Dr Louise Thornton

Objective: Research shows highly palatable foods can elicit addictive eating behaviours or 'food addiction'. Early adolescence is theorised to be a vulnerable period for the onset of addictive eating behaviours, yet minimal research has examined this. This study explored the prevalence and correlates of addictive eating behaviours in a large early adolescent sample. Methods: 6640 Australian adolescents (Mage = 12.7 ± 0.5, 49%F) completed an online survey. Addictive eating was measured with the Child Yale Food Addiction Scale (YFAS-C). Negative-binomial generalised linear models examined associations between addictive eating symptoms and high psychological distress, energy drink consumption, sugar-sweetened beverage (SSB) consumption, alcohol use, and cigarette use. Results: Mean YFAS-C symptom criteria count was 1.36 ± 1.47 (of 7). 18.3% of participants met 3+ symptoms, 7.5% endorsed impairment and 5.3% met the diagnostic threshold for food addiction. All examined behavioural and mental health variables were significantly associated with addictive eating symptoms. Effects were largest for high psychological distress and cigarette use; with those exhibiting high psychological distress meeting 0.65 more criteria (95%CI = 0.58¿0.72, p < 0.001) and those who smoked a cigarette meeting 0.51 more criteria (95%CI = 0.26¿0.76, p < 0.001). High psychological distress and consumption of SSB and energy drinks remained significant when modelling all predictors together. Conclusion: In this large adolescent study, addictive eating symptoms were common. Further research should establish directionality and causal mechanisms behind the association between mental ill-health, alcohol and tobacco use, and addictive eating behaviours. Cross-disciplinary prevention initiatives that address shared underlying risk factors for addictive eating and mental ill-health may offer efficient yet substantial public health benefits.

Background: Digital approaches are frequently described as an ideal way to engage young people with health interventions. However, uptake and adherence to these interventions is often poor. Identifying factors associated with engagement, and the best methods to encourage engagement, is a critical issue for the digital health field. This presentation will discuss young peoples' engagement with a healthy lifestyles app (the Health4Life app). Methods: The Health4Life app is a self-monitoring app for adolescents targeting six key health risk behaviours. Participants were students (n=3610) and teachers randomized to the intervention condition of a cluster randomized controlled trial of the 'Health4Life Initiative'. Students completed an online baseline assessment assessing their health behaviours, mental health and socio-demographic factors and were provided with access to the Health4Life app to complement the in-class Health4Life module. Teachers were asked to complete a logbook documenting if they prompted students to download and use the app. The date and time users accessed the Health4Life app and any self-reported data were also automatically collected. A series of hierarchical regressions were performed to ascertain factors associated with the likelihood that students accessed the app (uptake) and factors associated with how much and for how long students used the app and how much information they entered (use). Results: Of the 3610 students provided access to the Health4Life app, 407 accessed it. Factors associated with increased likelihood to access the app included teacher prompts, living in a major city and being female. Psychological distress was not a significant predictor of likelihood to access the app. When investigating factors potentially associated with app use all models were found not to be significant. Conclusion: Teachers are critical in the process of prompting at least initial engagement with health interventions within a school-based context and the need for targeted engagement strategies for a number of sub-groups of young people (e.g. males, those in regional communities). There is a need for more research investigating predictors of actual app use and engagement. Implications: These findings indicate that many clinical factors (e.g., psychological distress) may not be significant barriers to adolescents engaging with digital health interventions. Researchers should carefully consider the implications of excluding participants experiencing mental illness or psychological distress, as is common in research. The results also highlight the importance of researchers establishing good relationships with teachers and clinicians working in a school-based context.

