety in primary care and initial pharmacologic treatments.

METHOD

Annual incidence rates of generalised anxiety diagnoses and symptoms were calculated from 795 UK general practices contributing to The Health Improvement Network (THIN) database between 1998 and 2018. Poisson mixed regression was used to account for age, gender and general practitioner practice. Subsequent pharmacologic treatment was examined.

RESULTS

Generalised anxiety recording rates increased in both genders aged 18-24 between 2014 and 2018. For women, the increase was from 17.06 to 23.33/1000 person years at risk (PYAR); for men, 8.59 to 11.65/1000 PYAR. Increases persisted for a composite of anxiety and depression (49.74 to 57.81/1000 PYAR for women; 25.41 to 31.45/1000 PYAR for men). Smaller increases in anxiety were seen in both genders age 25-34 and 35-44. Anxiety rates among older patients remained stable, although a composite of anxiety and depression decreased for older women. About half of drug-naïve patients were prescribed anxiety drugs within 1 year following diagnosis. The most common choice was a selective serotonin reuptake inhibitor. Benzodiazepine prescription rate has fallen steadily.

CONCLUSIONS

We observed a substantial increase in general practitioner consulting for generalised anxiety and depression recently, concentrated within younger people and in particular women.

Suicidality and gambling among young adults in Great Britain: results from a cross-sectional online survey

BACKGROUND

Suicide rates in young people have increased in England and Wales since 2010. There are a range of possible explanations for this increase, and problem gambling has been suggested as a potential risk factor. We aimed to examine the association between suicidality (suicidal thoughts and suicide attempts) and problem gambling specifically for young adults in Great Britain, where gambling has become more widely available and normalised in the past two decades.

METHODS

We analysed data from the Emerging Adults Gambling Survey: a cross-sectional, online, non-probability sample survey of young adults aged 16-24 years living in Great Britain, who were selected from a YouGov online panel. Participants were eligible if they had not taken part in any other YouGov survey on gambling in the past year. We examined associations between problem gambling (defined as a score of 8 or higher on the Problem Gambling Severity Index [PGSI]) and suicidal thoughts and suicide attempts in the year before survey completion in a series of regression models, with and without adjustment for sociodemographic factors, alcohol use, video gaming, anxiety, loneliness, and impulsivity.

FINDINGS

3549 eligible participants completed the survey between June 25 and Aug 16, 2019. 24 (37·0% [95% CI 25·6-50·2]) of 62 men who had attempted suicide in the past year had survey scores that were indicative of problem gambling, compared with 38 (3·6% [2·6-5·0]) of 1077 men who had not attempted suicide or had suicidal thoughts in the past year. 13 (14·5% [8·5-23·6]) of 85 women who had attempted suicide in the past year had survey scores that were indicative of problem gambling, compared with 25 (2·0% [1·4-3·0]) of 1184 women who had not attempted suicide or had suicidal thoughts in the past year. The adjusted odds ratio for attempted suicide was 9·0 (4·1-19·7) in men with scores that indicated problem gambling and 4·9 (2·0-12·0) in women with scores that indicated problem gambling, compared with participants of the same gender with PGSI scores of 0.

INTERPRETATION

Problem gambling appears to be associated with suicide attempts in both young men and young women. This association persisted after adjusting for anxiety, impulsivity, life satisfaction, and other factors, which suggests that other mechanisms, such as the severity and multiplicity of harms experienced, or gambling to cope with life stressors, might underpin this relationship. Young people with problem-gambling behaviours should be considered at risk for suicidality.

FUNDING

Wellcome Trust.

Have decreases in young workers' risky drinking resulted in an increase in illicit drug use?

ISSUES ADDRESSED

Recent reductions in young people's risky alcohol use have been widely documented but have not been examined among employed youth. Young workers' risky drinking may have corresponded with increased illicit drug use. This study investigated these issues.

METHODS

Secondary analyses were conducted for 15-24 year old Australian workers using nationally representative data from 2007 to 2016. Frequency analyses examined alcohol and illicit drug use, Z scores assessed differences over time, and logistic regression examined predictors of illicit drug use.

