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Tom and Caroline

Electronic Cigarettes: Are they effective?

The Drugs and Addictions Research Group in the School of Psychology have just published their first ‘electronic cigarette’ study. 

These battery-operated devices are designed to resemble cigarette smoking by delivering nicotine via inhaled vapour without containing the harmful tars and carbon monoxide associated with tobacco smoking.  Whilst the World Health Organization have banned companies  making claims about their therapeutic success, most users state that they use the device to quit smoking. 

So are they effective?  We do not know yet whether the electronic cigarette (e-cigarette) provides a effective means of quitting as randomized controlled trials (RCTs) have not yet been completed (there is one underway in New Zealand).   Our study suggests however, that it can help to alleviate withdrawal symptoms and craving after a short period of deprivation.  We asked 86 participants to remain abstinent from smoking for a least one hour and rate their withdrawal symptom and craving before, and 20 minutes after, using an electronic cigarette for 5 minutes.  Although all e-cigarettes were tobacco flavoured, some contained nicotine and some didn’t (placebo).  For comparison purposes, a further group of participants just held the e-cigarette but didn’t use it. 

Compared to this ‘just hold’ group, those using the e-cigarette reported a significant reduction in craving and withdrawal symptoms.  For males, the nicotine e-cigarette was superior to placebo whilst females did just as well with the placebo.  Unlike other forms of nicotine replacement therapy (e.g. patch and gum), the e-cigarette delivers nicotine AND resembles the act of smoking thus providing the user with the ‘hand-mouth’ activity associated with tobacco smoking.  It is becoming increasingly recognized that these sensorimotor aspects of smoking may be an important aspect of smoking behaviour and our findings suggest that this might be more relevant for females. 

We also included a memory test in our study (remembering three letters whilst performing a distractor task which increased in length over consecutive trials).  Previous research has shown that memory and attention is worse during abstinence from smoking and can be restored after smoking a cigarette.  Participants who received the nicotine e-cigarette in this study did much better on this task compared to those who received placebo or who just held the e-cigarette.  This was particularly apparent at the longer interference intervals. 

Together, these findings suggest that the electronic cigarette has great potential as a quit smoking aid given that it can alleviate craving, withdrawal symptoms and the mild cognitive impairment associated with smoking deprivation.  Whether the placebo  is just as effective as the nicotine e-cigarette for female quitters is an interesting question which will remain unanswered until RCTs have been completed. 

Full article reference:  Dawkins, L., Turner, J., Hasna, S. & Soar, K. (2012)  The electronic-cigarette: Effects on desire to smoke, withdrawal symptoms and cognition.  Addictive Behaviors, 37: 970-973.

Or visit ROAR:  http://hdl.handle.net/10552/1568

Lynne

UEL’s Virtual Reality Research Making International Strides

Since 2003, I have been developing and refining a new tool for cognitive assessment of ‘higher mental functions’ and June 2012 has been a particularly good month for this research.

The human brain is a very complex organ, easily more complicated than the most sophisticated computers ever created. While the brain generally works as one unit, there are specialisations within it such that, for example, visual recognition occurs at the back of the brain roughly behind the ears. Relative to other mammals, the human frontal lobes (also known as the ‘pre-frontal cortex’ or PFC), occupy the largest proportion of the cortex, constitute one third of the brain, and have shown the greatest enlargement through evolution. Whilst more posterior areas of the brain are involved in primary aspects of mental abilities such as language, memory and vision, the PFC seems to play a more complex role in behaviour. The PFC acts as a kind of manager co-ordinating what the rest of the brain does and therefore is known as the ‘executive’ system; when the executive system is damaged, then a person can end up with a variety of problems in areas such as decision-making, planning, multi-tasking and adapting to new situations. This suggests that the PFC co-ordinates functioning at higher-levels of human behaviour.

