Factors influencing public health engagement in alcohol licensing in England and Scotland including legal and structural differences: comparative interview analysis.

Background: Greater availability of alcohol is associated with higher consumption and harms. The legal systems, by which premises are licensed to sell alcohol in England and Scotland, differ in several ways. The 'Exploring the impact of alcohol licensing in England and Scotland' study measured public health team activity regarding alcohol licensing from 2012 to 2019 and identified seven differences between England and Scotland in the timing and type of activities undertaken. Objectives: To qualitatively describe the seven previously identified differences between Scotland and England in public health approaches to alcohol licensing, and to examine, from the perspective of public health professionals, what factors may explain these differences. Methods: Ninety-four interviews were conducted with 52 professionals from 14 English and 6 Scottish public health teams selected for diversity who had been actively engaging with alcohol licensing. Interviews focused primarily on the nature of their engagement (n = 66) and their rationale for the approaches taken (n = 28). Interview data were analysed thematically using NVivo. Findings were constructed by discussion across the research team, to describe and explain the differences in practice found. Findings: Diverse legal, practical and other factors appeared to explain the seven differences. (1) Earlier engagement in licensing by Scottish public health teams in 2012-3 may have arisen from differences in the timing of legislative changes giving public health a statutory role and support from Alcohol Focus Scotland. (2) Public Health England provided significant support from 2014 in England, contributing to an increase in activity from that point. (3) Renewals of statements of licensing policy were required more frequently in Scotland and at the same time for all Licensing Boards, probably explaining greater focus on policy in Scotland. (4) Organisational structures in Scotland, with public health stakeholders spread across several organisations, likely explained greater involvement of senior leaders there. (5) Without a public health objective for licensing, English public health teams felt less confident about making objections to licence applications without other stakeholders such as the police, and instead commonly negotiated conditions on licences with applicants. In contrast, Scottish public health teams felt any direct contact with applicants was inappropriate due to conflicts of interest. (6) With the public health objective in Scotland, public health teams there were more active in making independent objections to licence applications. Further in Scotland, licensing committee meetings are held to consider all new applications regardless of whether objections have been submitted; unlike in England where there was a greater incentive to resolve objections, because then a meeting was not required. (7) Finally, Scottish public health teams involved the public more in licensing process, partly because of statutory licensing forums there. Conclusions: The alcohol premises licensing systems in England and Scotland differ in important ways including and beyond the lack of a public health objective for licensing in England. These and other differences, including support of national and local bodies, have shaped opportunities for, and the nature of, public health engagement. Further research could examine the relative success of the approaches taken by public health teams and how temporary increases in availability are handled in the two licensing systems. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Reseacrh programme as award number 15/129/11.

When alcohol becomes more widely available, harms tend to increase. In England and Scotland, this availability is controlled by local councils. They 'licence' shops, bars and other venues to allow them to sell alcohol. Local health teams, including doctors, often advise councils on licensing. In earlier work, we found seven differences in what Scottish and English health teams do on licensing. In this study, we explore these seven differences and why they came about. To do this, we interviewed 94 professionals working in public health across both countries. Scottish health teams got involved in licensing earlier than in England. This was partly because of when certain laws changed. Also, they were helped earlier by national organisations that try to reduce harm from alcohol. Scottish teams were more involved in local policies on licensing. This was probably because these policies changed more often in the Scottish system. Scottish teams involved the public more. This was partly because Scottish councils must set up 'local licensing forums'. Scottish teams also objected more often to licence applications. They generally felt that they could be more actively involved, because of a law in Scotland that says licensing must protect public health. This law does not apply in England. In England, health teams were more likely to talk to businesses that wanted licences. They were less likely to try to block applications. When they agreed changes to applications with businesses instead of objecting, fewer formal licensing meetings were needed. This was not the case in Scotland. Also, Scottish teams did not feel it was okay for them to talk to businesses. In summary, there are important differences in licensing law between Scotland and England. These matter for how health teams in the two countries engage with local councils, businesses and the public on licensing matters.

Public health engagement in alcohol licensing in England and Scotland: the ExILEnS mixed-method, natural experiment evaluation.