RESULTS

Risky drinking decreased significantly over time whilst low-risk drinking increased. This pattern was observed for both young workers and young employed illicit drug users. Whilst "any" illicit drug use did not change over time, methamphetamine use decreased, and cannabis and hallucinogen use increased. Drinking alcohol at risky levels (monthly) was associated with illicit drug use in 2016, as were being single and having high/very high levels of psychological distress.

CONCLUSIONS

Risky drinking reductions over time have not corresponded with increased illicit drug use. Nonetheless, as risky drinking remains high among young workers, and is strongly associated with illicit drug use, it warrants concerted health promotion efforts that may also help minimise illicit drug use. SO WHAT?: Despite a reduction in young workers' risky alcohol consumption, risky drinking is still high and may impact the health and safety of workers and the wider community. As risky drinking is strongly associated with illicit drug use, workplaces could potentially play a vital role in combating alcohol and illicit drug misuse.

Behaviour change interventions to reduce risky substance use and improve mental health in children in care: the SOLID three-arm feasibility RCT

Background

Looked-after children and care leavers (henceforth children in care) are young people placed under the care of local authorities, often because of a history of family abuse and/or neglect. These young people have significantly increased risk of substance use and mental health problems compared with peers.

Aim

The Supporting Looked After Children and Care Leavers In Decreasing Drugs, and alcohol (SOLID) trial aimed to investigate the feasibility of a definitive randomised controlled trial comparing two behaviour change interventions to reduce risky substance use (illicit drugs and alcohol) in and improve the mental health of children in care aged 12–20 years.

Methods

The study consisted of two phases: (1) a formative phase that adapted the motivational enhancement therapy and social behaviour and network therapy interventions for use with children in care and (2) a three-arm pilot randomised controlled trial (comparing motivational enhancement therapy, social behaviour and network therapy and usual care), and a linked process and economic (return on investment) evaluation. Trial feasibility was compared with prespecified STOP/GO criteria.

Setting

Six local authority areas in the north-east of England.

Participants

Children in care (aged 12–20 years) who screened positive for drug and/or alcohol use within the last 12 months were eligible for the trial. The formative and process evaluations included children in care, carers, social workers, and drug and alcohol workers.

Outcome measures

The primary outcomes were recruitment and retention rates at 12 months’ follow-up. Baseline and 12-month follow-up questionnaires measured self-reported drug and alcohol use, mental health and health-related quality of life. The process evaluation considered acceptability and engagement with the interventions and trial procedures.

Results

Formative findings (n = 65) highlighted the need for interventions to increase the emphasis on therapeutic relationships, use creative methods of engagement and support the identification of treatment goals wider than substance misuse. Within the randomised controlled trial, of 860 participants screened, 211 (24.5%) met the inclusion criteria. One hundred and twelve (53%) of the 211 eligible children were recruited and randomised. Just 15 of the 76 (20%) participants allocated to intervention attended any of the motivational enhancement therapy of social behaviour and network therapy sessions, and 60 (54%) participants completed the 12-month follow-up. The screening and recruitment of children in care required significantly more time and resource investment by researchers and children’s services than planned. The process evaluation (n = 116) demonstrated that, despite participants engaging in risky substance use, they did not often acknowledge this nor felt that they needed help. Children in care had complex, chaotic lives and children’s services departments were less research mature and extremely stretched; this, coupled with the multiple steps in the intervention pathway and study protocol, resulted in low adherence to the intervention and the trial.

Conclusions

The SOLID trial demonstrated successful engagement with children in care to adapt the motivational enhancement therapy and social behaviour and network therapy interventions. However, the pilot randomised controlled trial found that a definitive trial is not feasible. The current screen, refer and treat pathway for children in care did not work. There is an urgent need to radically rethink how we deliver therapeutic services for children in care. A pragmatic evaluation design, coupled with additional research resource for children’s services, is needed to evaluate these novel models of care at scale.