The executive system can be affected in many different ways; for example strokes, brain surgery or virtually any form of closed head injury (as in a car crash or fall) can all damage the system. Additionally, due to the integrated manner in which the brain works and the fact that the PFC gathers information from other parts of the brain, any change in the system ‘downstream’ can have an impact on higher level functions. Therefore, for example, cognitive problems associated with conditions such as multiple sclerosis or a wide range of different forms of dementia will also have an executive component. Further, since it is believed that the frontal lobes are not fully formed until the early 20s, the executive system will correspondingly not be fully functional until this point in life. Indeed, most forms of behavioural disorders linked to development during childhood such as Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) are linked with poor executive functioning. Finally, due to the hormonal and blood circulation system within the brain, the PFCs are susceptible to the impact of a large range of chemicals.

Given the centrality of the PFC and executive system to so many aspects of behaviour, accurately being able to assess the impact on someone’s life of dysfunction to it is a primary aim of clinical neuropsychologists; once this impact is known then it can possibly determine the course of rehabilitation therapy &/or decisions about going back to work. Unfortunately, the currently available tools for assessing damage to the executive system are notoriously unreliable and this has can greatly affect adjustment to life post-injury. While a number of experimental paradigms have been created to develop theoretical models of the PFCs, they have been poor at assessing dysfunction. Even where tests have been developed specifically to assess clinical populations, their success has been mediocre at best and often the findings are not of great use for health professionals working with the affected individuals. So for example, most assessments will fail to detect deficits in a significant proportion of patients. In a classic example, Eslinger & Damasio (1985) studied a patient known as EVR who had undergone surgery to remove a tumour located in his frontal lobes. Following recovery from the surgery, the patient’s general intellect was unaffected but his ability to manage everyday behaviour was severely changed. Having been a successful accountant pre-operatively, he ruined himself financially within two years. In the same time, he managed to get divorced, married again and divorced again! At a daily level, he would become immersed in the most mundane tasks sometimes taking hours to make the simplest of decisions; eventually the patient had to live in a care home since he could not be trusted to manage his own affairs. Despite this catastrophic change in behaviour, EVR passed all the tests of executive functions that were available at the time. Even when failure on the tasks does occur, the results do not necessarily translate into real-world behaviour; in other words, the tests lack ‘ecological validity’ in that they seldom map onto the problems in everyday living that are common subsequent to PFC damage.

To address the limitations of currently available tests of executive function, I have developed a test known as JEF^© (the Jansari assessment of Executive Functions) has been developed using non-immersive virtual reality (Jansari, Agnew, Akesson & Murphy, 2004). JEF^© uses a standard laptop and is presented as a computer-game with the participant navigating around the virtual environment of an office performing a number of tasks known to rely on intact executive functions. JEF^© is able to successfully detect the executive impairments of patients with brain injury that standard clinical tests fail to do (Jansari et al, 2004). Further, since an individualised profile is produced for each person showing their strengths and weaknesses, this has proven beneficial for the patients to understand their cognitive problems post-injury which itself can have significant positive impacts on psychosocial adjustment; additionally, these profiles can be used by rehabilitation therapists who are attempting to ameliorate the difficulties faced by the patient as well as aiding them to re-enter the workforce (or find gainful employment which can often be severely affected by brain injury).

Following the initial success of JEF^© with patients with brain damage, further studies have shown that it can be used in healthy brain-intact individuals to investigate the impact of chemical substances on higher mental functions. Montgomery, Hatton, Fisk, Ogden & Jansari (2010) have shown the negative impact of the recreational drug ecstasy while Montgomery, Ashmore & Jansari (2011) showed similar with cannabis. Montgomery, Seddon, Fisk, Murphy & Jansari (2012) have also shown that even an amount of alcohol that is within the legal limits for driving in the UK can significantly lower executive performance. Collaborating with one of our colleagues Lynne Dawkins and a colleague Trudi Edginton at Westminster University along with an MSc student, we have demonstrated that while heavy smoking impairs executive performance, nicotine itself can have facilitatory effects even in non-smokers (Jansari, Froggatt, Edginton & Dawkins, 2011). Since it is found that fewer smokers develop Senile Dementia of the Alzheimer’s Type (SDAT) and that nicotine can reduce agitation in dementia, these potentially positive effects of nicotine could have significant impacts on development of drug therapies to deal with dementia. JEF^© has also been used to demonstrate that Androgen-Deprivation Therapy (ADT) which is used for treating prostate cancer that has spread beyond the prostate gland significantly lowers executive performance; patients anecdotally report these problems but this is one of the first times that it has been demonstrated objectively possibly because of the insensitivity of the assessments used previously (Jansari, Mills, Edginton & Green (under review)). Since prostate cancer is the most common form of cancer in the UK and in many Western countries , large-scale drug trials are planned to evaluate this further. Finally, in a recent study in collaboration with Caroline Edmonds and an MSc student aided by the excellent programming skills of Tony Leadbetter we have developed a children’s version of the assessment, JEF-C^© to assess the development of executive functions during adolescence (Jansari, Gordon, Edmonds & Leadbetter, 2012). This is currently being used to investigate higher mental functions in children with ASD, ADHD and Traumatic Brain Injury (TBI).