Background: Online alcohol sales are experiencing rapid growth in many places, accelerated by the COVID-19 pandemic, prompting new laws and regulations. There are no comprehensive and systematic analyses of the laws or their effectiveness. Objective: To summarise international policies governing online alcohol sale and delivery, including changes occurring with COVID-19, and examine available evidence of retailer compliance with such policies. Method: A policy review of 77 jurisdictions in six English-speaking OECD countries: United States, Canada, United Kingdom, Ireland, Australia and New Zealand. We synthesised policies according to ten elements identified as potentially relevant for public health regulation. A systematic literature review of compliance evaluations in Medline, Medline Epub, EMBASE, CINAHL, Web of Science and Google Scholar. Results: 72 of 77 jurisdictions permitted online alcohol sales and home delivery. Few jurisdictions require age verification at the time of purchase (n = 7), but most require it at delivery (n = 71). Since the COVID-19 pandemic began, most jurisdictions (69%) have either temporarily or permanently relaxed liquor regulations for alcohol home delivery. Three articles examined retailer compliance with age restrictions and found relatively low compliance (0%-46%). Conclusion: Many jurisdictions permit the online sale and delivery of alcohol, but regulation of these sales varies widely. In most, regulations do not meet the same standard as bricks-and-mortar establishments and may be insufficient to prevent youth access.

Chronic diseases are the leading cause of disability and mortality globally. In Australia, females are at heightened risk. This research explored the prevalence, patterns, and correlates of six key risk behaviors (physical inactivity, poor diet, recreational screen time, inadequate sleep, alcohol use, and smoking) among adolescent females and whether knowledge of health guidelines was associated with adherence. Adolescent females completed an anonymous online questionnaire (N = 687; Mage = 13.82). Logistic regression assessed the association between knowledge and adherence. A Latent Class Analysis (LCA) and three-step procedure identified risk behavior clusters and their correlates. Despite positive health self-ratings (77% good/very good), most participants reported insufficient moderate-to-vigorous physical activity (MVPA; 89%), vegetable intake (89%), and excessive screen time (63%). Knowledge of guidelines was associated with adherence for MVPA, vegetable intake, sleep, and alcohol abstinence. Three classes emerged: "moderate risk" (76%), "relatively active, healthy eaters" (19%), and "excessive screen users" (5%). These risk-behavior clusters were associated with perceived value of academic achievement and physical wellbeing. Adolescent females commonly perceive they are in good health, despite engaging in unhealthy behaviors. Public health interventions should utilize effective behavior change strategies, adopt a multiple health behavior change approach (MHBC), and be tailored to specific risk profiles and values among females.

Adolescent substance use occurs within a rapidly changing social and environmental context. Prevention programs need to remain relevant and engaging for young people and include their perspective. The Climate Schools: Alcohol and Cannabis online prevention program was co-designed with adolescents in 2007 and has demonstrated its effectiveness in previous randomised controlled trials. Eleven years on, the current study conducted two focus groups with adolescents who had received the Climate Schools program, to obtain feedback regarding the acceptability and relatability of the program. A mixed-methods design (including a written questionnaire and class discussion) was employed to collect both quantitative and qualitative data from participants and an inductive analysis was undertaken to extract major themes. Participants reported an appreciation for the delivery mode (i.e., visual learning style and online platform) and said their knowledge of alcohol and cannabis had improved following the program. Participants also provided suggestions for increasing the relatability of the language and the characters by providing additional backstories and increasing the level of engagement with the program by reducing the length of individual lessons. The feedback obtained in this investigation will be instrumental in the refinement and future development of the Climate Schools program. More broadly, this study reinforces the importance of co-design and revision of substance misuse prevention programs, to ensure their continued engagement and efficacy.

