HIFA Discussion: Alcohol Use Disorders - Drink Aware and Change

Dear HIFA colleagues,

I would like to invite you to retweet the following that I have just sent on our X/Twitter account:

"Pls RT: I just took the DrinkAware test as if I drank 3 pints a day (well over the recommended limit). The result was "Great news! You are at lower risk of alcohol-related problems". We invite others to check. Thx NPW https://www.drinkaware.co.uk/tools/drinking-check#/ "

You can see the tweet and retweet here: https://twitter.com/hifa_org/status/1762399130154885617

We are unsure why the test - which is taken by 900 people every day - is providing such misinformation.

DrinkAware is funded by the alcohol industry.

Thank you for your help to publicise this issue.

Best wishes, Neil

HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil AT hifa.org

To which I replied:

RT'd as requested.. 

Reply from twitter ... 

This evergreen article was written 10 years ago
"Be aware of @Drinkaware "https://t.co/UGcVFb5gFB via @peter_g_miller et al

— Ash Paul (@pash22) February 27, 2024

McCambridge J, Kypri K, Miller P, Hawkins B, Hastings G. Be aware of Drinkaware. Addiction. 2014 Apr;109(4):519-24. doi: 10.1111/add.12356. Epub 2013 Oct 28. PMID: 24164565; PMCID: PMC3992896.

UPDATE 10th March

Dear HIFA colleagues,

Further to our discussions on HIFA, in the past week DrinkAware HAS CHANGED THEIR ADVICE to people who drink 42 units per week (3X the recommended maximum). Questions remain about how many people were misled by previous advice, whether that advice was deliberate, and whether WHO's AUDIT test (currently used as the basis for the DrinkAware test) should continue to be used by anyone as an unsupervised self-evaluation tool.

BACKGROUND On 22 February 2024 I reported on HIFA an apparent problem with DrinkAware, the UK's largest alcohol charity, funded by the alcohol industry. https://www.hifa.org/dgroups-rss/alcohol-use-disorders-79-role-alcohol-industry-10-alcohol-industry-and-misinformation

I took their Drinking Check. I posed as a man who drinks 42 units per week (3X the recommended maximum) and DrinkAware told me: "Great news! You are at lower risk of alcohol-related problems. This means you are at lower risk of serious diseases such as stroke, heart and liver disease, and seven types of cancer and may already be noticing the benefits of lower risk drinking such as deeper sleep, more energy and brighter moods."

There was no advice to reduce my consumption.

This test was repeated by other HIFA members in subsequent days, with the same results.

On 4 March 2024 we reported our findings to the World Health Organization.

CHANGE IN ADVICE Today, 10 March 2024, I took the test again. As before I posed as a man who drinks 42 units per week. This time I got a different result:

"You are on the right track. You are at lower risk of alcohol-related problems... To keep your health risks low, the UK Chief Medical Officers advice is to drink no more than 14 units a week. If you are regularly drinking above 14 units per week there are tips and advice below about how to cut down."

INTERPRETATION Prior to 4 March 2024, DrinkAware was encouraging many heavy drinkers (up to 42 units per week) to continue drinking as they are.

DrinkAware claims that its Drinking Check tool was used by 250,991 people in 2021, so it appears that potentially tens or even hundreds of thousands of people drinking 14-42 units per week may have been misinformed.

At some point between 4 March and 9 March, Drinkaware changed their Drinking Check tool so that heavy drinkers (up to 42 units per week) are now advised to cut down.

SHOULD WHO's AUDIT TEST BE USED AS AN UNSUPERVISED SELF-EVALUATION TOOL?

Previous messages on HIFA have suggested that AUDIT should only be used as a clinical tool by health professionals, and not as an unsupervised self-evaluation tool. WHO's AUDIT manual notes: 'Care must be taken to tell patients why questions about alcohol use are being asked and to provide information they need to make appropriate responses. A decision must be made whether to administer the AUDIT orally or as a written, self-report questionnaire.' https://iris.who.int/bitstream/handle/10665/67205/WHO_MSD_MSB_01.6a-eng.pdf

NEXT STEPS

How many people were misled by previous advice, was that advice deliberate, and should WHO's AUDIT test (currently used as the basis for the DrinkAware test) continue to be made available as an unsupervised self-evaluation tool?

