People with severe mental illness (SMI) die on average 15–20 years earlier than the general population, largely due to poor physical health. NICE guidance mandates annual physical health checks (PHCs) for individuals with SMI, including the “Core 6” parameters (alcohol and smoking status, blood pressure, body mass index, lipid profile and HbA1c or blood glucose). NICE also requires regular physical health monitoring for those prescribed antipsychotic medication. This audit aimed to assess PALT’s compliance with NICE standards and identify barriers to completion.

A retrospective clinical audit was conducted. 100 patients under the care of PALT for at least 12 months who were prescribed antipsychotic medication were included. Data was obtained from patient records between March–April 2025. Outcomes measured included completion of coded annual SMI PHCs, completion of Core 6 components, antipsychotic monitoring blood tests, and ECGs within the preceding 12 months. Engagement with PALT and evidence of invitation to SMI PHCs were also recorded. Results were analysed and compared against NICE standards and previous audits.

Overall, 59% of patients had an SMI PHC in the preceding 12 months, despite 98% engaging with PALT during the same period. Among those without a completed PHC, 95% had recent contact with PALT. Of the 41% who did not attend SMI PHC, only 34% had documented evidence of invitation.

Completion of individual ‘Core 6’ components was higher, ranging from 78–84%. Annual antipsychotic blood test monitoring showed good compliance at 79–84%, demonstrating improvement from previous audits. However, only 63% had an annual ECG. Even for antipsychotics with moderate-high risk of respective side effects, metabolic monitoring was suboptimal (46%), and prolactin monitoring was low (27%).

Although compliance with antipsychotic blood monitoring is improving, completion of annual SMI PHCs remains suboptimal. Better completion of individual ‘Core 6’ components suggests that this activity is being carried out, but in a fragmented manner. The high engagement with PALT relative to SMI PHC completion suggests a missed opportunity to integrate PHC with mental health appointments. Our recommendations focus on improving awareness and accurate identification of patients requiring SMI registration and physical health monitoring as well as strengthening communication with primary care and the SMI PHC team. Additionally, building capacity within PALT to deliver physical health assessments, blood tests and ECGs, may improve engagement and completion. Continued audit and wider dissemination of findings is needed for sustained improvement in physical healthcare for people with SMI.

Major depressive disorder (MDD) is the leading cause of disability worldwide, affecting roughly 322 million people. Recently, doses of psilocybin have shown promise in treating mood disorders, sparking interest in other dosing practices. According to anecdotal reports and observational studies, microdosing psilocybin yields benefits to mental health; however, rigorously controlled trials have failed to produce compelling evidence for this.

To conduct a phase II, double-blind, placebo-controlled, randomised partial crossover trial to compare microdosing psilocybin to placebo for MDD, evaluating its safety, tolerability and preliminary antidepressant effects.

Forty adults with MDD will be randomised to four doses of psilocybin (2 mg) or placebo (maltodextrin) once weekly over 4 weeks, then four doses of psilocybin (2 mg) once weekly for an additional 4 weeks. The primary efficacy end-point will be change in depression symptoms, as measured at baseline (0 weeks), after the experimental phase (4 weeks), and after the open-label phase (8 weeks). A battery of mood, well-being, attention, creativity, mindfulness and pro-sociality measures will be administered at each time point. Follow-ups will occur every 6 months for up to 2 years after the trial start date, as part of a long-term extension study.

The results of the primary outcome of this trial will be published as a manuscript in a peer-reviewed science or medical journal regardless of the magnitude or direction of effect.

Findings will inform future research on microdosing psilocybin for MDD, regarding dose regimens, effect sizes and expectancy bias. Findings will also facilitate discussions on the comparable benefits of sub- versus threshold doses of psilocybin and the therapeutic value of radically altered perception.

ClinicalTrials.gov identifier: NCT05259943.

Negative neuropsychiatric symptoms, such as apathy, are a core feature of Alzheimer’s disease. Previous studies have shown that levels of fasting plasma proline and differential activity of the catechol-O-methyltransferase (COMT) enzyme, which metabolises dopamine, influence negative symptoms in patients with severe psychiatric illness and those at risk for psychosis. For patients with the COMT high activity enzyme (as assessed via the COMT Val158Met polymorphism), high plasma proline was associated with less severe negative symptoms. Conversely, high proline was associated with more severe negative symptoms in patients with the low activity COMT enzyme.

