Association of time spent on social media with youth cigarette smoking and e-cigarette use in the UK: a national longitudinal study.

BACKGROUND: Social media may influence children and young people's health behaviour, including cigarette and e-cigarette use. METHODS: We analysed data from participants aged 10-25 years in the UK Household Longitudinal Study 2015-2021. The amount of social media use reported on a normal weekday was related to current cigarette smoking and e-cigarette use. Generalised estimating equation (GEE) logistic regression models investigated associations of social media use with cigarette smoking and e-cigarette use. Models controlled for possible confounders including age, sex, country of UK, ethnicity, household income and use of cigarette/e-cigarettes by others within the home. RESULTS: Among 10 808 participants with 27 962 observations, current cigarette smoking was reported by 8.6% of participants for at least one time point, and current e-cigarette use by 2.5% of participants. In adjusted GEE models, more frequent use of social media was associated with greater odds of current cigarette smoking. This was particularly apparent at higher levels of use (eg, adjusted odds ratio (AOR) 3.60, 95% CI 2.61 to 4.96 for ≥7 hours/day vs none). Associations were similar for e-cigarettes (AOR 2.73, 95% CI 1.40 to 5.29 for ≥7 hours/day social media use vs none). There was evidence of dose-response in associations between time spent on social media and both cigarette and e-cigarette use (both p<0.001). Analyses stratified by sex and household income found similar associations for cigarettes; however, for e-cigarettes associations were concentrated among males and those from higher household income groups. CONCLUSIONS: Social media use is associated with increased risk of cigarette smoking and e-cigarette use. There is a need for greater research on this issue as well as potential policy responses.

Associations of social media use with smoking and e-cigarettes: a national longitudinal study.

BACKGROUND: Social media use is high among children and young people and might influence health behaviours. We examined social media use and use of tobacco and e-cigarettes in the UK. METHODS: We used data from participants aged 10-25 years from the UK Household Longitudinal Study (January 2015-January 2022). Participants were asked: "On a normal weekday, that is Monday to Friday, how many hours do you spend chatting or interacting with friends through a social website or app like that?". Specific social media platforms were not specified. Responses were none, less than 1 h, 1-3 h, 4-6 h, 7 h or more. Outcomes were current tobacco smoking and e-cigarette use. Generalised Estimating Equation (GEE) logistic regression models investigated associations of social media use with tobacco and e-cigarette use, and fixed effects analyses investigated changes in social media use with uptake of both products. Models included possible confounders such as age, sex, household income, ethnicity (White vs non-White) and use of tobacco or e-cigarettes by others within the home. All participants gave written informed consent. FINDINGS: The analytic sample included 10 808 participants with 27 962 observations (mean age 15·7 years [SD 3·8], 5080 [47%] male, 5728 [53%] female, and 7868 [73%] White). Current tobacco smoking was reported at one or more timepoints by 929 (8·6%) participants, and current e-cigarette use by 270 (2·5%) participants. In adjusted GEE models, all levels of social media use were associated with greater odds of current smoking than no use. This association was particularly apparent at higher levels of use adjusted odds ratio [aOR] 3·11, 95% CI 2·41-4·03 for ≥7 h use vs no use), with similar associations for e-cigarettes (aOR 3·04, 2·11-4·40 for ≥7 h use vs no use). Fixed effects analyses also found increased use of social media to be associated with increased uptake of both products (eg, changing to using social media for ≥7 h/day was associated with >2 times the odds of taking up tobacco smoking [aOR 2·33, 1·28-4·24]). INTERPRETATION: These analyses suggest an association between social media use and e-cigarette and tobacco use. Potential pathways include promotion of these products on social media. Further research with details on specific platforms would be useful as well as with longer follow-up time. FUNDING: Cancer Research UK.

Evidence use in the UK's COVID-19 Free School Meals Policy: a thematic content analysis.