Background: International systematic reviews suggest an association between alcohol availability and increased alcohol-related harms. Alcohol availability is regulated through separate locally administered licensing systems in England and Scotland, in which local public health teams have a statutory role. The system in Scotland includes a public health objective for licensing. Public health teams engage to varying degrees in licensing matters but no previous study has sought to objectively characterise and measure their activity, examine their effectiveness, or compare practices between Scotland and England. Aim: To critically assess the impact and mechanisms of impact of public health team engagement in alcohol premises licensing on alcohol-related harms in England and Scotland. Methods: We recruited 39 diverse public health teams in England (n = 27) and Scotland (n = 12). Public health teams more active in licensing were recruited first and then matched to lower-activity public health teams. Using structured interviews (n = 66), documentation analysis, and expert consultation, we developed and applied the Public Health Engagement In Alcohol Licensing (PHIAL) measure to quantify six-monthly activity levels from 2012 to 2019. Time series of PHIAL scores, and health and crime outcomes for each area, were analysed using multivariable negative binomial mixed-effects models to assess correlations between outcome and exposure, with 18-month average PHIAL score as the primary exposure metric. In-depth interviews (n = 53) and a workshop (n = 10) explored public health team approaches and potential mechanisms of impact of alcohol availability interventions with public health team members and licensing stakeholders (local authority licensing officers, managers and lawyers/clerks, police staff with a licensing remit, local elected representatives). Findings: Nineteen public health team activity types were assessed in six categories: (1) staffing; (2) reviewing and (3) responding to licence applications; (4) data usage; (5) influencing licensing stakeholders/policy; and (6) public involvement. Usage and intensity of activities and overall approaches varied within and between areas over time, including between Scotland and England. The latter variation could be explained by legal, structural and philosophical differences, including Scotland's public health objective. This objective was felt to legitimise public health considerations and the use of public health data within licensing. Quantitative analysis showed no clear evidence of association between level of public health team activity and the health or crime outcomes examined, using the primary exposure or other metrics (neither change in, nor cumulative, PHIAL scores). Qualitative data suggested that public health team input was valued by many licensing stakeholders, and that alcohol availability may lead to harms by affecting the accessibility, visibility and norms of alcohol consumption, but that the licensing systems have limited power to act in the interests of public health. Conclusions: This study provides no evidence that public health team engagement in local licensing matters was associated with measurable downstream reductions in crime or health harms, in the short term, or over a 7-year follow-up period. The extensive qualitative data suggest that public health team engagement is valued and appears to be slowly reorienting the licensing system to better address health (and other) harms, especially in Scotland, but this will take time. A rise in home drinking, alcohol deliveries, and the inherent inability of the licensing system to reduce - or in the case of online sales, to contain - availability, may explain the null findings and will continue to limit the potential of these licensing systems to address alcohol-related harms. Future work: Further analysis could consider the relative success of different public health team approaches in terms of changing alcohol availability and retailing. A key gap relates to the nature and impact of online availability on alcohol consumption, harms and inequalities, alongside development and study of relevant policy options. A national approach to licensing data and oversight would greatly facilitate future studies and public health input to licensing. Limitations: Our interview data and therefore PHIAL scores may be limited by recall bias where documentary evidence of public health activity was not available, and by possible variability in grading of such activity, though steps were taken to minimise both. The analyses would have benefited from additional data on licensing policies and environmental changes that might have affected availability or harms in the study areas. Study registration: The study was registered with the Research Registry (researchregistry6162) on 26 October 2020. The study protocol was published in BMC Medical Research Methodology on 6 November 2018. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/129/11.

Research finds that when alcohol is more easily available, because more places sell alcohol or have longer opening hours, people tend to drink more and harms tend to increase. In England and Scotland, 'Licensing Committees' in local governments have power over which venues are given a licence to sell alcohol legally. They make decisions based on local policy and on licensing goals set out in law. Licensing laws are slightly different in both nations, and health representatives are often involved in trying to influence local licensing decisions and policies, to reduce alcohol-related harms. We aimed to find out what public health teams have done to influence alcohol licensing and whether their actions have affected alcohol-related harms. We recruited 39 public health teams (Scotland: 12; England: 27) and measured how active they were on licensing matters. We gathered detailed information (from interviews and papers) about their actions from 2012 to 2019, and asked them and others involved in licensing (including police, and local authority licensing teams and lawyers) about how their efforts might make a difference to harms. We gathered local data on alcohol-related health harms and crimes during 2009­19. We analysed whether any changes in these harms were related to the level of public health team activity, and explored differences between Scotland and England. Public health teams across Scotland and England took varied approaches to engaging in alcohol licensing, and their work was often welcomed by others working in the licensing system. However, we found no clear relationship between the level of licensing-related activity that public health teams engaged in and the levels of alcohol-related health harms or crime. This may be because their actions make only a modest difference to licensing decisions, or because it may take longer than the study period for them to have a sizeable impact. Reducing alcohol-related harms through licensing may require strengthening national licensing laws and the powers of public health teams, including by addressing online sales and home deliveries.

Alcohol branding during rugby union matches in Ireland after commencement of Sect. 15 from the Public Health (Alcohol) Act: a frequency analysis of highlights from the European Rugby Champions Cup and Six Nations Championship.