In this proof-of-concept cross-sectional study, we tested the hypothesis that proline and COMT Val158Met interact to modify negative symptom severity across neuropsychiatric disease, specifically now investigating patients with Alzheimer’s disease dementia.

Least Absolute Shrinkage and Selection Operator regression was employed to model the interaction between proline and COMT on negative symptoms in n = 50 patients with probable Alzheimer’s disease or mild cognitive impairment with underlying Alzheimer’s disease biomarkers.

The proline × COMT interaction significantly predicted symptoms as assessed via the negative items of the Positive and Negative Symptom Scale, interaction coefficient 0.025, p = 0.031, with a trend toward significance when assessed via the Scale for Assessment of Negative Symptoms in Alzheimer’s disease, interaction coefficient 0.075, p = 0.055. Higher proline was beneficial for both Val/Val and Val/Met dementia patients, but detrimental to patients with the low activity Met/Met COMT enzyme.

Higher proline also has opposing effects on negative symptoms by COMT genotype in patients with dementia and further supports the development of therapeutics aimed at modulating this interaction pathway across neuropsychiatric disorders.

Despite growing recognition as a public health concern, the burden of autism spectrum disorder (ASD) in Ethiopia remains poorly characterised owing to limited diagnostic capacity and epidemiological data, hampering evidence-based policy and intervention planning.

This study aimed to quantify the longitudinal burden of ASD in the Ethiopian paediatric population from 1990 to 2023 and project future trends to 2050 to inform national health strategies.

Using Global Burden of Disease (GBD) 2023 data, we estimated ASD prevalence, incidence and disability-adjusted life-years (DALYs) among Ethiopian children and adolescents. Trends were analysed using joinpoint regression and future burden was forecast to 2050 using autoregressive integrated moving average (ARIMA) modelling.

Between 1990 and 2023, ASD prevalence increased by 155%, from 271 805 to 693 644 cases. Correspondingly, the age-standardised prevalence rate increased from 950 to 1185 cases per 100 000 population. Although annual incident cases nearly doubled (from 24 576 to 47 274), the age-standardised incidence rate declined slightly from 86 to 81 cases per 100 000. DALYs increased by 162% to 134 386 in 2023, while the age-standardised DALY rate increased from 179 to 230 per 100 000. Projections to 2050 suggest that the overall ASD burden will persist, with a stable incidence rate but an increasing DALY rate.

Nearly 700 000 Ethiopian children and adolescents were living with ASD in 2023. The significant increases in prevalence and DALYs over three decades underscore the urgent need for a comprehensive national strategy, including enhanced diagnostic infrastructure and early intervention programmes.

Acute behavioural disturbance (ABD) is a contested term describing severe agitation and behavioural dysregulation, often preceding sudden death. Concerns regarding diagnostic clarity, racial bias and law enforcement restraint have been raised, and its clinical and forensic utility have been questioned.

To characterise fatal ABD cases following substance use to inform clinical management, forensic interpretation and policy.

Fifty-one deaths consistent with ABD were identified from the National Programme on Substance Use Mortality (NPSUM) using textual screening and Royal College of Emergency Medicine and Faculty of Forensic & Legal Medicine criteria.

All cases met Royal College of Emergency Medicine criteria and most met Faculty of Forensic & Legal Medicine (84.3%) criteria. Agitation was the most frequently observed sign (86.3% of cases). Stimulants, particularly cocaine and amphetamines, were also detected in 86.3% of cases, but not necessarily in the same cases, and the rate of stimulant detection was almost three times higher than that in in the broader NPSUM cohort (32.1%). Cocaine concentrations were higher in ABD cases than in all NPSUM cocaine-related deaths (0.848 mg/L v. 0.105 mg/L). Compared with the NPSUM cohort, ABD decedents were significantly younger (30.2 ± 7.5 v. 40.5 ± 13.4) and more likely to be male (92.2 v. 73.4%), from racially minoritised backgrounds (21.7 v. 3.9%) and living in deprived areas (87.0 v. 75.9%).

