Drugnet Ireland - Issue 46, Summer 2013

Cannabis misinterpretation and misadventure in a coroner's court
Tormey WP
Medicine, science, and the law, 2012, 52(4): 229–230.
www.drugsandalcohol.ie/19527

A 37-year-old, one-pack-per-day tobacco smoker collapsed and died at home. At autopsy, he had an occluded left anterior descending coronary artery. Δ(9)-Tetrahydrocannabinol-carboxylic acid was found in his urine but no cannabinoids were detected in his blood. Misadventure was the inquest verdict on the basis of the urinary cannabis, with acute myocardial infarction as the primary cause and cannabis as the secondary cause of death. Such a conclusion is a misinterpretation of the evidence when the time duration for cannabis as a trigger for myocardial infarction is at most two hours. The absence of cannabis in the blood likely places the time since inhalation at more than two hours. The role of tobacco smoking as a trigger was ignored. Cotinine, the biochemical marker of tobacco smoke, should be added to the standard toxicological screen in the guidelines on autopsy practice of the Royal College of Pathologists.

The epidemiology of assault-related hospital in-patient admissions and ED attendances
O'Farrell A, de la Harpe D and Geary U
Irish Medical Journal, 2013, 106(3).
www.drugsandalcohol.ie/19503

The aim of this study was to describe the epidemiology and impact of serious assault warranting in-patient care over six years and its impact on ED attendances in a large teaching hospital in Dublin over 2 years. There were 16,079 emergency assault-related in-patient hospital discharges reducing from 60.1 per 100,000 population in 2005 to 50.6 per 100,000 population in 2010. The median length of stay was 1 day (1-466) representing 49,870 bed days. The majority were young males (13,921, 86.6%; median age 26 years). Overall crime figures showed a similar reduction. However, knife crimes did not reduce over this period. Data on ED attendances confirmed the age and gender profile and also showed an increase at weekends. Alcohol misuse was recorded in 2,292/16079 (14%) of in-patient cases and 242/2484 (10%) in ED attendances. An inter-sectoral preventative approach specifically targeting knife crime is required to reduce this burden on health services.

Silk Road, the virtual drug marketplace: a single case study of user experiences
Van Hout MC and Bingham T
International Journal of Drug Policy, 2013, 1 March, Early online.
www.drugsandalcohol.ie/19490

Background: The online promotion of ‘drug shopping’ and user information networks is of increasing public health and law enforcement concern. An online drug marketplace called ‘Silk Road’ has been operating on the ‘Deep Web’ since February 2011 and was designed to revolutionise contemporary drug consumerism.

Methods: A single case study approach explored a ‘Silk Road’ user's motives for online drug purchasing, experiences of accessing and using the website, drug information sourcing, decision making and purchasing, outcomes and settings for use, and perspectives around security. The participant was recruited following a lengthy relationship building phase on the ‘Silk Road’ chat forum.

Results: The male participant described his motives, experiences of purchasing processes and drugs used from ‘Silk Road’. Consumer experiences on ‘Silk Road’ were described as ‘euphoric’ due to the wide choice of drugs available, relatively easy once navigating the Tor Browser (encryption software) and using ‘Bitcoins’ for transactions, and perceived as safer than negotiating illicit drug markets. Online researching of drug outcomes, particularly for new psychoactive substances was reported. Relationships between vendors and consumers were described as based on cyber levels of trust and professionalism, and supported by ‘stealth modes’, user feedback and resolution modes. The reality of his drug use was described as covert and solitary with psychonautic characteristics, which contrasted with his membership, participation and feelings of safety within the ‘Silk Road’ community.

Conclusion: ‘Silk Road’ as online drug marketplace presents an interesting displacement away from ‘traditional’ online and street sources of drug supply. Member support and harm reduction ethos within this virtual community maximises consumer decision-making and positive drug experiences, and minimises potential harms and consumer perceived risks. Future research is necessary to explore experiences and backgrounds of other users.

Effectiveness of motivational interviewing in influencing smoking cessation in pregnant and postpartum disadvantaged women
Hayes C, Collins C, O'Carroll H, Wyse E, Gunning M, Geary M and Kelleher CC
Nicotine & Tobacco Research, 2013, 15(5): 969–977.
www.drugsandalcohol.ie/19420

Introduction: Systematic assessments of Motivational Interviewing (MI) in smoking behavior have been rare to date. This study aimed to determine whether an integrated approach, involving staff training in MI techniques, was sufficient to affect change in smoking status or intensity in low-income pregnant and postpartum women.