Following the success of JEF^© a Swedish BSc student translated it into her native language and ran a study with a collaborator in Stockholm to look at how culturally appropriate it was in countries where English is not the first language; using this translated version, we compared Swedish TBI patients with matched controls. We found a significant difference between the two groups showing the utility of JEF^© in other cultures (Jansari, Debreceni, Bartfai & Eriksson, 2008). As a result, JEF^© has now been translated into French, Finnish, Dutch and Portuguese with trials underway to collect normative data in Belgium (French & Dutch), Finland (Finnish) and Brazil (Portuguese).

In June, I visited my collaborators in Belgium where data collection is going well for the French version and there are plans to see if the assessment can be used to look at cognitive impairments related to depression; similarly, research with the Dutch version is going well with plans to see if the assessment can be used with other neuropsychological disorders. Finally, I have been invited by a network of neuropsychologists in India in Mumbai, Delhi, Kolkota and Bangalore to be a co-applicant on a government grant to explore how JEF^© and JEF-C^© can be adapted for use in an Indian population.

So these are exciting times for UEL’s virtual reality research......

Ash

Hydration for Health Conference

Paula and I were invited to attend the Hydration for Health Annual Scientific Conference in Evian, France, funded by Danone Waters and Danone Research. The location was the Hotel Royal Evian, and the conference made the most of beautiful views from the hotel over Lake Leman, with cocktails and canapés on the terrace. This was the most relevant conference for our research and, with all the leaders in the hydration field present, provided a great opportunity to network. It was also a really sociable conference.

The programme considered hydration and thirst, kidney health, trends in fluid consumption, and ways to improve hydration status. While there were no papers specifically on hydration and cognition, all of the talks gave us lots of ideas for studies or different approaches to analysis. There were two sessions that particularly stood out for us.

Talks on the thirst mechanism addressed the question, “Why are we here if the thirst system works perfectly?” and asked, “what happens if we don’t drink?” and “why don’t people drink?” Suggestions were that unlike animals, which are adept at drinking when they are thirsty, humans have become dishabituated to the feeling of thirst. Consequently people do not drink enough which over a long period could lead to health problems. Experimental evidence on thirst was reviewed, including ways in which manipulating the way that we satiate thirst, such as consuming large amounts of fluid or regular sipping, affect exercise performance. Evidence on hydration in older adults, who are a high risk group for dehydration, was also presented. Some of the reasons for this high risk were discussed, including fluid preference, lifetime hydration habits and the ageing process, including diseases that influence hydration.

A session on how to improve hydration status was really useful to us because of its focus on measuring hydration using assessment of urine osmolality, which is one measure that we are currently using.  These were complex studies involving strategies for behavioural change aimed at increasing water consumption in adults, which seemed to have a good level of success. As well as providing useful technical information, it gave us ideas for ways to present data figuratively that Paula is likely to use in her PhD.

The poster stands were really varied. Of particular interest to us was a set of posters by Joan Gandy, a UK dietician and nutritionist, who reported data on worldwide fluid intake studies. The methodological detail on how this was achieved was particularly useful for us. There are clear differences between countries in the types of beverages consumed. In the UK most of our beverages are taken in the form of hot drinks, suggesting that we really are a nation of tea drinkers, along with Poland, Germany, Japan and Uruguay (or perhaps coffee drinkers…).

Caroline and Paula