Variability in diagnostic criteria highlights a need for clearer ABD definitions. Toxicology testing may assist in refining the ABD construct, but its results must be interpreted within broader clinical and social contexts. These findings support avoiding use of ABD as a stand-alone cause of death but retaining it as a clinical descriptor prompting urgent treatment, monitoring and reduced reliance on prolonged restraint.

Functional neurological disorder (FND) is a common neurological presentation and can be associated with high disability, high healthcare costs and difficulty accessing treatment. Effective treatments are still being established. A feasibility study evaluating eye movement desensitisation and reprocessing (EMDR) therapy as a treatment for FND (MODIFI) demonstrated positive outcomes. The experiences of EMDR for people with FND have not been previously reported.

We aimed to explore the experiences of participants who had completed EMDR therapy in the MODIFI trial.

Participants who completed EMDR therapy in MODIFI were invited to take part in semi-structured interviews on completion of the trial. Eleven participants consented to take part and were interviewed. Interviews were analysed with reflexive thematic analysis.

Analysis was organised into four main domains: (a) expectations before the trial; (b) preparedness for EMDR; (c) mysterious but unique journey and (d) it was hard, but worth it – ‘a rewarding challenge’. Within these domains, we identified ten themes.

Participants reported limited understanding of why or how EMDR might be helpful, but were still motivated to take part. Participants expressed that they had felt anxious about focusing on memories of past experiences. However, they described feeling safe and in control in the therapy, despite it being difficult at times. Overall, participants reported positive effects, and that perceived costs were worthwhile. These results add further support that a full-scale trial evaluating FND-focused EMDR is justified.

The effectiveness of electroconvulsive therapy (ECT) for depression strongly depends on patient characteristics. Clinical factors may increase (e.g. age, psychotic symptoms) or decrease (e.g. episode duration) response rates.

This prospective study aimed to develop an instrument for the prediction of ECT response in patients with unipolar depression.

N = 45 patients were assessed using the Göttingen Response to ECT Assessment Tool (GREAT; seven items, 0 to 14 points). Clinical outcome was measured using the Montgomery Åsberg Depression Rating Scale (MADRS). Response was defined as ≥ 50% MADRS-improvement or a clinical global impression improvement (CGI-I) score ≤ 2. Analyses were conducted between responders and non-responders.

Results showed a high correlation between GREAT-score and dichotomous response (r = 0.585) as well as MADRS-improvement (r = 0.554, both p < 0.001). Receiver operating characteristic (ROC)-analysis yielded an area under the curve (AUC) of 0.841 (asymptotic significance: p < 0.001). A cut-off point at ≥7 points predicted ECT response in individual cases with 80% accuracy. GLM-analyses showed a significantly better MADRS-improvement for patients with a GREAT-score ≥ 7 v. < 7 (interaction-effect: p < 0.001).

Our prospective study shows that an instrument consisting of seven clinical items is able to predict ECT response in depression with good accuracy. Limitations include a relatively small sample size and the lack of further potential predictors suggested by recent studies. GREAT will thus be modified to further improve its accuracy. Currently, it may give clinicians a relevant estimate of the likelihood and the extent of the individual response to ECT.

The global burden of dementia is escalating rapidly, with prevalence estimates rising from 57.4 million in 2019 to a projected 152.8 million by 2050. This increase carries profound economic implications; direct and indirect costs are forecasted to consume approximately 0.5% of global GDP by 2050. Health economic evaluation can support efficient allocation of resources but key challenges remain in determining what outcomes are valued and how. We discuss critically the role of the life course approach in informing health economic evaluations.

Various methods exist for determining the relative costs and benefits of different treatment approaches. Relatively simple methods use pre-determined quality of life values for different stages of dementia to model the ‘utilities’ generated by treatment. The more recent ICECAP approach includes a broader range of outcomes than just health states by considering aspects of capability.

Despite these innovations in determining health outcome measures challenges remain. Models must account for complex interactions between symptoms, disease progression and quality of life. Another challenge is accounting for the “Proxy-Patient” gap, where caregiver reports often diverge from patient experiences. Furthermore,economic models can struggle with the valuation of “process utility” and the difficulties of extrapolating data from brief clinical studies into long-term disease models spanning many years.

