Impact of standardised packaging in the UK on warning salience, appeal, harm perceptions and cessation-related behaviours: a longitudinal online survey.

INTRODUCTION: In the UK, since 20 May 2017, tobacco companies must sell cigarettes and rolling tobacco in standardised packs. METHODS: Three waves of a longitudinal online survey with smokers (≥16) before standardised packaging (wave 1 (W1): April to May 2016) and after standardised packaging (wave 2 (W2): September to November 2017; wave 3 (W3): May to July 2019). Of the 6233 smokers at W1, 4293 responded at W2 and 3175 at W3. We explored smokers' response to warning salience, appeal (appeal, quality, value, satisfaction and taste compared with a year ago), harm (harmfulness compared with a year ago, harm compared with other brands and whether some brands have more harmful substances), and quit plans, attempts and quitting. RESULTS: Compared with W1, the proportions noticing warnings first on packs, and rating cigarettes/rolling tobacco less appealing and worse value than a year ago, were higher at W2 and W3. Disagreeing that some brands contain more harmful substances was higher at W2. Interactions between social grade and survey wave for warning salience, and each appeal and harm outcome, were non-significant. Smokers switching from not noticing warnings first at W1 to noticing warnings first at W2, or who had a lower composite appeal score at W2, were more likely to plan to quit and to have made a quit attempt at W2. Smokers who switched to disagreeing that some brands contain more harmful substances at W2, after giving a different response at W1, were more likely to quit at W3. CONCLUSIONS: Standardised packaging appears to be having the intended impacts.

Youth perceptions of Brand variant names on standardised cigarette packs, and responses to replacing these with numbers: a focus group study in Britain.

Tobacco companies use brand variant name on cigarette packaging to differentiate, and create interest in, their products. We explored young peoples' reactions to brand variant names on cigarette packs and perceptions of replacing these with numbers, a proposed policy in Turkey. Twelve focus groups, segmented by gender, age (11-12, 13-14, 15-16) and social grade (ABC1, C2DE), were conducted across Britain from May-July 2018 (n = 89). Participants were asked what they thought about brand names in general, and on cigarette packs, and perceptions of replacing the brand variant name on cigarette packs with a number. Brand (variant) name was considered important for products, including cigarettes, and thought to communicate information about the product, image, price, and taste, and encourage purchase. Although replacing brand variant names on cigarette packs with numbers caused confusion, several participants mentioned that it would eliminate any remaining marketing power that the pack may have. They thought that numbered cigarette packs could be off-putting due to the absence of a familiar brand name, although the impact on smokers was considered negligible. Although adolescents were not clear on the rationale for numbered cigarette packs, some suggested that this would reduce one of the few remaining promotional features on standardised packs.

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 Response of Smokers to Health Warnings on Packs in the United Kingdom and Norway Following the Introduction of Standardized Packaging.

INTRODUCTION: Standardized packaging was phased in between May 2016 and May 2017 in the United Kingdom and July 2017 and July 2018 in Norway. In both countries, the health warnings on packs prior to standardized packaging being implemented were from the former Tobacco Products Directive library of warnings (text warnings covering 43% of the pack front and pictorial warnings covering 53% of the pack reverse). The warnings on packs, postimplementation, were from the current Tobacco Products Directive library of warnings (novel pictorial warnings covering 65% of the pack front and reverse) for the United Kingdom but unchanged in Norway. AIMS AND METHODS: Longitudinal online surveys were conducted prior to standardized packaging (United Kingdom: April-May 2016; Norway: May-June 2017) and postimplementation (United Kingdom: September-November 2017 and May-July 2019; Norway: August-September 2018). We explored smokers' response to the on-pack warnings (salience, cognitive reactions, and behavioral reactions). RESULTS: In the United Kingdom, noticing warnings on packs, reading or looking closely at them, thinking about them, thinking about the health risks, avoidant behaviors, forgoing cigarettes, and being more likely to quit due to the warnings significantly increased from waves 1 to 2, and then decreased from waves 2 to 3, but remained higher than at wave 1. In Norway, noticing warnings, reading or looking closely at them, thinking about them, thinking about the health risks, and being more likely to quit due to the warnings significantly decreased from waves 1 to 2; avoidant behaviors and forgoing cigarettes remained unchanged. CONCLUSIONS: The inclusion of large novel pictorial warnings on standardized packs increases warning salience and effectiveness. IMPLICATIONS: Two longitudinal online surveys in the United Kingdom and Norway explored the impact of standardized packaging on warning salience and effectiveness. That warning salience and effectiveness only increased in the UK postimplementation, where standardized packaging was implemented alongside new larger pictorial warnings on the pack front and reverse, and not in Norway, where standardized packaging was introduced but older smaller text warnings (pack front) and pictorial warnings (pack reverse) were retained, highlights the importance of removing full branding and introducing stronger warnings simultaneously.