Trial registration

This study is registered as PROSPERO CRD42018098974 and Current Controlled Trials ISRCTN80786829.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 13. See the NIHR Journals Library website for further project information.

Changes over time in young adults' harmful alcohol consumption: A cross-temporal meta-analysis using the AUDIT

BACKGROUND

Recent studies suggest that young adult participation in, and volume of, alcohol consumption has decreased. However, the evidence on trends in harmful alcohol consumption in this age group is limited. The current paper aims to examine changes over time in harmful alcohol consumption using a robust, widely employed measure.

METHODS

The literature was systematically searched for articles reporting on Alcohol Use Disorders Identification Test (AUDIT) scores in young adults aged 18-24 years. The key data extracted were year of measurement and mean AUDIT score (proportion above clinical cut-off was not relevant for these analyses). Cross-temporal meta-analysis was applied to the extracted data.

RESULTS

A decrease was found in young adults' AUDIT scores measured between 1989 and 2015 (b=-0.13, β=-0.38, p = 0.015, 95 % CI=-0.24, -0.03), representing a 0.63 standard deviation change over this period. Variance did not change over this time, suggesting scores decreased equally over the distribution.

CONCLUSIONS

Results indicate that harmful alcohol consumption in young adults may have declined between 1989 and 2015. Despite the continued problems posed by dependence and short and long-term harms, these promising findings offer hope that the considerable alcohol-related disease burden in this age group may be reduced. Ongoing data collection is required to evaluate whether these declines in young adulthood persist into later life, and future research should explore the reasons for declining harmful alcohol consumption in young adults.

Peer pressure and alcohol consumption in adults living in the UK: a systematic qualitative review

Background

Peer pressure to drink alcohol may influence excessive alcohol consumption, which can have adverse impacts on health and wellbeing. While peer pressure to drink alcohol is extensively studied among youth, less examination exists among adults. This systematic review examined qualitative research studies which explored the role and concept of peer pressure within the context of alcohol consumption in adults living in the UK.

Methods

Qualitative studies which explored peer pressure within the context of alcohol consumption or alcohol related behaviours and views in adults (age range approximately 18–52 years) living in the UK were included. Systematic searches conducted in Medline, PsycINFO and Web of Science identified 1462 references, of which 13 studies met inclusion criteria. Thematic analysis was conducted.

Results

Five overarching themes were identified. Four of these themes directly address aspects of peer pressure, including: experiences of peer pressure; consequences of peer pressure; strategies to deal with peer pressure; and conditions perceived to affect peer pressure. The fifth overarching theme explains the wider social context influencing peer pressure. Pressure to drink alcohol affects individuals across the life span and can be experienced as overt and aggressive, or subtle and friendly. Those consuming little or no alcohol are more likely to feel overt forms of peer pressure. Some developed strategies to cope with pressure from drinkers. Peer pressure can result in feelings of social isolation, or giving in by consuming alcohol against ones wishes.

Conclusion

Peer pressure to drink alcohol is a complex and multifaceted phenomenon experienced across adulthood requiring better understanding to support initiatives to decrease the impact of pressure-inducing environments and develop strategies to deal with perceived pressure conditions.

Trial Registration

The protocol for this review is registered with PROSPERO (CRD42019122201). Registered 11 February 2019

A growing need for youth mental health services in Canada: examining trends in youth mental health from 2011 to 2018

AIMS

The mental health of youth is continually changing and requires reliable monitoring to ensure that adequate social and economic resources are allocated. This study assessed trends in mental health among Canadian youth, 12-24 years old. Specifically, we examined the prevalence of poor/fair perceived mental health, diagnosis of mood and anxiety disorders, suicidality, perceived stress and sleep problems, substance use, and mental health consultations.

METHODS

Data were collected from eight cycles of the annual Canadian Community Health Survey (2011-2018). Prevalence of mental health outcomes was calculated from each survey, and meta-regression was used to assess trends over time. In the absence of a significant trend over time, the eight cycles were pooled together using meta-analysis techniques to gain precision. Trends in prevalence were assessed for the overall sample of youth (12-24 years) and separately for male and female adolescents (12-18 years) and young adults (19-24 years).