The Life Course Approach:Our work proposes integrating a ‘life course’ perspective into health economic approaches to better understand dementia within the context of a patient’s entire life. By utilizing the concepts of “Trajectories and Transitions”,economists can evaluate how dementia disrupts expected life paths–such as the loss of a planned retirement or the inability to fulfil the role of a grandparent. Additionally, the concept of “Linked Lives” offers insight into the social interdependencies that shape the “Proxy-Patient” gap. Qualitive methods offer an important lens to investigate these problems.

Incorporating life course and qualitative approaches could provide a more robust framework for valuing preferences in dementia. By capturing the impact of disrupted life expectations and social interconnectedness, economic analyses can more accurately reflect the true impact of the disease, leading to more equitable and efficient resource distribution.

Virtual reality is a promising intervention for schizophrenia spectrum disorders (SSDs), offering immersive environments to support therapy. However, evidence for its effectiveness across symptom domains remains inconsistent.

To assess the effectiveness of virtual reality-based therapies (VRT) for SSDs on symptomatology and psychosocial functioning compared with control conditions.

A systematic review and meta-analysis of controlled trials using virtual reality for individuals with SSDs was conducted. Searches were conducted across PubMed, PsychINFO, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials, from inception to March 2025. Random-effects models estimated pooled effect sizes (Hedges’ g) across outcomes, including Positive and Negative Symptom Scale, depression, paranoia and cognition. Risk of bias was assessed using the Joanna Briggs Institute Risk of Bias Tool.

From 2878 unique studies, 9 trials were eligible for meta-analysis. VRT was significantly more effective than control conditions in reducing overall psychotic symptoms (Hedges’ g = 0.53, p = 0.037). No significant effects were found for other domains (positive, negative, depressive or paranoia symptoms).

Virtual reality therapies are moderately effective at reducing overall psychotic symptoms. Unlike prior reviews, this study did not find significant effects on positive symptoms, possibly due to the heterogeneity of outcomes reported in existing interventions.

PROSPERO: CRD42023470849

Cognitive impairment in major depressive disorder (MDD) may be driven by neuro-inflammatory processes involving pro-inflammatory cytokines.

This study aimed to examine the relationship between serum tumour necrosis factor-alpha (TNF-α) levels and cognitive performance across different domains in individuals with MDD.

Sixty patients with MDD and 60 healthy controls were recruited. Cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and serum TNF-α levels were measured via flow cytometry.

After adjusting for covariates, RBANS total and subscale scores were significantly lower in MDD patients compared with controls (P < 0.001), while log10-transformed TNF-α levels were significantly higher in the MDD group (P = 0.006). In MDD patients, log10TNF-α levels were inversely correlated with immediate memory scores after adjusting for confounding factors (r = −0.35, P = 0.009); however, this relationship was not observed in healthy controls (r = −0.02, P = 0.90). Stepwise multivariate regression analysis further confirmed the negative association of log10TNF-α with immediate memory scores in MDD patients (β = −14.58, t = −4.14, P < 0.001), but not in healthy controls (β = −0.02, t = −0.14, P = 0.89).

These findings suggest that elevated serum TNF-α may contribute to the pathophysiology of MDD and is specifically associated with deficits in immediate memory.

People with intellectual disability experience substantial health inequities, including higher multimorbidity, increased healthcare utilisation and markedly reduced life expectancy. High-quality research is essential to address these disparities. The National Institute for Health and Care Research (NIHR) funded Research Delivery Network provides the infrastructure/expertise/support needed to deliver NIHR-funded studies, and supports studies funded by a non-commercial/industry partner. However, the effectiveness of NIHR-funded studies versus those supported in driving impactful intellectual disability research remains unclear.

To evaluate and compare the outcomes of NIHR-funded and supported intellectual disability research.

All NIHR studies (funded/supported) relating to intellectual disability (2010–2020) were identified through systematic register searches. Primary outcomes included publication rates and impact on local, national and international clinical guidelines. Data collection was supplemented with a questionnaire to chief investigators and literature searches. Quantitative analyses examined associations between funding status, study design, publication and guideline impact, whereas qualitative responses explored implementation challenges.

In total, 88 projects were identified, and 42% (37/88) were NIHR-funded. Overall, 81% of studies generated at least one publication and 28% informed clinical guidelines. NIHR funding was not significantly associated with publication or guideline impact. Randomised controlled trials (RCTs) were significantly more likely to be published and more likely to influence non-UK national and international guidelines than non-RCTs. The amount of funding showed no association with impact. Qualitative findings highlighted funding constraints, staff capacity and stakeholder engagement as key determinants of implementation.