BACKGROUND: Under Sect. 15 of the Public Health (Alcohol) Act 2018, Ireland has banned alcohol advertising in or on the sports area during a sports event, except for branded clothing. The restrictions commenced on 12th November 2021, but concerns have been raised that alcohol branding continues to feature in the now-prohibited sporting area. AIM: To examine the frequency and nature of alcohol brand references in or on the sporting area during two rugby union tournaments played in Ireland after Sect. 15 had commenced. METHODS: A frequency analysis recorded visual references to alcohol brands in or on the sporting area (lasting ≥ 1 s) during highlights of fixtures played in Ireland during the 2021/2022 European Rugby Champions Cup (n = 11 matches; 'ERCC') and 2022 Six Nations Championship (n = 3 matches). Highlights were obtained from the official YouTube channels of each tournament. RESULTS: Across both tournaments, 481 alcohol brand references were observed in or on the sporting area (ERCC = 420; Six Nations = 61). Most references were advertising for zero-alcohol variants (ERCC = 77.1%; Six Nations = 83.6%) but using similar brand iconography as their 'regular-strength' counterparts (e.g. brand names and logos). The remaining references were classified as alibi marketing for 'regular-strength' alcohol products (ERCC = 22.9%; Six Nations = 16.4%), as alcohol brand logos were presented without explicit reference to a zero-alcohol variant. CONCLUSIONS: Alcohol branding continued to feature in or on the sporting area after the commencement of Sect. 15 of the Public Health (Alcohol) Act. Clarification is needed over whether the promotion of zero-alcohol products and alibi marketing is compatible with Sect. 15 of the Act.

Measuring How Public Health Stakeholders Seek to Influence Alcohol Premises Licensing in England and Scotland: The Public Health Engagement In Alcohol Licensing (PHIAL) Measure.

OBJECTIVE: In the United Kingdom, some public health teams (PHTs) routinely engage with local alcohol premises licensing systems, through which licenses to sell alcohol are granted. We aimed to categorize PHT efforts and to develop and apply a measure of their efforts over time. METHOD: Preliminary categories of PHT activity were developed based on prior literature and were used to guide data collection with PHTs in 39 local government areas (27 in England; 12 in Scotland), sampled purposively. Relevant activity from April 2012 to March 2019 was identified through structured interviews (N = 62), documentation analysis, and follow-up checks, and a grading system was developed. The measure was refined based on expert consultation and used to grade relevant PHT activity for the 39 areas in 6-month periods. RESULTS: The Public Health engagement In Alcohol Licensing (PHIAL) Measure includes 19 activities in six categories: (a) staffing; (b) reviewing license applications; (c) responding to license applications; (d) data usage; (e) influencing licensing stakeholders or policy; and (f) public involvement. PHIAL scores for each area demonstrate fluctuation in type and level of activity between and within areas over time. Participating PHTs in Scotland were more active on average, particularly on senior leadership, policy development, and working with the public. In England, activity to influence license applications before decision was more common, and a clear increase in activity is apparent from 2014 onward. CONCLUSIONS: The novel PHIAL Measure successfully assessed diverse and fluctuating PHT engagement in alcohol licensing systems over time and will have practice, policy, and research applications.

Attending sporting mega events during COVID-19: mitigation and messaging at UK EURO 2020 matches.

The UEFA EURO 2020 football tournament was one of the largest Sporting Mega Events (SMEs) to take place during the COVID-19 pandemic. Mitigating the risk of virus transmission requires a multi-layered approach for any large event, more so in this case due to staging the tournament across eleven host countries. Yet, little is known about COVID-19 risks and mitigation from attending an event of this scale and nature. We examined the implementation of mitigation and messaging at EURO 2020 matches hosted at venues in the UK. The tournament was postponed from the summer of 2020 and played in June and July of 2021. Structured observations were conducted by 11 trained fieldwork-supporters at 10 matches played at Wembley Stadium, London, or Hampden Park, Glasgow. Fieldwork-supporters observed one-way systems and signage, and hand sanitizing stations inside the stadia, but reported significant variation in the implementation of staggered timeslots, testing upon entry, and procedures for exit. Adherence to planned measures by ticket holders and implementation by stewards waned as the tournament progressed culminating in an absence of enforced measures at the final. The non-compliance with COVID-19 mitigation measures was likely to have led to a significantly increased risk of transmission. Future events should consider how COVID-19 mitigation measures could become 'new norms' of fan behaviour, learning from what is already known about football fandom. Tournament organizers of SMEs can use these findings to promote clearer messaging on pandemic-driven changes in fan behaviour and best practices in mitigating risk at future sporting and cultural events.

The UEFA EURO 2020 football tournament saw one of the largest returns to spectating at sporting events during the COVID-19 pandemic. With the tournament taking place across 11 different countries, several measures (e.g. mask-wearing and social distancing) were put in place to protect ticket holders from spreading and catching COVID-19, and these were communicated to spectators before and during matches. This study considers how these measures were implemented at EURO 2020 matches hosted in the UK. Despite retaining the name 'EURO 2020', the tournament was postponed from the summer of 2020 and played in June and July of 2021. We recruited and trained 11 ticket holders who became observers at 10 matches played at Wembley Stadium, London, or Hampden Park, Glasgow. The results demonstrate that supporting normally at football matches during the pandemic times increased the risk of virus transmission. There were inconsistencies in how mitigation measures were planned and implemented by tournament organizers. Ticket holders were also less compliant with mitigation measures as the tournament progressed, likely made more difficult with relaxations in government restrictions. To limit virus transmission at future sporting and cultural events, messaging on mitigation measures must be clear, consistent and implemented as planned.