Impact of a ban on the open display of tobacco products in retail outlets on never smoking youth in the UK: findings from a repeat cross-sectional survey before, during and after implementation.

BACKGROUND: In the UK, a ban on the open display of tobacco products at the point of sale (POS) was phased in between 2012 and 2015. We explored any impact of the ban on youth before, during and after implementation. METHODS: A repeat cross-sectional in-home survey with young people aged 11-16 years old in the UK was conducted preban (2011, n=1373), mid-ban (2014, n=1205) and postban (2016, n=1213). The analysis focuses on the never-smokers in the sample (n=2953 in total). Preban, we quantified the associations of noticing cigarettes displayed at POS and cigarette brand awareness with smoking susceptibility. We measured any change in noticing cigarettes displayed at POS, cigarette brand awareness and smoking susceptibility between preban, mid-ban and postban. Postban, we assessed support for a display ban, perceived appeal of cigarettes and perceived acceptability of smoking as a result of closed displays. RESULTS: Preban, noticing cigarettes displayed at POS (adjusted OR [AOR]=1.97, 95% CI 1.30 to 2.98) and higher brand awareness (AOR=1.15, 95% CI 1.03 to 1.29) were positively associated with smoking susceptibility. The mean number of brands recalled declined from 0.97 preban to 0.69 postban (p<0.001). Smoking susceptibility decreased from 28% preban to 23% mid-ban and 18% postban (p for trend <0.001). Postban, 90% of never-smokers supported the display ban and indicated that it made cigarettes seem unappealing (77%) and made smoking seem unacceptable (87%). CONCLUSIONS: Both partial and full implementation of a display ban were followed by a reduction in smoking susceptibility among adolescents, which may be driven by decreases in brand awareness.

Adolescents' perceptions of tobacco accessibility and smoking norms and attitudes in response to the tobacco point-of-sale display ban in Scotland: results from the DISPLAY Study.

BACKGROUND: Scotland implemented a ban on open display of tobacco products in supermarkets in April 2013, and small shops in April 2015. This study aimed to quantify changes in perceived tobacco accessibility, smoking norms and smoking attitudes among adolescents in Scotland, following the implementation of partial and comprehensive point-of-sale (POS) tobacco display bans. METHODS: From the Determining the Impact of Smoking Point of Sale Legislation Among Youth (DISPLAY) Study's 2013-2017 annual surveys we retrieved data comprising 6202 observations on 4836 12-17-year-old adolescents from four schools. Applying generalised estimating equations, associations between time (postban: 2016-2017 vs preban:2013) and three outcomes were estimated. Outcomes were perceived commercial access to tobacco, perceived positive smoking norm (friends think it's OK to smoke) and positive smoking attitude (you think it's OK to smoke). Analyses were adjusted for sociodemographics, smoking status, family smoking, friend smoking and e-cigarette use. RESULTS: Crude trends showed an increase over time in perceived accessibility, norms and attitudes. However, after adjustment for confounders, mainly e-cigarette use, we found significant declines in perceived access (OR = 0.72, 95% CI 0.57 to 0.90) and in positive smoking attitude (OR = 0.67, 95% CI = 0.49 to 0.91), but no change in perceived positive smoking norm (OR = 1.00, 95% CI 0.78 to 1.29). Current/past occasional or regular e-cigarette use was associated with higher odds of perceived access (OR = 3.12, 95% CI 2.32 to 4.21), positive norm (OR = 2.94, 95% CI 2.16 to 4.02) and positive attitude (OR = 3.38, 95% CI 2.35 to 4.87). CONCLUSION: Only when taking into account that the use of e-cigarettes increased in 2013-2017 did we find that the POS tobacco display ban in supermarkets and small shops in Scotland was followed by reductions in adolescents' perceived accessibility of tobacco and positive attitudes towards smoking.

