health behaviours – Page 2

stopWatch – a smartwatch system that could help people quit smoking

Posted on October 24, 2019October 22, 2019 by lindsey.pike

Dr Andy Skinner and Chris Stone

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October sees the return of Stoptober, a Public Health England initiative to encourage smokers to quit. Campaigns like this and many others have been effective in reducing smoking in the UK over a number of decades. However, on average, about 15% of the UK’s population still smoke, and this costs the NHS more than £2.5bn each year.

To help address this, the NHS Long Term Plan has identified a range of measures to encourage healthier behaviours, including the need to speed up the introduction of innovative new health interventions based on digital technologies.

Here in the MRC IEU we’ve been working on a new wearable system that could help people stop smoking; stopWatch is a smartwatch-based system that automatically detects cigarette smoking. Because the system can detect when someone is smoking a cigarette, it can trigger the delivery of interventions to help that person quit smoking at precisely the time the interventions will be most effective.

Hand and wrist wearing stopWatch and holding a cigarette — The stopWatch could help people to stop smoking

What is stopWatch, and how does it work?

stopWatch is an application that runs on a commercially available Android smartwatch. Smartwatches now come equipped with motion sensors, just like the ones in smartphones that measure step counts and activity levels. As smartwatches are attached to the wrist, the motion sensors in a smartwatch can tell us how a person’s hand is moving. stopWatch takes data from the smartwatch’s motion sensors and applies machine learning methods to look for the particular pattern of hand movements that are unique to smoking a cigarette.

How can we use stopWatch to help people quit smoking?

It’s estimated about a third of UK smokers try to stop each year, but only a fifth of those that try manage to succeed. For most smokers an attempt to stop smoking ends with a lapse (having just one cigarette), that can quickly lead to a full relapse to smoking. As stopWatch can detect the exact moment a smoker lapses and has a cigarette, it can trigger the precise delivery of an intervention aimed specifically at helping prevent the lapse turning into a full relapse back to smoking.

Will the intervention work?

A recent article highlighted the potential for using mobile and wearable technologies, like stopWatch, to deliver these kinds of ‘just-in-time’ interventions for smoking. To develop our smoking relapse intervention we will be using the person-based approach, which has an excellent track record of delivering effective health behaviour change interventions. We will also be engaging the highly interdisciplinary cohort of PhD students in the new EPSRC Center for Doctoral Training in Digital Health and care, which brings together students with backgrounds in health, computer science, design and engineering.

However, that same article also pointed out that these types of intervention are still new, and that there has been little formal evaluation of them so far. So we don’t yet know how effective these will be, and it’s important interventions of this kind are subject to a thorough evaluation.

We will be working closely with colleagues in NIHR’s Applied Research Collaboration (ARC) West and Bristol Biomedical Research Centre who have expertise in developing, and importantly, evaluating interventions. We will also be working with the CRUK-funded Integrative Cancer Epidemiology Unit at the University of Bristol, collaborating with researchers who have detailed knowledge of developing interventions for specific patient groups.

The StopWatch display — On average, stopWatch detected 71% of cigarettes smoked and of the events stopWatch thought were cigarette smoking, 86% were actually cigarette smoking.

How good is stopWatch at detecting cigarette smoking?

In any system designed to recognise behaviours there is a trade-off between performance and cost/complexity. Other systems that use wearables to detect smoking are available, but these require the wearable be paired with a smartphone and need a data connection to a cloud-based platform in order to work properly. stopWatch is different in that it runs entirely on a smartwatch. It doesn’t need to be paired with a smartphone, and doesn’t need a data connection. This makes it cheaper and simpler than the other systems, but this also means its performance isn’t quite as good.

We recently validated the performance of stopWatch by asking thirteen participants to use stopWatch for a day as they went about their normal lives. On average, stopWatch detected 71% of cigarettes smoked (the system’s sensitivity), and of the events stopWatch thought were cigarette smoking, 86% were actually cigarette smoking (its specificity). This compares with a sensitivity of 82% and specificity of 97% for the systems that require smartphones and data networks.

When will stopWatch and the smoking relapse intervention be available and what will they cost?

The stopWatch system itself is available for research purposes to academic partners now, free of charge. We’re open to discussions with potential commercial partners – please get in touch if you’d like to discuss this (contact details below).

We aim to begin work on the smoking relapse intervention based on stopWatch next year, and we expect development and evaluation to take between 18 and 24 months. The cost of the intervention has yet to be determined. That will depend on many factors, including the partnerships we form to take the intervention forward.