Introduction and Aims: Online alcohol sales have experienced rapid growth in Australia in recent years, averaging 14% annual growth over the last 5 years. This study aims to provide information about the advertised sales and delivery practices of online alcohol retailers in Australia and the potential implications for alcohol-related harm. Design and Methods: A cross-sectional website content analysis of the 65 most visited Australian alcohol delivery websites. Data extracted for content analysis from each of the included websites fell under six broad categories: product range; average prices; promotions and discounting; payment and delivery; age verification methods; and policy statements. Results: Online alcohol retailers offer a variety of alcohol products cheaply, with around 20% selling a 750 mL bottle of wine for under AUD$5. Most (81.5%) offered discounts for purchasing greater quantities and (89.2%) offered visitors an opportunity to sign up to receive discounts and promotions directly via email. Concerningly, 13.8% of websites allowed customers to purchase alcohol using a 'buy now, pay later' scheme such as AfterPay or Zip Pay. Delivery in under two hours was available from 12% of retailers. Most retailers (75.4%) advertised a willingness to leave alcohol unattended at an address. Discussion and Conclusions: Online alcohol retailers offer a variety of alcohol products cheaply, accompanied by heavy promotions and discounting. Most retailers advertise a willingness to leave alcohol unattended at an address without having verified the purchasers age, which raises concerns about access to minors. Improved regulation of this growing industry in Australia is required. [Colbert S, Thornton L, Richmond R. Content analysis of websites selling alcohol online in Australia. Drug Alcohol Rev 2020].

Background: Smartphone applications (apps) designed to assist users to reduce hazardous and harmful alcohol consumption show potential as an inexpensive alternative to traditional brief intervention in primary care. The aim of this paper is to provide an overview of the literature on alcohol reduction apps and the availability of evidenced-based apps on top commercial app stores. Methods: We reviewed literature through to December 2019 using the databases PubMed, MEDLINE, PsycINFO and Google Scholar and keyword search terms smartphone/mobile/phone AND application/app AND alcohol. Articles were included if the primary intervention was a smartphone app and the study measured participant changes in frequency or volume of alcohol consumption. Results: 21 relevant articles were identified that evaluated 19 unique smartphone apps. Of the 19 unique apps, seven were designed for use among youth and 12 in adult populations. The available evidence for the efficacy of alcohol reduction apps among youth is inconclusive, with results from these evaluations not showing a clear benefit in reducing alcohol consumption compared to control groups. The results of apps designed for adult populations appears more promising, but results are still mixed. Of the 19 alcohol reduction apps that have been evaluated only eight of these are currently publicly available in commercial app stores. Of these eight apps, only four were demonstrated in the literature to assist with reducing alcohol consumption. Conclusion: The evidence for alcohol reduction apps is promising but inconclusive. Few apps that have been evaluated in the scientific literature are currently available for download in commercial app stores.

Background: Digital mental health interventions can be effective for treating mental health problems, but uptake by consumers and clinicians is not optimal. The lack of an accreditation pathway for digital mental health interventions is a barrier to their uptake among clinicians and consumers. However, there are a number of factors that may contribute to whether a digital intervention is suitable for recommendation to the public. The aim of this study was to identify the types of evidence that would support the accreditation of digital interventions. Method: An expert workshop was convened, including researcher, clinician, consumer (people with lived experience of a mental health condition) and policymaker representatives. Results: Existing methods for assessing the evidence for digital mental health interventions were discussed by the stakeholders present at the workshop. Empirical evidence from randomised controlled trials was identified as a key component for evaluating digital interventions. However, information on the safety of users, data security, user ratings, and fidelity to clinical guidelines, along with data from routine care including adherence, engagement and clinical outcomes, were also identified as important considerations when evaluating an intervention. There are considerable challenges in weighing the evidence for a digital mental health intervention. Conclusions: Empirical evidence should be the cornerstone of any accreditation system to identify appropriate digital mental health interventions. However, robust accreditation systems should also account for program and user safety, user engagement and experience, and fidelity to clinical treatment guidelines.