I invite HIFA members to suggest next steps. Are you a health journalist (or do you know a health journalist) who might be interested to look into this in more depth? Please pass this on and/or contact me: neil@hifa.org

Meanwhile I shall report this new finding to WHO.

I look forward to your comments and suggestions: hifa AT hifaforums.org

Best wishes, Neil

Finally ...

Dear HIFA colleagues,

We now enter our 6th and final week of the deep-dive into Alcohol Use Disorders, where I invite you to reflect on what has been discussed so far (and what has not been discussed). In your view, what is the key learning in relation to the 5 questions we have explored:

1. Do people understand the health, socio-economic and environmental harms of alcohol? What matters to them? How can they be better informed? How to reduce stigma? 2. Do health workers have adequate knowledge to prevent and manage alcohol use disorders among their patients? What matters to them? How can they be better informed? 3. What is the role of the alcohol industry? What can be done to address misinformation from the alcohol industry? 4. Do public health professionals and policymakers have adequate knowledge to prevent and treat alcohol use disorders in their country? What are current national policies and what more can be done to fully implement those policies? 5. How can we define and measure alcohol use disorders?

To help with this, I have prepared a full compilation of our discussion so far (205 pages):

https://www.hifa.org/sites/default/files/publications_pdf/Alcohol_Use_Disorders_Compilation2.pdf

I shall now work on an edited version (selected text organised under subheadings for each of the 5 questions and for other topics) and will get this to you asap.

Many thanks, Neil

HIFA Discussion: Alcohol Use Disorders - Do people understand the harms of alcohol?

Dear All (with further editing since posting)

The discussion, points, angles, questions ... are coming thick and fast it is difficult to keep up.

Many thanks for the summaries; and of course the discussion which archived also acts as a resource - repository:

https://www.hifa.org/news/hifa-announces-deep-dive-discussion-alcohol-use-disorders-starts-5-february-2024

I wonder whether the question: 

"Do people understand the harms of alcohol?" must always be placed in context?

It is radically different when asked of the tee-total, dry, safe drinker; and someone (still) actually in their alcohol drinking?

It occurs to me that alcohol, even more so than 'other' substance misuse (heroin...) represents what must be *the* contradiction, paradox in healthcare - except the tragic loss that is suicide.

Contrast substance misuse inc. alcohol, with 'help-seeking' and 'The Sick role'

https://www.england.nhs.uk/blog/ed-mitchell-2/

Plus, the (medical) sociology of the decision to consult/refer, and how in mental health (UK), the mental capacity act is apparently being misapplied ('policy-drift'?**):

https://www.lawsociety.org.uk/topics/blogs/are-mental-health-and-capacity-laws-at-risk-of-being-toxic

https://www.communitycare.co.uk/2017/08/23/flawed-use-mental-capacity-act-key-theme-safeguarding-adults-reviews-report-finds/

Individual
   |

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :   POLITICAL 

|

Group

	continental drift
	policy drift?

Previously, I highlighted how as a Community Psychiatric Nurse 1985-1995 (adult) .. if a patient/client was not working to control/reduce their alcohol consumption they may be 'counselled' re a pending discharge and referral back to their GP - family physician. In supervision with the team's manager they would want to know what is 'happening'. It being important not to create (social) dependency, or worse support someone in their alcohol misuse.

There was a sense, still is(?) that in substance misuse (across forms) - the individual has to reach 'rock-bottom', literally the 'gutter' that is the point they decide (really?)** to live, or carry on to suffer irreversible brain damage, or premature death. Regards the 'brain damage' it was a struggle for 45-60 minutes given the impact upon short-term memory, what time, .... is it indeed? When the patient was not living alone, how did the relative, family cope?