Impact of public health team engagement in alcohol licensing on health and crime outcomes in England and Scotland: A comparative timeseries study between 2012 and 2019.

Background: Public health teams (PHTs) in England and Scotland engage to varying degrees in local alcohol licensing systems to try to reduce alcohol-related harms. No previous quantitative evidence is available on the effectiveness of this engagement. We aimed to quantify the effects of PHT engagement in alcohol licensing on selected health and crime outcomes. Methods: 39 PHTs in England (n = 27) and Scotland (n = 12) were recruited (of 40 contacted) for diversity in licensing engagement level and region, with higher activity areas matched to lower activity areas. Each PHT's engagement in licensing for each 6 month period from April 2012 to March 2019 was quantified using a new measure (PHIAL) developed using structured interviews, documentary analyses, and expert consultation. Outcomes examined were ambulance callouts, alcohol-related hospital admissions, alcohol-related and alcohol-specific mortality and violent, sexual and public order offences. Timeseries were analysed using multivariable negative binomial mixed-effects models. Correlations were assessed between each outcome and 18-month average PHIAL score (primary metric), cumulative PHIAL scores and change in PHIAL scores. Additionally, 6-month lagged correlations were also assessed. Findings: There was no clear evidence of any associations between the primary exposure metric and the public health or crime outcomes examined, nor between cumulative PHIAL scores or change in PHIAL score and any outcomes. There were no significant associations in England or Scotland when analysed separately or between outcomes and lagged exposure metrics. Interpretation: There is no clear evidence that allocating PHT resources to engaging in alcohol licensing is associated with downstream reductions in alcohol-related health harms or crimes, in the short term or over a seven year follow-up period. Such engagement likely has benefits in shaping the licensing system to take account of health issues longer term, but as current systems cannot reduce alcohol availability or contain online sales, their potential benefits are somewhat constrained. Funding: The ExILEnS project is funded by the NIHR Public Health Research Programme (project number 15/129/11). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Alcohol Packaging As a Promotional Tool: A Focus Group Study With Young Adult Drinkers in Scotland.

OBJECTIVE: Little research has been conducted on consumer perceptions of alcohol packaging as a marketing tool. The aim of this study was to explore how young adults view and engage with alcohol packaging. METHOD: Eight focus groups were conducted in Glasgow (Scotland) with current drinkers (n = 50), segmented by age (18-24, 25-35), gender (female, male), and social grade (ABC1, C2DE). Participants were shown, allowed to handle, and asked about a range of alcoholic products. RESULTS: Five main themes emerged from the data. The first was the ubiquity of alcohol packaging, with frequent exposure reported in different settings, such as shops and drinking venues, and via marketing. The second was appeal, with pack graphics (e.g., color), structure (e.g., shape, size), and promotions (e.g., gifts, limited editions) allowing alcohol packs to catch attention, enabling products to stand out on shelves, and helping to create product and brand liking, interest, and choice. Third, alcohol packaging was frequently associated with specific occasions and activities. Fourth, alcohol packaging informed perceptions of product-consumer targeting, suitability, and intended drinker profiles. Fifth, alcohol packaging also engaged nonvisual senses (e.g., touch, sound, smell), guiding expectations of product taste and palatability. CONCLUSIONS: For young adult drinkers in Scotland, alcohol packaging can capture attention, create appeal, and help shape perceptions of the product, drinker, and drinking experience.

Stakeholder views of current laws surrounding alcohol at UK football matches: Is it a case of using a "sledgehammer to crack a nut"?

BACKGROUND: In 2021, a fan-led review of football governance in England recommended that legislation surrounding alcohol and football be reviewed to determine whether it is still fit for purpose, the first such review since the mid-1980s. Restricting football fans' alcohol consumption has been debated in the UK for over 40 years. However, more research is needed into the current attitudes of fans and influential stakeholders on this matter. METHODS: Focus groups with football supporters (n=79) and semi-structured interviews (n=15) with key organisational stakeholders were conducted between November 2019 and February 2021. Focus groups included fans who regularly attended matches and supported various teams from professional leagues in Scotland and England, casual fans who usually watched games at home or in bars, and fans who followed the Scotland and England national teams. Stakeholders were selected to represent organisations likely to be instrumental in any regulatory change, such as the UK and Scottish Governments, Police, football supporters' groups and safety organisations. RESULTS: The current law does not allow for alcohol to be consumed within view of the pitch. Participants from England suggested this could be changed. While in Scotland, where the legislation only allows alcohol to be sold in hospitality, most participants were in favour of allowing the general sale of alcohol at football stadia via a pilot scheme. The reasons for these changes included: reducing unhealthy drinking behaviours; minimising the health and safety risk of fans arriving at the stadium just before kick-off; and a potential increase in much needed revenue for clubs. CONCLUSION: Our data suggests an evidence-based review of current laws regarding alcohol and football may be appropriate. However, any discussion regarding changes to the law regarding alcohol at football stadia, including potential pilot schemes, should be evaluated and monitored in terms of both financial impact and the impact on public health and safety.