RESULTS

The prevalence of poor/fair perceived mental health, diagnosed mood and anxiety disorders, and past-year mental health consultations increased from 2011 to 2018, most strongly among young adult females. Past-year suicidality increased among young adult females but did not change for other age and sex groups. Notably, the prevalence of binge drinking decreased by 2.4% per year for young adult males, 1.0% for young adult females and 0.7% per year for adolescent males, while staying relatively stable for adolescent females. Prevalence of cannabis use declined among adolescents before legalisation (2011-2017); however, this trend did not persist in 2018. Instead, the 2018 prevalence was 5.6% higher than the 2017 prevalence (16.3 v. 10.7%). The combined prevalence of other illicit drug use was stable at 4.6%; however, cocaine use and hallucinogens increased by approximately 0.2% per year.

CONCLUSIONS

Our findings highlight a growing need for youth mental health services, as indicated by a rise in the prevalence of diagnosed mood and anxiety disorders and past-year mental health consultations. The reason for these observed increases is less apparent - it may represent a true rise in the prevalence of mental illness, or be an artefact of change in diagnostic practices, mental health literacy or diminishing stigma. Nonetheless, the findings indicate a need for the health care system to respond to the rising demand for mental health services among youth.

Resilience-based alcohol education: developing an intervention, evaluating feasibility and barriers to implementation using mixed-methods

Alcohol education must ensure that young people have appropriate information, motivation and skills. This article describes the fifth phase in a program of intervention development based on principles of social marketing and intervention mapping. The aim was to enhance drink refusal self-efficacy (DRSE) and help develop skills for non-drinking or moderate drinking. We conducted a mixed-methods feasibility trial that measured intervention effects among 277 UK secondary school students aged 14-16, and used qualitative methods to explore four teachers' experiences of delivering the intervention. The intervention did not produce the desired changes in DRSE or alcohol use, but nor did it increase alcohol use. In the qualitative process evaluation, time constraints, pressure to prioritize other topics, awkwardness and embarrassment were identified as barriers to fidelitous delivery. A more intense and/or more prolonged intervention delivered with greater fidelity may have produced the desired changes in DRSE and alcohol use. This study illustrates how principles of social marketing and intervention mapping can aid development of resilience-based education designed to help students develop skills to drink moderately, or not drink. It also highlights the need to consider the constraints of micro-social (school) and macro-social (societal) cultures when designing alcohol education.

Lesbian, gay or bisexual identity as a risk factor for trauma and mental health problems in Northern Irish students and the protective role of social support

Background: People identifying as lesbian, gay or bisexual (LGB) have been shown to experience more trauma and poorer mental health than their heterosexual counterparts, particularly in countries with discriminatory laws and policies. Northern Ireland is a post-conflict region with high rates of trauma and mental health problems, as well as significant levels of prejudice against the LGB community. To date, no studies in Northern Ireland have compared trauma exposure, social support and mental health status of LGB students to their heterosexual peers. Objective: The present study aimed to assess whether LGB status was associated with more trauma exposure and poorer mental health, and whether social support mediated these associations. Method: The sample was comprised of 1,116 university students. Eighty-nine percent (n = 993) identified as heterosexual and 11% (n = 123) identified as LGB. Path analysis was used to test the hypotheses. Results: LGB status was significantly associated with increased trauma exposure and with symptoms of PTSD, depression and anxiety, but not with problematic alcohol use. These associations were mediated by social support from family only. Conclusions: These results evidence vulnerabilities among Northern Irish students identifying as LGB in relation to trauma and mental health compared with their heterosexual peers. However, social support from family has the potential to mitigate risk. Educational initiatives should raise awareness of the importance of familial support for LGB youth, and those young people who lack family support should be considered an at-risk group, warranting particularly intensive targeting by relevant supports.