Have e-cigarettes renormalised or displaced youth smoking? Results of a segmented regression analysis of repeated cross sectional survey data in England, Scotland and Wales.

OBJECTIVES: To examine whether during a period of limited e-cigarette regulation and rapid growth in their use, smoking began to become renormalised among young people. DESIGN: Interrupted time-series analysis of repeated cross-sectional time-series data. SETTING: Great Britain PARTICIPANTS: 248 324 young people aged approximately 13 and 15 years, from three national surveys during the years 1998-2015. INTERVENTION: Unregulated growth of e-cigarette use (following the year 2010, until 2015). OUTCOME MEASURES: Primary outcomes were prevalence of self-reported ever smoking and regular smoking. Secondary outcomes were attitudes towards smoking. Tertiary outcomes were ever use of cannabis and alcohol. RESULTS: In final models, no significant change was detected in the pre-existing trend for ever smoking (OR 1.01, CI 0.99 to 1.03). There was a marginally significant slowing in the rate of decline for regular smoking (OR 1.04, CI 1.00 to 1.08), accompanied by a larger slowing in the rate of decline of cannabis use (OR 1.21, CI 1.18 to 1.25) and alcohol use (OR 1.17, CI 1.14 to 1.19). In all models and subgroup analyses for smoking attitudes, an increased rate of decline was observed after 2010 (OR 0.88, CI 0.86 to 0.90). Models were robust to sensitivity analyses. CONCLUSIONS: There was a marginal slowing in the decline in regular smoking during the period following 2010, when e-cigarettes were emerging but relatively unregulated. However, these patterns were not unique to tobacco use and the decline in the acceptability of smoking behaviour among youth accelerated during this time. These analyses provide little evidence that renormalisation of youth smoking was occurring during a period of rapid growth and limited regulation of e-cigarettes from 2011 to 2015. TRIAL REGISTRATION NUMBER: Research registry number: researchregistry4336.

An Exploration of the Impact of Non-Dependent Parental Drinking on Children.

AIMS: To examine the impact of non-dependent parental drinking on UK children aged 10-17. METHODS: Cross-sectional survey of UK parents and their children in 2017 (administered to one parent in a household, then their child, totaling 997 adults and 997 children), providing linked data on parental drinking from parent and child perspectives. The survey included measures of parents' alcohol consumption and drinking motivations (both reported by parents) and children's exposure to their parent's drinking patterns and children's experiences of negative outcomes following their parent's drinking (both reported by children), plus sociodemographic measures. RESULTS: Logistic regression analysis indicates a significant positive association between parental consumption level and children reporting experiencing negative outcomes. Witnessing a parent tipsy or drunk and having a parent who reported predominantly negative drinking motives were also associated with increased likelihood of children reporting experiencing negative outcomes. Age was also associated, with older children less likely to report experiencing negative outcomes following their parent's drinking. CONCLUSIONS: Findings suggest levels of and motivations for parental drinking, as well as exposure to a parent tipsy or drunk, all influence children's likelihood of experiencing negative outcomes.

Awareness of product-related information, health messages and warnings on alcohol packaging among adolescents: a cross-sectional survey in the United Kingdom.