The role of alcohol packaging as a health communications tool: An online cross-sectional survey and experiment with young adult drinkers in the United Kingdom.

INTRODUCTION: Alcohol packaging is a potentially valuable means of communicating product and health-related information, with growing academic and political interest in its role as a health communications vehicle. METHODS: An online cross-sectional survey and experiment were conducted with a non-probability sample of 18-35-year-old drinkers in the United Kingdom (n = 1360). The survey assessed exposure to, and engagement with, current messaging on packs, and support for displaying product and health-related information. For the randomised experiment, participants were shown, and asked questions about, a vodka bottle with either no warnings (control), small text warnings, large text warnings or pictorial (image-and-text) warnings; the main binary outcome measures were negative product appeal and social acceptability, and positive cognitive and behavioural impact. RESULTS: Two-fifths of the sample rarely or never saw on-pack health-related information, with almost three-quarters rarely or never reading or looking closely at this. There was strong support for displaying a range of product and health-related information (e.g. units, ingredients) on packs. Relative to the control, products with warnings were more likely to be perceived as unappealing and socially unacceptable, and to positively impact alcohol-related cognitions and behaviours. For example, pictorial warnings were 10 times as likely to positively influence cognitions and behaviours (AOR = 10.01, 95% CI: 8.09, 17.46). DISCUSSION AND CONCLUSIONS: Alcohol packaging could have an important role in delivering health messaging. Large pictorial or text warnings may help counteract the appeal and social acceptability of alcohol products and increase awareness of risks, potentially supporting a reduction in consumption and related harms.

Challenges associated with e-cigarette use by people in custody in Scottish prisons: a qualitative interview study with prison staff.

OBJECTIVES: Little is known about the perspectives of staff working in prisons where e-cigarettes are permitted. Scotland now permits people in custody (PiC), but not staff/visitors to use e-cigarettes, following implementation of smoke-free prisons policy in 2018. Previous studies, conducted before and immediately after the introduction of e-cigarettes in Scottish prisons, have evidenced stakeholder support for their use by PiC. This study focuses on key challenges associated with e-cigarette use in prisons, using data collected from prison staff once e-cigarettes had been allowed in a smoke-free environment for 6-9 months. SETTING: Five prisons in Scotland. PARTICIPANTS: Sixteen qualitative interviews were conducted with prison staff from five prisons varying by population (sex, age and sentence length). Data were managed and analysed using the framework approach. RESULTS: While these staff confirmed strong support for the smoke-free prison policy and reported some benefits of replacing tobacco with e-cigarettes, they also spoke of the challenges e-cigarettes pose. These included: workplace e-cigarette vapour exposures; perceptions that e-cigarettes provide a new, effective way for some PiC to take illegal drugs, particularly new psychoactive substances; organisational challenges relating to the value attached to e-cigarettes in prisons; and implications for long-term nicotine use and tobacco cessation. Staff anticipated difficulties in tightening restrictions on e-cigarette use by PiC given its scale and significance among this population. CONCLUSIONS: Maximising the benefits of e-cigarette use by PiC is likely to require multiple measures to support effective and safe use and e-cigarette reduction/cessation where desired. This includes monitoring any misuse of e-cigarettes, and provision of guidance and support on appropriate e-cigarette use and how to limit or quit use if desired. Findings are relevant to jurisdictions considering or planning changes in prison smoking or vaping policies.

E-Cigarette Advertising in the UK: A Content Analysis of Traditional and Social Media Advertising to Observe Compliance with Current Regulations.

INTRODUCTION: The advertising of e-cigarettes in the UK is regulated through the revised EU Tobacco Products Directive and the Tobacco and Related Products Regulations, with further rules set out in the Advertising Standards Authority (ASA) Committees of Advertising (CAP) Code. Focusing on the ASA CAP Code Rules, we examined e-cigarette advertising regulation compliance in traditional advertising channels and on social media. METHODS: We conducted a content analysis of UK e-cigarette and related product advertising using a randomly selected sample (n = 130) of advertising in traditional channels and on Instagram which appeared between January and December 2019. All ads were independently double-coded to assess compliance with each CAP Code Rule. RESULTS: In traditional channels, our sample of advertising had largely good compliance. Only very small numbers of these ads appeared to be clearly in breach of any of the ASA rules (5% were in breach of Rule 22.7; 2% of Rule 22.9; and 1% of Rule 22.10). In contrast, we judged that all of the Instagram sample (n = 30) was in breach of Rule 22.12. For some rules, it was not possible to make definitive judgments about compliance, given uncertainty regarding how a rule should be interpreted and applied. CONCLUSIONS: We found overall good compliance for advertising in traditional channels, but assessed all of our social media advertising samples was in breach of regulations. Current guidance on e-cigarette advertising could be improved to facilitate e-cigarette advertising assessment and regulation. It would be beneficial to bring consumer perspectives into the assessment of regulation compliance. IMPLICATIONS: The regulation of e-cigarette advertising is a global concern. The UK Government has a statutory obligation to review the Tobacco and Related Products Regulations by May 2021. This study assessed compliance with current UK e-cigarette advertising regulations on placement and content. We identified areas where greater clarity is needed and outlined implications for future regulation.