What’s next?

We’re currently putting stopWatch through its paces in some tough testing in occupational settings. This will stress the system so that we can identify any weaknesses, find out to how to improve the system, and develop recommendations for optimising the use of stopWatch in future studies and interventions.

We’re also developing a new smartwatch-based system for the low burden collection of self-report data called ‘dataWatch’. This is currently undergoing feasibility testing in the Children of the 90s study.

Contact the researchers

Dr Andy Skinner Andy.Skinner@bristol.ac.uk

Drinking in pregnancy: lasting effects of low-level alcohol use?

Posted on July 29, 2019 by lindsey.pike

Kayleigh Easey, a PhD student and member of the Tobacco and Alcohol Research Group (TARG) at the School of Psychological Science at the University of Bristol, takes a look at a recent systematic review investigating effects of parental alcohol use and offspring mental health.

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It’s generally well known that drinking large amounts of alcohol during pregnancy is linked to Foetal Alcohol Syndrome (FAS), and negative outcomes such as premature birth and an increase in the risk of miscarriage. However, less is known about the effects of low to moderate alcohol use during pregnancy on offspring outcomes after birth, and even less for mental health outcomes in the child, particularly internalising disorders such as depression. Despite government guidelines being updated by the Department of Health in January 2016, advising pregnant women that the safest approach is to abstain from drinking alcohol altogether through their pregnancy, there remains uncertainty amongst the public as to whether a ‘drink or two’ is harmful or not.

Is a ‘drink or two’ harmful during pregnancy?

Researchers within the field mostly agree that abstinence from alcohol during pregnancy is the safest approach, but the evidence to support this is relatively weak, often due to study design and sample limitations. A previous meta-analysis highlighted how there are relatively few studies investigating low levels of alcohol use in pregnancy. Their analyses mainly focused on pregnancy outcomes such as gestational diabetes and childhood outcomes linked to FAS such as behavioural problems. Until now, a comprehensive review had not been undertaken on the effects of light to moderate drinking in pregnancy and offspring mental health.

Our research sought to review and summarise what literature was currently available for drinking alcohol in pregnancy and offspring mental health outcomes. Overall, we found that over half of the analyses included in the review reported an association between drinking in pregnancy and offspring mental health problems, specifically anxiety, depression, total problems and conduct disorder. By excluding FAS samples we were more certain that the findings we were reporting were representative of lower levels of drinking in pregnant women. However, we can’t be certain that many of the included studies are not still capturing higher levels of alcohol use in pregnancy, and potentially children with undiagnosed foetal alcohol spectrum disorders – a known problem in researching prenatal alcohol use.

Our review also highlights the differences across studies measuring drinking in pregnancy and offspring mental health, with all but four studies using a different measure of drinking alcohol in pregnancy, making comparison difficult. This means it is difficult to establish between studies if there is a ‘cut off’ level for what is potentially a hazardous level of alcohol exposure during pregnancy.

Abstinence seems to be the safest approach

The associations we find do not provide evidence of a causal effect on their own, which can be difficult to demonstrate. However, it is important for women to understand what the current evidence shows, to allow them to make informed decisions about drinking during pregnancy. Women should be able to use this information to inform their choices, and to avoid potential risks from alcohol use, both during pregnancy and as a precautionary measure when trying to conceive.

As such, people may take from this that the current advice of abstaining from alcohol during pregnancy is certainly sensible, at least until evidence is available to indicate otherwise. We suggest that future work is needed to investigate whether light to moderate alcohol use in pregnancy may be harmful to different mental health outcomes in children from large cohort studies, which is exactly what I am currently doing within my PhD research using the Children of the 90s study.

This blog post was originally posted on the Alcohol Policy UK website.

Can lifestyle changes prevent prostate cancer or delay the need for treatment?

Posted on June 10, 2019June 10, 2019 by lindsey.pike

This men’s health week, National Institute for Health Research Biomedical Research Centre and Integrative Cancer Epidemiology Programme PhD student Meda Sandu outlines findings from research on how we can best prevent and treat prostate cancer.