BACKGROUND: Alcohol packaging can be used to communicate product-related information, health messages and health warnings to consumers. We examined awareness and recall of such information and messaging among adolescents in the United Kingdom. METHOD: A cross-sectional survey was conducted with 11-19 year olds in the United Kingdom (n = 3399), with participants asked if they had seen any information, health messages or warnings on alcohol packaging in the past month (Yes/No) and, if so, what they recalled. We also assessed higher-risk drinking among current drinkers (≥5 Alcohol Use Disorders Identification Test-Consumption) and susceptibility to consume among never-drinkers. RESULTS: One-third (32%) of participants had seen information, health messages or warnings on alcohol packaging. Chi-Square tests showed awareness was greater for current drinkers than non-drinkers (46% vs. 19%; P < 0.001), higher-risk drinkers than lower-risk drinkers (55% vs. 39%; P < 0.001), and susceptible never-drinkers than non-susceptible never-drinkers (21% vs. 16%; P = 0.01). Ten messages were recalled, with drinking responsibly (18%) and not drinking during pregnancy (13%) most recalled. CONCLUSION: Most young drinkers, including almost half of higher-risk drinkers, did not recall seeing any information, health messages or warnings on alcohol packaging in the past month, suggesting that current labelling is failing to reach this key audience.

Introduction of Standardized Tobacco Packaging During a 12-Month Transition Period: Findings From Small Retailers in the United Kingdom.

INTRODUCTION: Factory-made cigarettes (FMC) and roll-your-own (RYO) tobacco have had to be produced in standardized packaging since May 20, 2016 in the United Kingdom, with a minimum pack size of 20 sticks for FMC and 30 g for RYO. Manufacturers and retailers were given a 12-month transition period. METHODS: An observational study was conducted using monthly Electronic Point of Sale data from 500 small retailers in England, Scotland, and Wales, between May 2016 and May 2017. The 20 top selling tobacco products (15 FMC, 5 RYO) were monitored to observe when standardized packs were first introduced, the proportion of retailers selling each fully branded and standardized product, and the average number of monitored fully branded and standardized products sold by each retailer. The number of unique tobacco-related product codes sold by each retailer was also recorded each month. RESULTS: Eighteen of the fully branded products continued to be sold throughout the transition period and no standardized variants were sold in the first 5 months. It was not until month eleven that the average number of standardized products sold by retailers exceeded the fully branded products. The average number of unique tobacco-related product codes sold by each retailer decreased by a third over the transition period. CONCLUSIONS: Tobacco companies used the transition period to delay the removal of fully branded products and gradually introduce standardized variants. This staggered introduction may have mitigated some of the immediate intended effects of the legislation by desensitizing consumers to new pack designs. IMPLICATIONS: Evaluation research from countries which have introduced standardized packaging for tobacco products is key to help inform future implementation. This is the first study to monitor the transition from fully branded to standardized products using real-time retail data. The findings demonstrate that tobacco companies delayed the introduction of standardized products and removal of fully branded packaging. Countries seeking to introduce standardized packaging should consider what length of transition is allowed, as the protracted 12-month period in the United Kingdom appeared longer than needed to transition stockholding and may have mitigated immediate intended effects by desensitizing consumers to new pack designs.

The Response of Young Adult Smokers and Nonsmokers in the United Kingdom to Dissuasive Cigarettes: An Online Survey.

Introduction: The cigarette stick is an important communications tool as well as the object of consumption. We explored young adults' responses to cigarettes designed to be dissuasive. Methods: Data come from a cross-sectional online survey, conducted in September 2015, with 16- to 24-year-old smokers and nonsmokers (N = 997) in the United Kingdom. Participants were shown images of a standard cigarette (white cigarette paper with imitation cork filter), a standard cigarette displaying the warning "Smoking kills" on the cigarette paper, and an unattractively colored cigarette (green cigarette paper and filter). They were asked to rate each of the three cigarettes, shown individually, on eight perception items, and to rate the three cigarettes, shown together, on how likely they would be to try them. Ordering of the cigarettes and questions, with the exception of the question on trial, was randomized. Results: The eight perception items were combined to form a composite measure of cigarette perceptions. For smokers and nonsmokers, the two dissuasive cigarettes (cigarette with warning, green cigarette) were rated significantly less favorably than the standard cigarette, and less likely to encourage trial. For cigarette perceptions, no significant interaction was detected between cigarette style and smoking status or susceptibility to smoke among never smokers. A significant interaction was found for likelihood of trying the cigarettes, with dissuasive cigarettes having a greater impact with smokers than nonsmokers. Conclusions: This study suggests that dissuasive cigarettes may help to reduce the desirability of cigarettes. Implications: The cigarette stick is the object of tobacco consumption, which is seen every time a cigarette is smoked. It is also an increasingly important promotional tool for tobacco companies. In this study, young adults rated two dissuasive cigarettes (a green colored cigarette and a cigarette displaying a health warning) more negatively than a standard cigarette, and considered them less likely to encourage product trial. Our findings suggest that it may be possible to reduce the desirability of cigarette sticks by altering their design, for example, with the addition of a warning or use of an unattractive color.