The impact of the initial Covid-19 lockdown upon regular sports bettors in Britain: Findings from a cross-sectional online study.

BACKGROUND: In Britain, unprecedented restrictions on daily life associated with the Covid-19 pandemic included the suspension of professional sports events during the initial 'lockdown'. This provides opportunities to observe changes in sports bettors' behaviour when their primary form of activity is removed and assess the impact of Covid-19 related circumstances upon gambling. METHODS: In July 2020, we conducted an online cross-sectional survey of people who bet regularly (at least monthly) on sports before Covid-19 (n = 3866). Bi-variate analyses compared changes in gambling behaviours before and during the initial lockdown. Multi-variate logistic regression models explored associations between problem gambling (men) and moderate risk or problem gambling (MRPG) (women) with changes in Covid-19 related circumstances and changing gambling behaviours during Britain's initial 'lockdown' (March-June 2020). RESULTS: 29.8% of male sports bettors and 33.4% of female sports bettors stopped gambling altogether during the initial Covid-19 lockdown, though 17.3% of men and 16.5% of women started a new form of gambling during lockdown. Among men, adjusted odds ratios of problem gambling were higher among those starting a new gambling activity during lockdown (OR = 2.50 [95% CI 1.38-4.53]). Among women, adjusted odds ratios of MRPG were higher among those whose frequency of gambling on any activity increased during lockdown (OR = 4.21 [1.99-8.92] and among those shielding for health reasons. Poorer wellbeing was associated with problem gambling for men and MRPG for women. CONCLUSIONS: Those changing gambling behaviours during the initial Covid-19 lockdown (e.g. increasing gambling frequency or starting a new gambling activity) are potentially vulnerable to gambling harms.

Initial Views and Experiences of Vaping in Prisons: A Qualitative Study With People in Custody Preparing for the Imminent Implementation of Scotland's Prison Smokefree Policy.

INTRODUCTION: Scotland is one of the few countries in which e-cigarettes were available in prisons before the introduction of a comprehensive national smokefree policy, to assist in its implementation. This qualitative study explores the initial views and experiences of vaping in this specific context, from the perspective of people in custody (prisoners). AIMS AND METHODS: Twenty-eight people in custody were interviewed approximately 1-2 months after rechargeable e-cigarettes were made available in prisons and 2-5 weeks before implementation of a smokefree policy. Data were thematically analyzed to identify the range and diversity of views and experiences. RESULTS: Participants expressed support for e-cigarettes in preparation for the smokefree policy, describing their symbolic and practical value in this context. Uptake of vaping was strongly influenced by the need for participants to manage without tobacco in the near future. Participants evaluated their initial vaping experiences, either positively or negatively, in relation to the utility of e-cigarettes for mandated smoking abstinence and in providing satisfaction, pleasure, and novelty. Participant views on several issues related to e-cigarette use, both specific to the prison population (product choice and cost) and more generally (safety and long-term use), are explored. CONCLUSIONS: Our findings suggest possible benefits of e-cigarettes as one means of supporting smokefree policy in a population with many smokers. They also point to potential challenges posed by vaping in prisons and smokefree settings caring for similar populations. There is a need for ongoing measures to maximize the health benefits of smokefree settings and for further research on vaping in situations of enforced abstinence. IMPLICATIONS: To our knowledge, no published studies have explored views and experiences of vaping in prison, when rechargeable vapes were new and the removal of tobacco was imminent. The results can inform tobacco control policy choices, planning and implementation in prisons and similar settings. In prison systems that permitting vaping, it is important that other measures (eg, information campaigns and nicotine dependence services) are implemented concurrently to minimize potential risks to the health or personal finances of people in custody.

Protocol for a Mixed-Method Investigation of the Impact of the COVID-19 Pandemic and Gambling Practices, Experiences and Marketing in the UK: The "Betting and Gaming COVID-19 Impact Study".