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Prostate cancer (PCA) is the second most common cancer in the adult population in the UK, with over 47, 000 new cases being diagnosed each year. Over 400, 000 people assigned male at birth live with or after a diagnosis of PCA. Localised PCA is cancer that is confined in the prostate gland and has not spread to other organs. Localised PCA often grows slowly, may not give any symptoms and/or require treatment. However, occasionally this type of cancer is aggressive in nature, can spread fast and will require treatment. Patients who undergo radical treatment, such as surgery and radiotherapy, often report side effects which significantly impact their wellbeing and enjoyment of life, such as urinary and bowel incontinence, low libido, erectile dysfunction, fatigue, mood swings. Our research looks at lifestyle interventions that may help prevent PCA, as well as identifying cases when treatment may be delayed, in an attempt to best support outcomes for people with PCA.

How does treatment choice affect survival?

In the ProtecT study people were randomised to various treatments or active surveillance where no treatment is given but the patient is regularly followed-up. The study found similar chances of surviving localised PCA, with those in the active surveillance group only having a very small decrease in survival compared to the other groups. This prompted a spur of research in identifying modifiable factors which could delay PCA progression and therefore avoid unnecessary treatment.

One of the aims of our research is to look at dietary and lifestyle changes that are acceptable and achievable to PCA patients, which could reduce PCA risk and progression. These could prevent PCA or, for those who have already been diagnosed with localised disease, delay treatment and therefore avoid the associated side effects.

Dietary and physical activity interventions in people with PCA

In the PrEvENT feasibility randomised controlled trial, patients who underwent prostate removal surgery were randomly assigned to both a dietary and a physical activity intervention. The dietary intervention consisted of either:

a lycopene supplement, which is an antioxidant found in tomatoes and has been previously be suggested to be protective for PCA
eating 5 portions of fruit and vegetable per day and replacing dairy milk with a vegan option (soy, almond, oat, coconut etc)
continue as normal.

The physical activity intervention asked participants to do 30 minutes of brisk walking five times a week.

Image by PublicDomainArchive from Pixabay

For each intervention, we looked at the change in metabolites, which are very small molecules found in blood that reflect metabolic patterns, a very useful measure in diseases where there are metabolic changes, such as cancer. We found that eating more fruit and vegetables and decreasing dairy changed blood metabolite levels. Of particular interest was the change in pyruvate levels, a metabolite used as fuel in the pathway of cancer cell proliferation. This suggests that our interventions could lead to less energy being available to the proliferation of cancerous cells, which could lead to lower PCA risk and progression.

Can we predict which PCA cases do not need treatment?

A second aim of my research is to identify blood markers that can help distinguish disease that is unlikely to cause problems from aggressive disease that will advance rapidly and require treatment. We looked at the ProtecT trial and provisionally identified metabolites that could help predict PCA progression. This would allow clinicians to more accurately decide if the patient should take up treatment or if active surveillance would be appropriate.

Patients diagnosed with localised PCA have 96% chance of surviving 15 years after diagnosis. However, PCA risk factors have yet to be conclusively identified. In addition, the diagnosing techniques are invasive and there is uncertainty around which localised cases are likely to advance. More research is therefore needed to establish potential risk factors which could help prevent PCA, and blood-based markers that could predict the aggressiveness of localised PCA cases. We are also looking at the relationship between PCA risk and progression and blood DNA methylation markers, which allow cells to control the expression of genes and have previously been suggested to be responsive to both environmental factors and causes of cancer and could help us better understand the aetiology of PCA.

So what does this mean for people with prostate cancer?

Although more research is required as our studies were small and did not aim to have definitive answers, we did find some evidence to suggest that some lifestyle changes, namely increased fruit and vegetable consumption and replacing milk with non-dairy options and walking 30 minutes a day, 5 times a week are acceptable to PCA patients and that these interventions may have promising effects on blood metabolites. Identifying lifestyle factors which may have a protective role could help prevent PCA cases. Our research also identified metabolites which may help predict the aggressiveness of PCA which could help patients diagnosed with localised PCA avoid serious side effects by not undertaking unnecessary treatment.

Further reading and resources

Find out more about prostate cancer

Find out more about the treatments available for prostate cancer

Journal paper: Hamdy et al (2016) 10 year outcomes after monitoring, surgery, or radiotherapy for localised prostate cancer (the ProtecT trial)

Journal paper: Hackshaw-McGeagh et al (2016) Prostate cancer – evidence of exercise and nutrition trial (PrEvENT): study protocol for a randomised controlled feasibility trial.

Why haven’t e-cigarettes stubbed out cigarettes?