Is having to reach the gutter, the bottom, a trope/myth? In psychosis rather than assume the patient is beyond being reached prior to being medicated there are psycho-social interventions that can be commenced: being available / with. Here though this is usually 'first episode'. There is no analogue here, unless first admission to an in-patient unit is taken as a golden opportunity? But this also depends on its nature (funding, staffing - expertise), a general adult mental health ward, or specialist unit.

https://www.imdb.com/title/tt0048347/

What is the current strategy?

In terms of 'HIFA' - and the person that counts**, not only do they not have the 'information'; they do not have the EXISTENTIAL INFORMATION as it relates to them: 'Health Information for YOU'!

Again in Hodges' model we can contrast the dichotomy/polarisation of INDIVIDUAL :: GROUP.

The model's being situated; and able to encompass data, information, knowledge (facts, for example, and their delivery) - wisdom (Multi-contextual / transdisciplinary..).

I admire people who work in these services (learning disability and palliative care); as they must be severely tested as they retain an ability - the humanity - to 'see' the person whatever the patient's situation with their lack of awareness (capacity..?) and its critical salience.

Peter Jones
Community Mental Health Nurse and Researcher
Blogging at "Welcome to the QUAD"
http://hodges-model.blogspot.com/
http://twitter.com/h2cm
h2cmng at yahoo.co.uk

Location: It was just a cappuccino.

**Which points to the relevance of the POLITICAL care/knowledge domain in Hodges' model.

HIFA Discussion: Alcohol Use Disorders (37) Do people understand the harms of alcohol? (9) How can they be better informed? (5)

Further to the post on 1st February 2024:

HIFA discussion on Alcohol Use Disorders, 5 Feb - 17 Mar 2024

- I have f/w some reflections (edited here). You may have your own experiences, skills, knowledge to contribute?

<>

As a teenager you were very aware of peer pressure (as a social expectation) to drink. Is it an acquired taste?

The media played a key role - advertising "Tetley Bitter-men", "Double Diamond - works wonders", Babycham, Advocaat, Martini Rosso .. and many of the popular TV series we consumed (pardon the pun).

Getting in the pub AND served was a right of passage - and a rather 'tame' one for a white, male.

In the family the harms and risks of alcohol were explained. 

Sometimes they were demonstrated at parties, weddings, the aunt, uncle - relative who was notorious for having too much.

Studying literature at school did have a role to play - although less directly.

Although on reflection when there were school assemblies I wonder if 'drink' (Church of England) was mentioned?
Interesting perhaps - the change in daily school routine.

I remember at a birthday party for a fellow class pupil at a social club, the birthday boy was sick all over the table - yes - had been drinking.

Tempered my attitude early on - c.15.

As a nursing asst. and student nurse you realised the other - dark - side. The key being the contradiction that alcohol represents:

• Drink to relax, socialise, be friendly, enjoy yourself;
• Impact of your health, risk of addiction, violence, (brewer's droop was an early lesson - tho not practically);
• IF YOU develop a drink problem then you're on your own and so is your family (there are of course agencies in developed nations - but the funding disparity - as in, gambling, tobacco?).

In a 'local' - public house - pub it was known in 1970s for some regulars (invariably men) to down c.12 (more?) pints in a night - even after drinking hours: they were heavy goods vehicle drivers.

---------
I may have posted before - how in 1987-88 I completed a study of alcohol (intervention) teams, Preston, Salford, Blackburn here in NW England. The consultant psychiatrist made a key point about the (much debated even then) use of economic levers to help reduce alcohol consumption.

Scotland have just updated their intervention:

https://www.theguardian.com/society/2024/feb/08/scotland-raises-minimum-alcohol-prices-by-almost-one-third

As a student nurse - I was already aware of some of the inorganic molecules that have been found in space: the original primordial soup!

The chemical names still remind me of a chemical plant, such as the former ICI plant at Widnes / Runcorn, Cheshire, England, e.g.:

https://thumbs.dreamstime.com/b/heavy-industry-panorama-night-panoramic-view-chemical-plant-refinery-blue-sky-illumination-some-freight-85481422.jpg

This in-turn takes me to the miracle that is the liver - the biological chemical plant - with a potential powerful message in how 'alcohol' is broken down:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527027/

Sometimes insight into this can work wonders in terms of motivation for change - the facts - not trying to scare (waste of time)...?