Free School Meals (FSM) are a well-recognised intervention for tackling food insecurity among school children. National school closures during the COVID-19 pandemic meant that there was a need to rapidly adapt the delivery of FSM. A range of food-assistance policies were implemented, but it is not clear if they were evidence-based. This study aimed to determine the transparency of evidence use and identify other competing influences in the UK's FSM policy decisions. Thematic content analysis was used to review 50 publicly available policy documents and debate transcripts on FSM policy published between March 2020-2021. This period covered the first national school closures (March 2020-July 2020), school holidays and the second national school closures (January 2021- March 2021). The Evidence Transparency Framework was used to assess the transparency of evidence use in policy documents. We found that overall transparency of evidence use was poor but was better for the Holiday Activities and Food (HAF) programme. The Government showed preference for replacing FSM with food parcels, rather than more agentic modes of food assistance such as cash-vouchers. This preference appeared to be closely aligned with ideological views on the welfare state. With an absence of evidence, value-based reasoning took precedent and was polarised by social media. This paper highlights the need for a formal review into FSM, one which includes a comparison of low and high agentic food assistance policies. Such a review would address the evidence gap, improve food assistance policy, and aid policymakers in future periods of uncertainty.

Patterns of cigarette and e-cigarette use among UK adolescents: a latent class analysis of the Millennium Cohort Study.

BACKGROUND: Patterning of cigarette and e-cigarette use among young people remains poorly characterized. We aimed to describe these patterns in the UK Millennium Cohort Study at age 14 and 17 years. METHODS: Data on cigarette and e-cigarette use come from 9731 adolescents. Latent class analysis assigned participants to membership of classes of product use and multinomial logistic regression analyses assessed differences in the likelihood of belonging to classes by sociodemographic (age, gender, ethnicity, household income, maternal education and country of residence) and smoking-related social factors (caregiver tobacco use, caregiver e-cigarette use and peer smoking). RESULTS: We identified four classes of use: 45.8% of adolescents 'continued to abstain' from cigarettes or e-cigarettes; 21.3% 'experimented' (used once or in the past but not currently) with cigarettes and/or e-cigarettes by age 17 but were not current users; 19.0% were 'late adopters', characterized by low levels of use at age 14 but high levels of experimentation and current use at age 17; and 13.9% were 'early adopters', characterized by high levels of experimentation and current use at ages 14 and 17. At age 17, 70.4% of 'early adopters' smoked cigarettes regularly plus an additional 27.3% experimented with cigarettes. Corresponding percentages for e-cigarettes were 37.9% and 58.9%. Tobacco and e-cigarette use by caregivers, and cigarette use by peers, were associated with being both 'late adopters' and 'early adopters'. CONCLUSIONS: Approximately one in seven adolescents in the UK are 'early adopters' of nicotine products. This highlights the need to develop and implement effective policies to prevent nicotine use uptake.

Changing awareness and sources of tobacco and e-cigarettes among children and adolescents in Great Britain.

INTRODUCTION: It is illegal in the UK to sell tobacco or nicotine e-cigarettes to people under the age of 18 years, as is displaying tobacco cigarettes at the point of sale. This paper examined changes in exposure to display of these products in shops and sources of these products among children and adolescent users over time METHODS: Data from representative repeated online cross-sectional surveys of youth in Great Britain (11-18 years) were used (2018-2022; n=12 445). Outcome measures included noticing product displays and sources of e-cigarettes and tobacco cigarettes. Logistic regressions examined the associations of these outcome variables over time and with sociodemographic variables. RESULTS: Of 12 040 participants with complete data, 10.1% used some form of nicotine product (4.2% cigarettes, 2.9% e-cigarettes, 3.0% both) at least occasionally. The likelihood of noticing tobacco cigarettes on display fell over time for both supermarkets (2018: 67.1% to 2022: 58.5%) and small shops (2018: 81.3% to 2022: 66.3%), but the likelihood of noticing e-cigarettes in supermarkets rose (2018: 57.4% to 2022: 66.5%). Sources of tobacco cigarettes did not differ over time, but e-cigarette users were more likely to get their e-cigarettes from small shops in 2022 (51.2%) vs 2019 (34.2%) (OR 2.02, 95% CI 1.24, 3.29). CONCLUSION: This study provides evidence that current policies to limit awareness of and access to both tobacco and e-cigarettes among adolescents in the UK may not be effective. UK policies on the advertising, promotion and sale of both tobacco and e-cigarettes need to be reinforced to deter use among children and adolescents.

Multistate transition modelling of e-cigarette use and cigarette smoking among youth in the UK.