Methods: Overall, 500 consecutive smokers were recruited at first prenatal visit to public antenatal clinics. Following staff training, 500 more were recruited (intervention group). Data were recorded at 28–32 weeks gestation, after birth, at 3–4 and 7–9 months postpartum. The primary outcome measure was self-reported continued abstinence from smoking verified by urinary cotinine analysis. Changes in smoking intensity were also measured.

Results: There was no significant difference in the proportion of smokers in the intervention and control groups who reported stopping smoking at 28–32 weeks gestation (8.2% vs. 8.8%; p = .73), 1 week after birth (8.6% vs. 11.4%; p = .14), 3–4 months after birth (5.8% vs. 4.8%; p = .48), or 7–9 months after birth (5.2% vs. 4.0%; p = .36). Although more cases were nonsmoking at the second visit, 14.8% [95% CI = 11.8–18.5] vs. 13.1% controls [95% CI = 10.3–16.6], this was not statistically significant.

Conclusions: MI delivered at a number of time points during pregnancy and up to 9 months postpartum failed to affect quit rates. It may have had a small effect in preventing relapse among spontaneous quitters in late pregnancy though the validity of this remains uncertain.

Attitudes of women from five European countries regarding tobacco control policies
Dresler CM, Wei M, Heck JE, Allwright S, Haglund M, Sanchez S et al.
Scandinavian Journal of Public Health, 2013, 41(2): 126–133.
www.drugsandalcohol.ie/19419

Aims: Tobacco-related cancers and, in particular, lung cancer still represent a substantial public health epidemic across Europe as a result of high rates of smoking prevalence. Countries in Europe have proposed and implemented tobacco control policies to reduce smoking prevalence, with some countries being more progressive than others. The aim of this study was to examine factors that influenced women’s attitudes in five European countries relative to comprehensive smoke-free laws in those countries.

Methods: A cross-sectional landline telephone survey on attitudes towards tobacco control laws was conducted in France, Ireland, Italy, the Czech Republic and Sweden. Attitudinal scores were determined for each respondent relative to questions about smoke-free laws. Logistic regression models were used to obtain odds ratios with 95% confidence intervals.

Results: A total of 5,000 women were interviewed (1,000 women from each country). The majority, regardless of smoking history, objected to smoking in public buses, enclosed shopping centers, hospitals, and other indoor work places. More women who had quit smoking believed that new tobacco control laws would prompt cessation, compared with women who still smoked.

Conclusions: In general, there is very high support for national smoke-free laws that cover bars, restaurants, and public transport systems. As such laws are implemented, attitudes do change, as demonstrated by the differences between countries such as Ireland and the Czech Republic. Implementing comprehensive smoke-free laws will gain high approval and will be associated with prompting people to quit.

Reductions in cardiovascular, cerebrovascular, and respiratory mortality following the national Irish smoking ban: interrupted time-series analysis
Stallings-Smith S, Zeka A, Goodman P, Kabir Z and Clancy L
PLoS ONE, 2013, 8(4).
www.drugsandalcohol.ie/19756

Background: Previous studies have shown decreases in cardiovascular mortality following the implementation of comprehensive smoking bans. It is not known whether cerebrovascular or respiratory mortality decreases post ban. On 29 March 2004, the Republic of Ireland became the first country in the world to implement a national workplace smoking ban. The aim of this study was to assess the effect of this policy on all-cause and cause-specific, non-trauma mortality.

Methods: A time-series epidemiologic assessment was conducted, utilizing Poisson regression to examine weekly age and gender-standardized rates for 215,878 non-trauma deaths in the Irish population aged 35 years and over. The study period was from 1January 2000 to 31 December 2007, with a post-ban follow-up of 3.75 years. All models were adjusted for time trend, season, influenza, and smoking prevalence.

Results: Following ban implementation, an immediate 13% decrease in all-cause mortality (RR: 0.87; 95% CI: 0.76 0.99), a 26% reduction in ischemic heart disease (IHD) (RR: 0.74; 95% CI: 0.63–0.88), a 32% reduction in stroke (RR: 0.68; 95% CI: 0.54– 0.85), and a 38% reduction in chronic obstructive pulmonary disease (COPD) (RR: 0.62; 95% CI: 0.46–0.83) mortality was observed. Post-ban reductions in IHD, stroke, and COPD mortalities were seen in ages 65 years and over, but not in ages 35–64 years. COPD mortality reductions were found only in females (RR: 0.47; 95% CI: 0.32–0.70). Post-ban annual trend reductions were not detected for any smoking-related causes of death. Unadjusted estimates indicate that 3,726 (95% CI: 2,305 4,629) smoking-related deaths were likely prevented post-ban. Mortality decreases were primarily due to reductions in passive smoking.