Which brings me to the obvious 'contradiction' in caring for people with a primary / secondary problem with alcohol.

Having a liver function test.

If it's OK that *means* I can carry on!!

I have over the years developed what imho I consider to be potentially therapeutic relationships with patients affected by alcohol.

I say potentially as I, with supervision, have had to withdraw input and discharge them. Even if the client can't 'draw the line', you cannot support the patient in their damaging alcohol consumption and related behaviours. The offer of further support was offered, with signposts should there be a change of  mind.

Alcohol, tobacco - vapes, the 'mental pollution' that can be passed as legitimate 'advertising', fake news ... still calls for a generic model, a universal conceptual framework for personal and global health - across literacies and forms of informatics:

'alcohol'
https://hodges-model.blogspot.com/search?q=alcohol

Just to close I saw an item (I will try to find...) on the preponderance of 'smoking' in films 1940s - present day.

Still a problem now.

Of course: advocacy for health requires constant vigilance.

HIFA discussion on Alcohol Use Disorders, 5 Feb - 17 Mar 2024

Dear all on HIFA,

It's just 4 days to go before the official launch of our deep-dive discussion on Alcohol Use Disorders, 5 February to 17 March 2024.

Please forward this message to your contacts and networks and invite them to join! www.hifa.org/joinhifa

More information here:
https://www.hifa.org/news/hifa-announces-deep-dive-discussion-alcohol-use-disorders-starts-5-february-2024

HIFA is grateful for sponsorship from the Ulrich and Ruth Frank Foundation for International Health known online as NextGenU.org.

Note: We have opportunities for further sponsored discussions in 2024. We have 20 working groups on standby to plan and implement a discussion [ https://www.hifa.org/projects ]. Or we can start a new group to address a topic that is important to you. Also new in 2024 there is the option to have live webinars to complement our forum discussions.

To discuss possibilities, please contact: neil AT hifa.org

With thanks, Neil

HIFA Partnerships and Projects working group: https://www.hifa.org/projects/partnerships-and-projects

HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization.

'Pharma©opia’ (1992) by General Idea outside Museo Jumex © Moritz Bernoully c/o FTWeekend

 INDIVIDUAL
  |

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

	Pharma©opia’ (1992) by General Idea outside Museo Jumex © Moritz Bernoully

Cepeda, G., Mexican art's early champion. Collecting,  FTWeekend, 25-26 November 2023, p.5. 

Image source:
https://www.ft.com/content/96f76039-0703-455f-acbb-d1a74827ee73

With my inversion of the original image.

Health information & 7th Global Alcohol Policy Conference

Politicians -
GIVE HEALTH LITERACY A CHANCE!

INDIVIDUAL

|

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

cognitive access, basic literacy	'legibility', digital access
PUBLIC - MENTAL - HEALTH Society Communities Most vulnerable groups Digital divide	"Why are alcohol companies pushing for QR codes on labels? Well, which of these two labelling methods actually shows the risk of alcohol consumption, 1 or 2? QR codes are a way for producers to say they are informing consumers, without doing so." @InstAlcStud economic access Health Information For All POLICY 7th Global Alcohol Policy Conf. Alcohol Taxes - False economy?

My source: https://x.com/InstAlcStud/status/1703658612109742578?s=20

Book: Empire of Pain

individual
|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

PSYCHOLOGICAL PAIN	Empire of Pain
How do governments recognise individual pain? How do governments recognise individual trauma?	A protest sculpture of a bent heroin spoon is placed outside the Purdue Pharma headquarters in Connecticut in 2018 © New York Times / Redux / eyevine c/o FT.

Gapper, J., Deadly Painkillers, Life&Arts, FTWeekend, 1-2 May, 2021. p.8.

Online: https://www.ft.com/content/1db7800f-78d5-474e-9b1e-744b1c1a837c

Book cover: https://www.foyles.co.uk/

BBC Radio 4: Start the Week, The opioid crisis and erosion of trust

Gambling: First Team Standing

... not just the shirt on your back ...

 individual 

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

gambling?	gambling?
gambling?	TRANMERE F.C.