Posted on May 31, 2019May 31, 2019 by lindsey.pike

On World No Tobacco Day, PhD researcher Jasmine Khouja outlines the evidence around e-cigarettes.

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There are an estimated 3.2 million e-cigarette users in Great Britain, and the majority of users have switched from smoking to vaping in search of a less harmful alternative to help them quit. In a recent study, people who used e-cigarettes to quit smoking were more likely to be smoke-free after one year compared to people who used more traditional methods such as nicotine patches. So, why are some smokers reluctant to try e-cigarettes, and why have some people been unable to quit smoking using them? The media, researchers, public health officials, and the general public have all played a role in discouraging some smokers from vaping.

E-cigarettes in the media

As a researcher in the field of e-cigarette use, I have often looked at news articles about vaping and felt exasperated. We frequently see e-cigarettes portrayed as a harmful option; according to many news articles, e-cigarettes are dangerous, lead to heart attacks and are as bad for your lungs as cigarettes. The same news outlets often report the opposite finding and say e-cigarettes are actually better for you. This flip-flopping leaves smokers confused and could discourage them from trying e-cigarettes for fear that vaping is actually more harmful than smoking.

Science in the media

So, why do the media keep switching their stance on e-cigarettes? They’re getting their information from the research community, and this community is divided. Some researchers claim that the costs of unknown health risks of vaping and the popularity of e-cigarettes among children and adolescents outweigh the potential benefits of helping smokers to quit, and others claim vice versa.

As researchers, we should be impartial and only provide the public with information which we can back up with evidence from our research, but, as we are still human, our opinions tend to seep through into how we report our findings and even what we choose to research. This lack of agreement in the research community is fuelling the media’s flip-flopping , leading to public confusion and reluctance to try e-cigarettes to help them quit smoking.

Public attitudes to vaping

With all of this contrasting information, it’s no wonder the general public’s opinion of vaping seems to be split too. Negative public opinion can have an impact on whether a smoker wants to try an e-cigarette. Quitting smoking isn’t easy; the last thing smokers want is to feel judged when they are trying to quit.

Negative public attitudes to vaping could put smokers off trying vaping but also affects where they can vape. Many businesses include e-cigarettes in their smoke free policies so that vapers have to stand outside with smokers. When trying to quit, it’s not ideal to be surrounded by the very thing you’re trying to wean yourself off. It’s like being on a diet and spending every meal at an all you can eat buffet when all you can eat is a salad; it’s tempting to slip into old habits. So, despite there being no indoor vaping ban (as there is with cigarettes), vapers are forced outside into a situation where they are more likely to start smoking again.

Unintended consequences of policy

It’s not just organisational policies attempting to control e-cigarette use; in 2016, a legislation called the Tobacco Products Directive (TPD) added a section on e-cigarettes in an attempt to regulate the devices. There were a number of unpopular changes to e-cigarette products as a result. Changes to the amount of nicotine allowed in products and restrictions on innovation of new products may have had unintended consequences.

With the introduction of the TPD, a limit was set on how much nicotine a vape product could contain. Nicotine is the key ingredient in cigarettes which keeps people smoking, and although it is highly addictive, nicotine is not the cigarette ingredient which is likely to kill smokers. E-cigarettes help people to quit smoking because they can contain nicotine which satisfies smokers cravings while exposing them to fewer toxins than smoking would. Limiting the amount of nicotine in these products means that heavier smokers don’t receive enough nicotine from an e-cigarette to satisfy their nicotine addiction and this makes them more likely to start smoking again.

The TPD also requires companies to register products in advance of bringing them to market. Where the e-cigarette industry was creating new, more effective devices at a very fast pace, users now can’t buy these products for a substantial amount of time after they have been developed. This restriction on innovation means that while consumers are waiting for these better products to become available, they could be trying products that don’t meet their needs. I often hear tales of “I tried one once and it was just like puffing air, so I kept smoking instead”. They have tried one product, it wasn’t good enough, and they assume all other products will be just as bad. By restricting innovation, we limit the amount of better-quality devices on the market and increase the likelihood that a smoker looking to quit will come across a poor device and turn back to smoking.

Making it easy to stop smoking

Many smokers want to quit and we, as researchers, media representatives, public health officials and even members of the public, need to make it as easy as possible for them to do so. We need to be clearer in the information we provide, be more accepting of vaping and not limit products which could help the most addicted smokers. I still have hope that smoking will be stubbed out in my generation, and that e-cigarettes could be the disruptive technology needed to help us achieve this.