Conclusions: The national Irish smoking ban was associated with immediate reductions in early mortality. Importantly, postban risk differences did not change with a longer follow-up period. This study corroborates previous evidence for cardiovascular causes, and is the first to demonstrate reductions in cerebrovascular and respiratory causes.

A comparative analysis of health policy performance in 43 European countries
Mackenbach JP and McKee M
Journal of Public Health, 2013, 23(2): 195–344.
www.drugsandalcohol.ie/19744

Background: It is unknown whether European countries differ systematically in their pursuit of health policies, and what the determinants of these differences are. In this article, we assess the extent to which European countries vary in the implementation of health policies in 10 different areas, and we exploit these variations to investigate the role of political, economic and social determinants of health policy. Data and Methods: We reviewed policies in the field of tobacco; alcohol; food and nutrition; fertility, pregnancy and childbirth; child health; infectious diseases; hypertension detection and treatment; cancer screening; road safety and air pollution. We developed a set of 27 ‘process’ and ‘outcome’ indicators, as well as a summary score indicating a country’s overall success in implementing effective health policies. In exploratory regression analyses, we related these indicators to six background factors: national income, survival/self expression values, democracy, government effectiveness, left-party participation in government and ethnic fractionalization.

Results: We found striking variations between European countries in process and outcome indicators of health policies. On the whole, Sweden, Norway and Iceland perform best, and Ukraine, Russian Federation and Armenia perform worst. Within Western Europe, some countries, such as Denmark and Belgium, perform significantly worse than their neighbours. Survival/self-expression values and ethnic fractionalization were the main predictors of the health policy performance summary score. National income, survival/self-expression values and government effectiveness were the main predictors of countries’ performance in specific areas of health policy.

Conclusions: Although many new preventive interventions have been developed, their implementation appears to have varied enormously among European countries. Substantial health gains can be achieved if all countries would follow best practice, but this probably requires the removal of barriers related to both the ‘will’ and the ‘means’ to implement health policies.

Smoking in vehicles is lower than mobile telephone use while driving, but is socially patterned
Gilroy I, Donnelly N, Matthews W, Doherty K, Conlon G, Clarke A et al.
Irish Medical Journal, 2013, 106(4): 1–2.
www.drugsandalcohol.ie/19671

Legislation is being considered which bans smoking in cars carrying children under the age of 16. This was an observational survey of smoking by drivers and passengers and mobile phone use by drivers in 2,230 cars over three time periods in two Dublin locations. The observed prevalence of mobile telephone use (2.56%) was higher than smoking (1.39%) (p<0.01), but was low in both. There was no significant variation according to time of day. There was an inverse pattern according to car value for smoking drivers (p=0.029). Eight adult passengers and just one child were observed as being exposed to a smoking adult driver. In conclusion, the public health importance of regulating passive smoke exposure is clear but the resources required to police such a ban in vehicles may be labour intensive for the yield in detection or prevention.

Substance use in young persons in Ireland, a systematic review
Murphy K, Sahm L, Lambert S and Byrne S
Addictive Behaviors, 2013, 3 April, Early online.
www.drugsandalcohol.ie/19669

Adolescence is a time of physical and mental development when small changes can impact on the rest of a person's life. Substance use in this crucial period can have long-lasting consequences for the individual and for society. The prevalence of substance use in young people is an area of concern for policy makers and health workers. This systematic review looked at prevalence for four substances, alcohol, tobacco, cannabis and benzodiazepines, across the Republic of Ireland for persons between the ages of 13 and 24, and compared usage between 2000 and 2012. Eighteen articles were included in the review. It was seen that tobacco, alcohol and cannabis use has fallen in the lifetime and previous month use. The level of benzodiazepine use has remained similar in the period of study. Future work should redress the imbalance in substance use research that sees the majority of researchers looking at a few substances while little work is done on the others.

Tackling alcohol abuse among adolescents requires a multi-faceted approach involving parents and schools
Fitzgerald A and Dooley B
Psychiatry Professional, 2013, Spring: 6–8.
www.drugsandalcohol.ie/19643

Underage drinking is a major public health concern in many parts of the world. The initiation of alcohol consumption, and heavy or risky drinking, begins during adolescence. Patterns of alcohol use increase during adolescence and the peak period for alcohol consumption and alcoholrelated harm occurs in late adolescence and early adulthood. Heavy drinking by adolescents can have several serious health and social consequences, including impairments in cognitive functioning, poor school performance, future risk of development of alcohol problems, fatal and non-fatal accidents,6 and poor psychosocial outcomes.

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