See also on W2tQ: gambling , addiction

Loot boxes: GET YOURS TODAY!

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

LOOT BOXES 'Liminality' - a journey - into gambling?	e-Gaming Immersive Worlds Part-work encyclopaedias Model part-work products (so many plastic things)
Antique collectables - Football cards Stamps, Coins ...	Overall cost Oversight: parental Policy - Government

There are no loot boxes in Hodges' model, but then again,

you could say there are four.

The loot boxes in Hodges' model are not free,

the cost is time.

For many that is already a major expenditure and at the expense of relationships, friendships and studies.

Like many games there is a challenge in Hodges' model.

By all means please do explore the knowledge (care) domains of Hodges' model.

You are then invited to reflect, weigh, balance ... and find the real loot boxes you seek.

Your mission [ if you choose to accept it ;-) ] is to learn from each of the boxes about the situation you find yourself in and fuse these new insights into one.


WHO: Gaming disorder

Note to self:
#h2cm has an addictive - memetic quality (but is not a 'memetic hazard')
As a tool it is not the only one, but is a key resource for reflection, critique and problem solving.

Book: "Short Sentence" by Jessica Berens [RIP]

Telegraph Obituaries

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

	Short Sentence - Three Years in Dartmoor Prison

See also:
Capital letter. Start of Sentence.

Knife crime: treat as a 'disease'.. (in Hodges' model)


Source:
Jessica Berens, inspiring writer-in-residence at Dartmoor Prison who wrote a witty and observant book about the experience – obituary, The Telegraph. 13 April 2019.
My source print copy, p.31.

c/o R Layard "Enact policies to boost emotional health"

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

individual well-being MENTAL HEALTH "HAPPINESS - EMOTIONAL HEALTH	"EVIDENCE-BASED" "overarching criterion for measurement" processes - SCIENCES" PHYSICAL HEALTH
COMMUNITY WELL-BEING Society Social values Social cohesion	POLICIES on - "schools, mental health, family support, child support, addiction, social work,  loneliness, methods of management and town planning."

"Fortunately more and more governments are beginning to think along these lines."

Prof. Richard Layard* (2019) FT Weekend, 9-10 March. "Enact policies to boost emotional health"
Author of: Happiness - Lessons from a new Science

*Co-director, Well-Being Programme, Centre for Economic Performance, London School of Economics, UK

Capital letter. Start of Sentence.

Prison, Offenders, Release ... in h2cm

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Mental Health Assessment - diagnosis? Learning disability Ongoing counselling, legacy issues PTSD? Addiction services Custody Liaison Mental Health Nurses Understanding of – my [care] plan, stress & vulnerability, relapse signature Literacies, writing, numeracy Life chances Key skills: interviews, exams, assertiveness, strengths ...	Medication: prescribing, compliance, concordance, safe prescribing Addiction, Substance misuse Assurance of physical health, exercise Location – familiar with the area? Logistics – transport Technology* Treatment for Offenders Sentence length
Re-integration into society Social attitudes Sex Offenders Role of family Relationships (Legacy issues - 'resolve'?) (Re-)Housing The social network they may return to Contact with a  support group* Having a ‘buddy’ when available	Determinate Sentence (half) Policy (integration?) and Funding Offender Assessment System Rehabilitation of offenders Employment – work Opportunities for training - education Allocation to a GP and other health services Organisation of State Benefits Probation services, Charities Statutory supervision Mental Health Act Community assignment

Once we have sufficiently addressed what is identified using Hodges' model, we can can stand together in the center with an improved chance of achieving person-centred care and Recycling Lives?

 
If you can suggest changes, additions, please get in touch h2cmng AT yahoo.co.uk

HIT: Health Information Technology? Wanna bet...?