Background: Lifestyle risk behaviours typically emerge during adolescence, track into adulthood, and commonly co-occur. Interventions targeting multiple risk behaviours in adolescents have the potential to efficiently improve health outcomes, yet further evidence is required to determine their effect. We reviewed the effectiveness of eHealth school-based interventions targeting multiple lifestyle risk behaviours. Methods: In this systematic review and meta-analysis, we searched Ovid MEDLINE, Embase, PsycINFO, and the Cochrane Library databases between Jan 1, 2000, and March 14, 2019, with no language restrictions, for publications on school-based eHealth multiple health behaviour interventions in humans. We also screened the grey literature for unpublished data. Eligible studies were randomised controlled trials of eHealth (internet, computers, tablets, mobile technology, or tele-health) interventions targeting two or more of six behaviours of interest: alcohol use, smoking, diet, physical activity, sedentary behaviour, and sleep. Primary outcomes of interest were the prevention or reduction of unhealthy behaviours, or improvement in healthy behaviours of the six behaviours. Outcomes were summarised in a narrative synthesis and combined using random-effects meta-analysis. This systematic review is registered with PROSPERO, identifier CRD42017072163. Findings: Of 10 571 identified records, 22 publications assessing 16 interventions were included, comprising 18 873 students, of whom on average 56·2% were female, with a mean age of 13·41 years (SD 1·52). eHealth school-based multiple health behaviour change interventions significantly increased fruit and vegetable intake (standard mean difference 0·11, 95% CI 0·03 to 0·19; p=0·007) and both accelerometer-measured (0·33, 0·05 to 0·61; p=0·02) and self-reported (0·14, 0·05 to 0·23; p=0·003) physical activity, and reduced screen time (-0·09, -0·17 to -0·01; p=0·03) immediately after the intervention; however, these effects were not sustained at follow-up when data were available. No effect was seen for alcohol or smoking, fat or sugar-sweetened beverage or snack consumption. No studies examined sleep or used mobile health interventions. The risk of bias in masking of final outcome assessors and selective outcome reporting was high or unclear across studies and overall we deemd the quality of evidence to be low to very low. Interpretation: eHealth school-based interventions addressing multiple lifestyle risk behaviours can be effective in improving physical activity, screen time, and fruit and vegetable intake. However, effects were small and only evident immediately after the intervention. Further high quality, adolescent-informed research is needed to develop eHealth interventions that can modify multiple behaviours and sustain long-term effects. Funding: Paul Ramsay Foundation and Australian National Health and Medical Research Council.

Early initiation of substance use significantly increases one's risk of developing substance use dependence and mental disorders later in life. To interrupt this trajectory, effective prevention during the adolescent period is critical. Parents play a key role in preventing substance use and related harms among adolescents and parenting interventions have been identified as critical components of effective prevention programs. Despite this, there is currently no substance use prevention program targeting both students and parents that adopts online delivery to overcome barriers to implementation and sustainability. The Climate Schools Plus (CSP) program was developed to meet this need. CSP is an online substance use prevention program for students and parents, based on the effective Climate Schools prevention program for students. This paper describes the development of the parent component of CSP including a literature review and results of a large scoping survey of parents of Australian high school students (n = 242). This paper also includes results of beta-testing of the developed program with relevant experts (n = 10), and parents of Australian high school students (n = 15). The CSP parent component consists of 1) a webinar which introduces shared rule ranking, 2) online modules and 3) summaries of student lessons. The parent program targets evidence-based modifiable factors associated with a delay in the onset of adolescent substance use and/or lower levels of adolescent substance use in the future; namely, rule-setting, monitoring, and modelling. To date, this is the first combined parent-student substance use prevention program to adopt an online delivery method.

Objectives: This review aimed to identify free, high-quality, smoking cessation mobile applications (apps) that adhere to Australian smoking cessation treatment guidelines. Methods: A systematic search of smoking cessation apps was conducted using Google. The technical quality of relevant apps was rated using the Mobile Application Rating Scale. The content of apps identified as high quality was assessed for adherence to smoking cessation treatment guidelines. Results: 112 relevant apps were identified. The majority were of poor technical quality and only six 'high-quality' apps were identified. These apps adhered to Australian treatment guidelines in part. The efficacy of two apps had been previously evaluated. Conclusions: In lieu of more substantial research in this area, it is suggested that the high-quality apps identified in this review may be more likely than other available apps to encourage smoking cessation. Implications for public health: Smoking cessation apps have the potential to address many barriers that prevent smoking cessation support being provided; however few high-quality smoking cessation apps are currently available in Australia, very few have been evaluated and the app market is extremely volatile. More research to evaluate smoking cessation apps, and sustained funding for evidence-based apps, is needed.