INTRODUCTION: E-cigarette use remains a controversial topic, with questions over how people transition between e-cigarette use and cigarette smoking. This paper examined transitions into and out of nicotine product use in a representative sample of UK youth. METHODS: We used Markov multistate transition probability models on data from 10 229 participants (10-25 years old) in the UK Household Longitudinal Study (2015-2021). We used four product use states ('never', 'non-current use', 'e-cigarette only' and 'smoking and dual use') and estimated likelihood of transitions according to sociodemographic characteristics. RESULTS: Among participants who had never used nicotine products, most were still non-users a year later (92.9% probability; 95% CI 92.6%, 93.2%); a small proportion transitioned to using e-cigarettes only (4.0%; 95% CI 3.7%, 4.2%) and cigarettes (2.2%; 95% CI 2.0%, 2.4%). Those aged 14-17 years were the most likely to start using a nicotine product. E-cigarette use was less persistent overtime than cigarette smoking, with a 59.1% probability (95% CI 56.9%, 61.0%) of e-cigarette users still using after 1 year compared with 73.8% (95% CI 72.1%, 75.4%) for cigarette smoking. However, there was a 14% probability (95% CI 12.8%, 16.2%) that e-cigarette users went onto smoke cigarettes after 1 year, rising to 25% (95% CI 23%, 27%) after 3 years. CONCLUSION: This study found that although overall nicotine product use was relatively rare, participants were more likely to experiment with e-cigarette use than cigarette smoking. This was mostly not persistent over time; however, approximately one in seven transitioned to cigarette smoking. Regulators should aim to deter all nicotine product use among children.

Risk factors for adolescent smoking uptake: Analysis of prospective data from the UK Millennium Cohort Study.

INTRODUCTION: Most people who smoke initiate smoking in adolescence. Risk factors for smoking are changing over time as demographics shift, and technologies such as social media create new avenues for the tobacco industry to recruit smokers. We assessed risk factors associated with smoking uptake and regular smoking among a representative cohort of UK adolescents. METHODS: Data come from 8944 children followed prospectively as part of the UK Millennium Cohort Study. Smoking uptake was assessed as adolescents who had never smoked tobacco at the age of 14 years, but reported smoking ≥1 cigarette per week by the age of 17 years (regular smoking). We used logistic regression to assess associations between smoking uptake and selected sociodemographic factors including household income, caregiver smoking, peer smoking, and social media use. Weighted percentages and Office for National Statistics Data were used to estimate numbers of regular smokers and new smokers in the UK. RESULTS: Among the whole sample, 10.6% of adolescents were regular smokers at the age of 17 years. Of these, 52% initiated smoking between the ages of 14 and 17 years. Uptake was more common if caregivers smoked (13.6% vs 5.0%, p<0.001) or friends smoked (12.6% vs 4.3%, p<0.001), and among those reporting >5 hours/day of social media use (9.8% vs 4.1%, p=0.006). Applying these percentages to population data, an estimated 160000 adolescents in the UK were regular smokers by the age of 17 years, of whom more than 100000 initiated smoking between the ages of 14 and 17 years. CONCLUSIONS: This analysis of smoking uptake and regular smoking highlight that smoking behavior remains highly transmissible within families and peer groups, reinforcing inequalities. Social media are highlighted as a potential vector.

The Ultra-Processed Food Content of School Meals and Packed Lunches in the United Kingdom.

British children have the highest levels of ultra-processed food (UPF) consumption in Europe. Schools are posited as a positive setting for impacting dietary intake, but the level of UPFs consumed in schools is currently unknown. This study determined the UPF content of school food in the UK. We conducted a pooled cross-sectional analysis of primary (4-11 years, n = 1895) and secondary schoolchildren (11-18 years, n = 1408) from the UK's National Diet and Nutrition Survey (2008-2017). Multivariable quantile regression models determined the association between meal-type (school meal or packed lunch) and lunchtime UPF intake (NOVA food classification system). We showed that on average, UPF intake was high in both primary (72.6% total lunch Kcal) and secondary schoolchildren (77.8% total lunch Kcal). Higher UPF intakes were observed in packed lunch consumers, secondary schoolchildren, and those in lower income households. This study highlights the need for a renewed focus on school food. Better guidance and policies that consider levels of industrial processing in food served in schools are needed to ensure the dual benefit of encouraging school meal uptake and equitably improving children's diets.

Dietary quality of school meals and packed lunches: a national study of primary and secondary schoolchildren in the UK.