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

HIT on Vulnerable individuals Self-exclusion What do these words mean to you - 'Fixed' 'Odds' 'Betting' 'Terminals' ? 'Cognitive access' Children Gambling advertising in football	FIXED ODDS BETTING TERMINALS Stakes £50 or £30 or £20 or £2 £300 per minute Physical access HIT - the button yet again... "... not a single fixed odds betting terminal among the 35,000 or so in Britain which has ever had a losing week" Guardian
HIT on Relationships and Families Breakdown Loss of Social Capital: Crime Job-loss 'Civil Society' "A Government gets the  citizenry it legislates for"?	Department for Digital, Culture,  Media & Sport 12-Week Public consultation HIT to the gambling industry 60,000 jobs Staff training & awareness £1.8 billion market HIT on Tax £700 million Tracey Crouch MP Gambling Minister

Source: Various

Your odds on favourite: Hodges' model

HAYDOCK PARK 3:00

The Hodges-Jones Classic Integrated, Holistic &
Multidisciplinary Care Chase

Going: heavy

26m 1.75f

4	REALPOLITIK	250	225
3	SOCIAL SHENANIGANS	33	25
1	INTERPERSONAL SKILLS	5	3	4
2	HARD SCIENCE	Evs	10-11	5-6	10-11	5-6
5	SPIRITUAL LEANINGS	75	50	45	50
6	SOCIO-TECH NEGLECT	750	1000

Additional links:
Gamblers Anonymous

Gam-Anon

Gambling Commission

Inspired by BBC News and living by Haydock Park Racecourse

Ref info:
http://www.ukhorseracing.co.uk

Book chapter: Substance Misuse and Mental Health

With the chapter on socio-technical structures within Hodges' model due to appear very soon there is news of an exciting further project - a different publisher with a more purely clinical and social care focus.

Between now and 1 May I have accepted an invitation to produce a chapter addressing the holistic aspects of substance misuse and mental health. More to follow and a deadline to work to ....

Smoke gets in your eyes, hair, socks and underwear....

July 1 2007 England: at last smoke free indoor public spaces!

I don't smoke. Hate cigarettes, but not people who smoke.

I've seen cigarettes used to control patients in the past and seen the effects on people when if the supply of cigarettes was not 'managed' then major problems ensued.

Both patients, staff and nicotine were well and truly locked in an institutionalised embrace. This relationship was strongest in the old mental health institutions on the long-stay (or 'rehab' wards).

I used to arrive home from work and ALL my clothes absolutely reeked of cigs. Into the shower. Nausea as the water ran over my hair.

As I prepare to return to work in the community: on home visits if someone goes to light up, I beg their pardon and acknowledge that I am a guest in their home - but could they please possibly hold-on a while. This isn't just a strategy to shorten visits. The first lesson of first aid is DO NOT become the next casualty. I also take the role of health promotion seriously. When people put the smokes away, I thank them on leaving highlighting the great favour granted to me. In summer and sometimes winter - their addiction helps me to help them - an excuse for us to venture outside to have a walk: ecotherapy! If people value your input, most do not mind. They also remember for next time - so social skills are employed. If needed though in the car I have a jacket just for the 'smoky visits'.

Cigarettes have been the cause of so many problems on wards resulting in aggressive behaviour.

Before I start sounding holier-than-thou - one of the worst instances was an elderly gentleman on a then 'psycho-geriatric' ward who with no smokes was livid. He wielded his zimmer walking frame at staff. We sorted the problem, calmed him down and no one was hurt; but the distress caused to this gentleman and many others over decades....

IF there is a benefit to be associated with cigarettes it's teaching the art of anticipating a person's needs and differentiating between the person and their behaviour.

An organic, naturally occurring pesticide must be bad for you and that's just one of the poisons in a cigarette (a regular chemical factory).

There is an established body of research on the links and effects between mental health, specific diagnostic groups and smoking. As for summer 2007 looking at the grey skies over the UK at present, many people WILL struggle. You have to wonder how referrals to all mental health services (primary and secondary care) will run over the next 12 months (next spring!) and how well we can monitor the effects?

Source: Nicotine molecule image (permission sought): Ron Perry and Sarah Frisken

P.S. To what extent have cigarettes affected human genetic development?