The COVID-19 pandemic led to unprecedented restrictions on people's movements and interactions, as well as the cancellation of major sports events and social activities, directly altering the gambling landscape. There is urgent need to provide regulators, policy makers and treatment providers with evidence on the patterns and context of gambling during COVID-19 and its aftermath. This protocol describes a study addressing the following three questions: (1) How has COVID-19 changed gambling practices and the risk factors for, and experience of, gambling harms? (2) What is the effect of COVID-19 on gambling marketing? (3) How has COVID-19 changed high risk groups' gambling experiences and practices? This mixed-method study focuses on two groups, namely young adults and sports bettors. In workpackage-1, we will extend an existing longitudinal survey of gambling in young adults (aged 16-24 years) (first wave conducted June-August 2019), adding COVID-19-related questions to the second wave (July-August 2020) and extending to a third wave in 2021; and undertake a survey of sports bettors in the UK (baseline n = 4000, ~July-August 2020), with follow-ups in ~October-November 2020 and ~February-March 2021. In workpackage-2, we will examine changes in expenditure on paid-for gambling advertising from January 2019 to July 2021 and undertake a mixed-method content analysis of a random sample of paid-for gambling advertising (n ~ 200) and social media marketing (n ~ 100) during the initial COVID-19 "lockdown". Workpackage-3 will involve qualitative interviews with a purposive sample of (a) young adults (aged 18-24 years) and (b) sports bettors.

Extending health messaging to the consumption experience: a focus group study exploring smokers' perceptions of health warnings on cigarettes.

Introduction: While most countries require health warnings on cigarette packs, the Scottish and Canadian Governments are considering requiring health warnings on cigarette sticks. Methods: Twenty focus groups were conducted in Glasgow and Edinburgh (Scotland) with smokers (n = 120) segmented by age (16-17, 18-24, 25-35, 36-50, >50), gender and social grade, to explore perceptions of cigarettes displaying the warning 'Smoking kills' on the cigarette paper and any demographic differences in how smokers responded to these. Results: A warning on each cigarette was thought to prolong the health message, as it would be visible when a cigarette was taken from a pack, lit, left in an ashtray, and with each draw, and make avoidant behavior more difficult. That it would be visible to others was perceived as off-putting for some. It was felt that a warning on each cigarette would create a negative image and be embarrassing. Within several female groups they were viewed as depressing, worrying and frightening, with it suggested that people would not feel good smoking cigarettes displaying a warning. Within every group there was mention of warnings on cigarettes potentially having an impact on themselves, others or both. Some, mostly younger groups, mentioned stubbing cigarettes out early, reducing consumption or quitting. The consensus was that they would be off-putting for young people, nonsmokers and those starting to smoke. Conclusions: Including a warning on each cigarette stick is a viable policy option and one which would, for the first time, extend health messaging to the consumption experience.

Association of Video Game Use With Body Mass Index and Other Energy-Balance Behaviors in Children.

Importance: Childhood obesity is one of the biggest public health threats facing the UK, and video game use is considered a risk behavior for obesity among children. However, few studies have explored the prospective association between video game use and body mass index (BMI) or the potential mediators of this association. Objectives: To investigate whether a longer-term association exists between video game use at a young age and BMI SD score in later years, independent of television use, and to ascertain whether this association is mediated by other energy-balance behaviors. Design, Setting, and Participants: This cohort study is a secondary analysis of data from the Millennium Cohort Study, a nationally representative sample of children who were born in the UK between September 1, 2000, and January 31, 2002, that focused on data collected when the children were aged 5, 7, 11, and 14 years. Data for all variables, except BMI, were provided by parental or caregiver reporting if the children were younger than 14 years of age. At age 14 years, the children self-reported their own behavior. Initial data analysis was conducted between September 18, 2018, and September 28, 2018, with supplementary analyses conducted from October 7, 2019, to November 22, 2019. Main Outcomes and Measures: The main outcome variable was BMI SD scores, with video game use as the exposure variable of interest. Physical activity, bedtime regularity, sugar-sweetened beverage consumption, and high-calorie food consumption were included as potential mediating behaviors. Results: The full sample comprised 16 376 children and had a nearly equal number of boys (8393 [51.3%]) and girls (7983 [48.7%]). Every 1 SD increase in the number of hours of video game use at age 5 years was associated with a ß = 0.018 higher BMI SD score at age 14 years (95% CI, 0.004-0.032). A small partial mediation of this association was found (direct association: ß = 0.017 [95% CI, 0.003-0.031]; indirect association: ß = 0.0011 [95% CI, 0.0003-0.0019]), suggesting that irregular bedtimes and higher consumption of sugar-sweetened beverages were mediators. The mediation model accounted for 36.7% (95% CI, 35.5-37.8) of the variance of the BMI SD score at age 14 years. Conclusions and Relevance: Results of this study suggest a small (and not clinically meaningful) association between video game use in early childhood and higher BMI in later years, which may be mediated by irregular bedtimes and higher consumption of sugar-sweetened beverages. Future interventions to prevent childhood obesity should incorporate health promotion in mainstream video games to target children most at risk because of their high level of video game use.

Perspectives on smokefree prison policy among people in custody in Scotland.