OBJECTIVE: School lunches represent a key opportunity to improve diets and health of schoolchildren. No recent nationally representative studies have examined the nutritional differences between school meals and packed lunches in the UK. This study aimed to characterise and compare the nutritional quality of school meals and packed lunches among primary and secondary school-age children. DESIGN: A pooled cross-sectional analysis of the UK's National Diet and Nutrition Survey (2008-2017). SETTING: United Kingdom. PARTICIPANTS: 3001 children (aged 4-16 years) who completed a 3/4-d food diary which recorded meal type (school meal/packed lunch). Multivariable logistic regression models assessed associations of meeting food and nutrient recommendations by meal type. Analyses were stratified by academic key stages (KS). RESULTS: KS-1 (4-7 years) and 2 (8-11 years) children consuming school meals were more likely to meet minimum recommendations for vegetables, protein-rich foods and fibre, and not exceed maximum recommendations for salt, savoury and sweet snacks compared with pupils consuming packed lunches. However, in KS-3 (12-14 years) and 4 (14-16 years), these effects were reduced. As children aged, the median weight of fruits, vegetables, protein-rich foods and dairy products consumed typically decreased for both school meals and packed lunches, and generally an increasing proportion of school meals contained sweet and savoury snacks. CONCLUSION: These findings suggest school meals are nutritionally superior to packed lunches but are not yet optimal. Quality declined at higher KS. Actions to improve lunches of primary and secondary schoolchildren across the UK are needed, with attention to KS-3 and 4 in secondary schools.

The Impact of the Universal Infant Free School Meal Policy on Dietary Quality in English and Scottish Primary School Children: Evaluation of a Natural Experiment.

The Universal Infant Free School Meal (UIFSM) policy was introduced in September 2014 in England and January 2015 in Scotland and offered all infant schoolchildren (ages 4-7 years) a free school lunch, regardless of income. Yet, impacts of UIFSM on dietary intakes or social inequalities are not known. A difference-in-differences study using the National Diet and Nutrition Survey assessed pooled pre-UIFSM (2010-2014) and post-UIFSM (2014-2017) dietary data. English or Scottish infant schoolchildren (4-7 years; n = 458) were the intervention group, with junior schoolchildren (8-11 years; n = 401) as controls. We found that implementation of UIFSM led to an increase in infant schoolchildren having a school meal. Impacts on key food groups such as fruit and vegetables or sweetened beverages were not seen. However, there was evidence that the UIFSM policy lowered consumption of foods associated with packed lunches, such as crisps, and some nutrients, such as total fat and sodium. Policy impacts differed by income group, with larger effect sizes in low-income children. In conclusion, evaluation of UIFSM demonstrated some improvements in dietary quality but the findings suggest school meal quality needs to be improved to fully realise the benefits of UIFSM.

The ultra-processed food content of school meals and packed lunches in the UK, 2008-17: a pooled cross-sectional study.

BACKGROUND: British children have the highest ultra-processed food (UPF) intake in Europe, concerning as UPF is linked to adverse health outcomes. Schools are a potential setting for intervention, yet the rate of UPFs consumed at schools is currently unknown. This study aimed to describe the UPF content of school food in the UK and to explore differences in UPF content by meal type (school meals and packed lunches [food from home]) and children's household income. METHODS: We performed a pooled cross-sectional analysis of 1895 primary school children (aged 4-11 years) and 1408 secondary school children (aged 11-18 years) using data from the UK's National Diet and Nutrition Survey (from Feb, 2008, to June, 2017). Student's meal type was recorded using food diaries. UPF intake was defined using the NOVA food classification system. Income was measured through interview. We used quantile regression models to assess the association between meal type and lunchtime UPF intake (by both the percentage of calories and weight). We stratified models by school phase (primary or secondary) and interacted meal type with income. FINDINGS: The majority of schoolchildren's lunch was defined as UPFs, with secondary school children having higher median intakes of UPFs than primary school children (78% kcal [IQR 58-95] vs 73% kcal [55-86). School meals were associated with a lower median UPF intake than packed lunches for primary school children (61% kcal [IQR 44-75] vs 81% kcal [71-91]) and for secondary school children (70% kcal [IQR 48-89] vs 84% kcal [65-99]). Results were similar when UPFs were analysed as a percentage of the total weight of lunch. Overall, income was inversely associated with UPF lunch content. However, in primary school children, there was no significant association between percentage of UPF content of school meals by weight. INTERPRETATION: In the first nationally representative study, we showed that UK school children have a high intake of UPFs at lunch. UPF intake was increased in children who consumed packed lunches, secondary school children, and children of a lower income. School meal procurement policies must be re-evaluated to protect children from high UPF intake. FUNDING: This study was funded by the National Institute for Health Research School for Public Health Research.