Adolescent health and future cardiovascular disability: it’s never too early to think about prevention

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Falling Rates of Hospital Admissions for Alcoholic Liver Disease in Northeast Italy: A Retrospective Study on a Large Database

AIM

To describe recent trends in hospital admission rates for alcoholic liver disease (ALD) in the Veneto region of Italy.

METHODS

This retrospective cohort study is based on anonymous hospital discharge records (HDRs) for 2000-2017 from all public and accredited private hospitals operating within the context of the Regional (Veneto) Health Services that are conserved in National/Regional database. It examined the HDR's of all the hospitalizations of the residents of the Veneto region that were registered under an ALD diagnosis. These were classified under three subheadings: acute alcoholic hepatitis Alcoholic liver cirrhosis and 'other ALD'.

RESULTS

During 2000-2017, 30,089 hospital admissions (out of a total regional population of 4,900,000) were registered for ALD. Hospitalization stratified by age showed that the percentage attributable to acute alcoholic hepatitis is higher in younger age groups: 42% in 15-24-year-old (odds ratios (ORs): 14.74; CI95%: 7-30.86; P < 0.000) and 15% in the 25-44-year-old (OR: 3.51; CI95%: 3.12-3.94; P < 0.000). A longitudinal analysis of hospitalization patterns showed a 7% increase in average age in both sexes (from 58.8 ± 9.2 to 62.4 ± 9.7) and a substantial decrease (63.5%) in standardized hospitalization rates (HRs, χ2 trend: 4099.827; P < 0.000) and a smaller decrease (47%) in standardized mortality rates (χ2 trend: 89.563; P < 0.000).

CONCLUSIONS

The fall in the overall ALD-related HR in the Veneto region can be explained by a decrease in population alcohol consumption. Increase in the HRs for acute alcoholic hepatitis in the age group 15-44 suggests an ongoing need for strategies to prevent alcohol abuse by young people.

Improving men's health: successful initiatives and barriers to progress

Peter Baker, Director, Global Action on Men's Health ( peter.baker@gamh.org ), discusses initiatives to encourage men to take care of their health and examines the barriers that prevent men from seeking help.

Subgroup trends in alcohol and cannabis co-use and related harms during the rollout of recreational cannabis legalization in Washington state

BACKGROUND

The US state of Washington legalized recreational cannabis in 2012; how this impacted the co-use of cannabis and alcohol in the population overall and among key subgroups has not been examined. The aim of this study is to investigate changes in patterns of alcohol- and cannabis use and alcohol-related harms during the rollout of retail recreational cannabis stores.

METHODS

Data come from six cross-sectional samples recruited between January 2014-October 2016 via Random Digit Dial procedures (N = 5492). Survey-weighted multivariable regression adjusting for gender, age, race/ethnicity, education, employment, marital status, cannabis use, and survey year were used for statistical analyses.

RESULTS

In the sample overall, no significant changes were observed in any alcohol use measures between 2014-2016, while the prevalence of cannabis use significantly (P < 0.05) increased from 25.0% to 31.7%, the prevalence of alcohol-related harms at home significantly decreased from 2.1% to 1.0%, and the prevalence of alcohol-related financial harms decreased from 1.5% to 0.8%. Both women and men significantly increased any cannabis use, while women also experienced significantly fewer alcohol-related harms at home and financial harms over time, and increases in the prevalence of cannabis users/non-drinkers. Those 18-29 years old significantly reduced the number of drinking days and overall volume in the past 30 days, and those 30-49 years old significantly decreased alcohol-related harms at home and financial harms. Those 50+ years old significantly increased any cannabis use and simultaneous use of cannabis and alcohol. Non-cannabis users slightly decreased average number of drinks/day, and cannabis users significantly decreased alcohol-related financial harms.

CONCLUSIONS

Between 2014-2016, the years during and immediately following the introduction of legal recreational cannabis stores in Washington state, there were no significant changes in cannabis and alcohol co-use or overall alcohol consumption. The only significant changes in the sample overall were an increase in any cannabis use and decreases in alcohol-related harms at home and alcohol-related financial harms.