NIHR-funded intellectual disability research was no more likely than NIHR-supported studies to result in publications or guideline impact.

Treatment-resistant depression (TRD) is common and associated with substantial disability and economic burden. It is estimated to affect over 100 million people worldwide and approximately 2.7 million people in the United Kingdom. Ketamine has emerged as a novel therapy for TRD, with studies demonstrating rapid antidepressant effects. However, ketamine is also used recreationally and can result in multi-systemic morbidity, accidental injury, assault and death. In the past decade there has been a marked increase in people entering treatment for harmful ketamine use in the UK, alongside a significant rise in ketamine-related deaths. The Royal College of Psychiatrists Margaret Slack Travelling Fellowship aims to broaden Higher Trainee’s academic knowledge and experience in a centre of excellence.

Gold Coast Health’s (GCH) Specialist Neurostimulation and Mood Disorder Service is Queensland’s first public service, and one of Australia’s first, to establish a ketamine clinic for TRD. The service is the Queensland site for the TREK trial, a multi-centre randomised controlled trial comparing intranasal esketamine and subcutaneous racemic ketamine for TRD. The service has supported several other multi-centre studies on ketamine that have shown efficacy and safety.

The author was awarded the 2025 Margaret Slack Travelling Fellowship to visit GCH in August 2025, to observe the ketamine clinic, TREK trial, Alcohol and Other Drugs Service, and speak with multi-disciplinary staff and patients to develop clinical insights.

The author attended presentations by Prof Colleen Loo, Black Dog Institute, on “Extending Knowledge and Clinical Experience on the Use of Ketamine” and “Ketamine for the Treatment of Depression in Older Adults” by Associate Prof, Shanthi Sarma, GCH (11 and 15 August 2025).

The author delivered oral presentations at GCH, “Understanding Ketamine Use Disorder: Perspectives from England and Considerations for Ketamine Clinics”, and “Promoting Awareness on Ketamine Use Disorder: Enabling early identification, treatment and referral”, at the International Medicine in Addiction conference in Sydney (18 and 30 August 2025).

There is demonstrated interest from British and Australian clinicians in the use of ketamine to effectively and safely treat TRD, in addition to ketamine use disorder, its risks and systemic harms. This interest creates opportunities to strengthen collaboration and shared learning between psychiatry, urology, and addiction disciplines internationally. It also supports the development of improved services for people receiving ketamine for TRD and for those using non-prescribed ketamine, promoting safe, evidence-informed practice.

Community treatment orders (CTOs) permit compulsory mental healthcare outside hospital. Such orders have become part of an increasing number of mental health laws, even if there is a lack of consensus on their effects, negative personal experiences, diverging ethical positions and expectations that governments should reduce or abandon coercive practices. It is therefore surprising that there is limited research describing the availability and restrictiveness of CTO legislation, and we found no comprehensive European study. Such studies could contribute to clarification of differing positions and, through that, informing further research and discussions of how to promote voluntary options in clinical practice.

To establish the availability of CTO legislation across Europe, and how regimes in different ways restrict the person.

Data were collected from 33 European countries through a network of researchers and practitioners, and links to relevant legislation were provided.

We found 13 CTO regimes across the 33 countries: two-thirds therefore managed without them. Despite some variation, most law texts specified restrictions related to legal criteria, enforcement mechanisms and safeguards. Restrictions on the person were often specified in separate tailored plans, and most regimes permitted indefinite renewals, which means that the duration of restrictions can be ascertained only in retrospect.

CTO law texts preclude scrutiny of overall restrictiveness, which might add to current uncertainties regarding the proportionality of CTOs and their role in balancing individuals’ rights to both autonomy and care. The current policy drive towards community care should not automatically lead to new CTO regimes until their effectiveness and de facto restrictiveness are established.

There is ample evidence that women do not progress in mental health publishing as quickly as men. The movement from first to last (senior) author is one indicator of progression.

To understand whether there are changes in women’s authorship position following our academic institution’s introduction of support mechanisms to reduce the gender gap in career development.