PURPOSE: This paper aims to explore smokefree prison policy, from the perspective of people in custody in Scotland. DESIGN/METHODOLOGY/APPROACH: In total, 77 people in custody in Scotland were interviewed in the period leading up to implementation of a nationwide prison smokefree policy. Data were thematically analysed to identify the diversity of views and experiences. FINDINGS: Participants described a widespread awareness in prisons of plans to implement a smokefree policy from 30 November 2018. Opinions about smokefree prisons varied among participants based on perceptions of the fairness, and anticipated positive and negative consequences of removing tobacco from prisons. At the time of the interviews, people in custody were responding to the impending smokefree policy, either by proactively preparing for the smokefree rule change or by deploying avoidance strategies. Participants described opportunities and challenges for implementing smokefree policy in prisons across three main themes: the role of smoking in prison, prison smoking cessation services and motivations for quitting smoking among people in custody. ORIGINALITY/VALUE: This study exploring smokefree prisons from the perspectives of people in custody has several novel features which extend the evidence base. The findings highlight measures for jurisdictions to consider when planning to prohibit smoking in their prisons in the future. These include the need for evidence-based smoking cessation support in advance of smokefree policy, effective communication campaigns, consideration of broader structural determinants of health in prison and ongoing measures to reduce rates of return to smoking post release.

Implementation of a peer-led school based smoking prevention programme: a mixed methods process evaluation.

BACKGROUND: Smoking prevention programmes that reach adolescents before they experiment with tobacco may reduce the prevalence of tobacco use. ASSIST is a school-based, peer-led smoking prevention programme that encourages the diffusion of non-smoking norms among secondary school students (aged 12-13), and was shown in a randomised control trial (conducted 2001-2004) to reduce the prevalence of weekly smoking. This paper presents findings from a process evaluation of the implementation of ASSIST in Scotland in 2014-2017. It examines acceptability and fidelity of implementation and explores the context of message diffusion between peers. METHODS: Mixed method implementation study with students (n = 61), school staff (n = 41), trainers (n = 31) and policy and commissioning leads (n = 17), structured observations (n = 42) and student surveys (n = 2130). RESULTS: ASSIST was delivered with a high degree of fidelity to the licensed manual with all elements of the programme implemented. Student survey findings indicated that the frequency of conversations about smoking increased over the ASSIST delivery period (18% at baseline, 26% at follow-up), but student recollection of conversations about smoking with peer supporters was low (9%). The delivery context of ASSIST was important when considering perceptions of message diffusion. In the study schools, survey findings showed that 0.9% (n = 19) of participants were regular smokers (at least once a week), with nine out of ten (89.9%, n = 1880) saying they had never smoked. This very low prevalence may have affected when and with whom conversations took place. Study participants indicated that there were wider benefits of taking part in ASSIST for: peer supporters (i.e. personal and communication skills); schools (an externally delivered health promotion programme that required minimal resource from schools); and communities (via communication about the risks of smoking to wider social networks). CONCLUSIONS: ASSIST in Scotland was delivered with a high degree of fidelity to the licensed programme and was acceptable from the perspective of schools, students and trainers. Targeting ASSIST in deprived areas with higher youth smoking prevalence or in other countries where youth smoking rates are rising or higher than in Scotland may be particularly relevant for the future delivery.

The Response of Retailers in Scotland to the Standardised Packaging of Tobacco Products Regulations and Tobacco Products Directive.

INTRODUCTION: With most marketing channels prohibited, the retail environment has assumed greater importance for tobacco companies, even in markets with a ban on the open display of tobacco products. Research has yet to qualitatively explore how retailers respond to standardized packaging in a country where this has been introduced. METHODS: As part of the DISPLAY study, face-to-face interviews were conducted with 24 small retailers in Scotland between May 23 and June 26, 2017; the interviews were conducted after The Standardised Packaging of Tobacco Products Regulations and the Tobacco Products Directive were fully implemented. RESULTS: We found high retailer compliance with the legislation. With price-marked packs and packs containing less than 20 cigarettes and 30 g of rolling tobacco banned, retailers stated that this helped simplify ordering and stock management. The removal of price-marked packs also allowed them some flexibility to set their own prices, but many chose to stick closely to recommended retail price in order to remain competitive and avoid complaints from customers. In contrast to one of the tobacco industry's arguments against standardized packaging, most retailers suggested that transaction times had not increased, even though the changes had only recently come into force. CONCLUSIONS: This study challenges some of the arguments used against standardized packaging and provides an insight into the storage and pricing strategies adopted by retailers following the removal of price-marked packs. IMPLICATIONS: This study explores the response of the retailers to the introduction of standardized tobacco packaging and provides an insight into the storage and pricing strategies adopted by retailers following the removal of price-marked packs. It explores the importance of the retailer in tobacco companies' desire to maintain tobacco sales and challenges some of the arguments used against standardized packaging, such as an increase in transaction times. Countries seeking to introduce standardized packaging should monitor the experiences of retailers, preferably from preimplementation through to post implementation, to help understand how retailers respond to this policy and to inform compliance.