It is unclear whether individuals searching the Internet for assistance with thoughts of suicide are likely to encounter predominantly helpful or harmful resources. This study investigated websites retrieved by searching Google for information and support for suicidal thoughts. Google searches retrieved a high percentage of irrelevant websites (26%, n¿=¿136). Of the 329 relevant websites retrieved, the majority were suicide preventive (68%); however, a considerable proportion of sites expressed mixed (22%) or neutral (8%) suicide attitudes, and 1% were explicitly pro-suicide. The results highlight a need for suicide prevention organization websites to be made more easily accessible. In the meantime, clinicians should be aware of appropriate websites to recommend to clients.

DESIGN AND METHODS: Participants were recruited via an advertisement on Facebook, a local research register and university psychology courses. Participants completed a self-report survey regarding substance use, history of mental health issues and current psychological distress.

Recruiting participants is a challenge for many health, medical and psychosocial research projects. One tool more frequently being used to improve recruitment is the social networking website Facebook. A systematic review was conducted to identify studies that have used Facebook to recruit participants of all ages, to any psychosocial, health or medical research. 110 unique studies that used Facebook as a recruitment source were included in the review. The majority of studies used a cross-sectional design (80%) and addressed a physical health or disease issue (57%). Half (49%) of the included studies reported specific details of the Facebook recruitment process. Researchers paid between $1.36 and $110 per completing participants (Mean = $17.48, SD = $23.06). Among studies that examined the representativeness of their sample, the majority concluded (86%) their Facebook-recruited samples were similarly representative of samples recruited via traditional methods. These results indicate that Facebook is an effective and cost-efficient recruitment method. Researchers should consider their target group, advertisement wording, offering incentives and no-cost methods of recruitment when considering Facebook as a recruitment source. It is hoped this review will assist researchers to make decisions regarding the use of Facebook as a recruitment tool in future research.

Background: Depression and binge drinking behaviours are common clinical problems, which cause substantial functional, economic and health impacts. These conditions peak in young adulthood, and commonly co-occur. Comorbid depression and binge drinking are undertreated in young people, who are reluctant to seek help via traditional pathways to care. The iTreAD project (internet Treatment for Alcohol and Depression) aims to provide and evaluate internet-delivered monitoring and treatment programs for young people with depression and binge drinking concerns. Methods: Three hundred sixty nine participants will be recruited to the trial, and will be aged 18-30 years will be eligible for the study if they report current symptoms of depression (score 5 or more on the depression subscale of the Depression Anxiety Stress Scale) and concurrent binge drinking practices (5 or more standard drinks at least twice in the prior month). Following screening and online baseline assessment, participants are randomised to: (a) online monthly self-assessments, (b) online monthly self-assessments¿+¿12-months of access to a 4 week online automated cognitive behaviour therapy program for binge drinking and depression (DEAL); or (c) online monthly assessment¿+¿DEAL¿+¿12-months of access to a social networking site (Breathing Space). Independent, blind follow-up assessments occur at 26, 39, 52 and 64-weeks post-baseline. Discussion: The iTreAD project is the first randomised controlled trial combining online cognitive behaviour therapy, social networking and online monitoring for young people reporting concerns with depression and binge drinking. These treatments represent low-cost, wide-reach youth-appropriate treatment, which will have significantly public health implications for service design, delivery and health policy for this important age group. Trial registration: Australian and New Zealand Clinical Trials Registry ACTRN12614000310662. Date registered 24 March 2014.