Data from publicly held databases in three cohorts (2016, 2018 and 2020) were assessed for gender and authorship position at the Institute of Psychiatry, Psychology and Neuroscience. Regression analyses included authorship gender and change over time in authorship roles, by school and topic.

We found substantial, statistically significant differences in gender between author roles (χ2(2) = 29.18, P < 0.0001), with women being mainly first authors (marginal mean 62.2:40.1%, respectively, odds ratio 2.463, 95% CI 1.807 to 3.357). The three schools differed (χ2(2) = 14.06, P < 0.001) and, although men were predominant as last authors in all topics in both 2016 and 2020, women did show a modest increase. The trend for an interaction between gender and first-author publications on the likelihood of last-author publications in 2018 (incidence rate ratio 1.839, 95% CI 0.914 to 3.698) had disappeared by 2020.

Although women were represented as first and corresponding authors, there was still a gender gap for last-author positions. Over time, women have increased their representation in many of the topic areas. The disappearance of any gender-moderating effect suggests that institutional policies may have had an effect, in addition to sector-wide changes.

International guidance recommends that long-acting injectable (LAI) antipsychotics be considered for routine management of first-episode schizophrenia. Reliable national estimates of utilisation are lacking for most countries, including Ireland.

To determine the prevalence of LAI antipsychotic prescribing in Ireland between 2014 and 2024 and explore the effects of age, sex and socioeconomic status on prescribing trends.

The annual prescribing prevalence was calculated per 1000 individuals with schizophrenia aged 15–69 using the national pharmacy claims database. The effects of year, age, sex, socioeconomic class and antipsychotic medication on LAI antipsychotic prescribing trends were examined using log-linear regression.

The prevalence of LAI antipsychotic prescribing decreased from 327/1000 in 2014 to 281/1000 in 2024, with an average annual change in prescribing rate of −1.49% [95% CI −1.98, −0.79]. In 2024, paliperidone LAIs were most commonly prescribed (40.2%). Prescribing prevalence increased with age, with the lowest prescribing prevalence occurring among those aged 15–24 years (79/1000) and the highest among those aged 65–69 years (434/1000). The prescribing prevalence increased significantly among those aged 25–34 years only (+2.7% [95% CI 1.7, 4.3]). Prescribing rates decreased across all ages between 45 and 69 years; the largest decrease occurred among those aged 65–69 years (−4.3% [95% CI −5.7, −2.9]). Higher rates of prescribing were seen in male compared with female patients across all age bands, with the highest male-to-female ratio (2.94) occurring among those aged 25–34 years.

Approximately 28% of Irish individuals with schizophrenia are prescribed an LAI antipsychotic. Prescribing rates have decreased by 14% since 2014. Priorities for future research include implementation science studies to identify strategies that can effectively increase LAI antipsychotic prescribing.

Comorbid obsessive–compulsive disorder (OCD) or obsessive–compulsive symptoms (OCS) are common in people with severe mental illness (SMI; including schizophrenia, bipolar disorder and schizoaffective disorder), with little known about associations with smoking.

To estimate the association between OCD/OCS and smoking status among people with SMI in a huge electronic database.

Using the Clinical Records Interactive Search (CRIS) platform for data of service users in the South London and Maudsley (SLaM) NHS Foundation Trust, tobacco smoking status was retrospectively detected through an algorithm of natural language processing technique, categorising into ‘current smoker’, ‘ex-smoker’ and ‘non-smoker’ by the clinical notes of SMI individuals during 2007–2015. A hierarchical assignment rule was applied following the order of ‘smoker’, ‘ex-smoker’ and then ‘non-smoker’ in an individual. Logistic regression was used to examine the association between smoking and OCS in people with SMI for univariable and multivariable analyses.

We identified 15 479 SMI individuals (56% male; mean age 41 years old), with 90.4% ever smoked. Among them, 2320 (15%) had OCS (without OCD), while 2174 (14%) had a clinical diagnosis of comorbid OCD. After adjusting for demographics and functional status as confounders, both SMI individuals with OCS only and an OCD diagnosis were significantly more likely to have ever smoked (adj. odds ratio 1.47, 95% CI 1.23, 1.76 and adj. odds ratio 1.33, 95% CI 1.11, 1.60, respectively) compared with those without OCD/OCS.

In this large-scale analysis of people with SMI, we found that individuals with OCS or OCD were more likely to have ever smoked.