Use of Cigarettes With Flavor-Changing Capsules Among Smokers in the United Kingdom: An Online Survey.

INTRODUCTION: Cigarettes with flavor-changing capsules in the filter have experienced phenomenal global growth in the last decade. We explore sociodemographic and smoking-related factors associated with using capsule cigarettes, how frequently users burst the capsule, and reasons for using them. METHODS: An online survey was conducted in the United Kingdom between April and May 2016 with 6234 factory-made and/or hand-rolled cigarette smokers. This analysis focuses on 3620 factory-made cigarette smokers, aged 18 years and over, who had smoked in the past month. RESULTS: Thirteen percent smoked capsule cigarettes, with younger smokers more likely than older smokers to do so. Capsule use was significantly more common among White non-British than White British and among those planning to quit in the next 6 months than those not planning to quit. Most capsule users who crushed the capsule did so always (51%) or most of the time (18%), with more frequent crushing of capsules more common among females, younger and middle-aged participants, White British, and those with a lower score on the Heaviness of Smoking Index. The most common reasons for using capsule cigarettes were that they taste better (52%), are smoother (41%), provide a choice of flavors (32%), and the enjoyment of clicking the capsule (25%). Capsule and noncapsule smokers did not differ significantly in their perceptions of the harmfulness of their brand relative to other brands. CONCLUSIONS: Our study provides an insight into how and why smokers of capsule cigarettes use these products, with the key drivers of use being taste, flavor choice, and interactivity. IMPLICATIONS: Cigarettes with capsules in the filter that can be burst to change the flavor have experienced remarkable growth since being introduced in 2007, but little is known about how and why smokers use these products. Thirteen percent of factory-made cigarette smokers in our sample smoked a brand with a capsule in the filter, with approximately two-thirds crushing the capsule all or most of the time. Capsule use was more likely among younger participants. The main reasons for smoking capsule cigarettes were related to how they taste, having a choice of flavors, and enjoyment of clicking the capsule (interactivity).

Difference between recommended retail price and sales price for tobacco products in independent and convenience (small) retailers before and after the introduction of standardised tobacco packaging in the UK.

AIM: Recommended retail price (RRP) is a marketing strategy used by tobacco companies to maintain competitiveness, communicate product positioning and drive sales. We explored small retailer adherence to RRP before and after the introduction of the Standardised Packaging of Tobacco Products Regulations in the UK (fully implemented on 20 May 2017) which mandated standardised packaging of cigarettes and rolling tobacco, set minimum pack/pouch sizes and prohibited price-marking. METHOD: Monthly electronic point of sale data from 500 small retailers in England, Scotland and Wales were analysed. From May 2016 to October 2017, we monitored 20 of the best-selling fully branded tobacco products (15 factory-made cigarettes, 5 rolling tobacco) and their standardised equivalents. Adherence to RRP was measured as the average difference (%) between monthly RRPs and sales prices by pack type (fully branded vs standardised), price-marking on packaging and price segment. RESULTS: The average difference between RRP and sales price increased from +0.36% above RRP (SD=0.72) in May 2016, when only fully branded packs were sold, to +1.37% in October 2017 (SD=0.30), when standardised packs were mandatory. Increases above RRP for fully branded packs increased as they were phased out, with deviation greater for non-price-marked packs and premium products. DISCUSSION: Despite tobacco companies emphasising the importance of RRP, small retailers implemented small increases above RRP as standardised packaging was introduced. Consequently, any intended price changes by tobacco companies in response to the legislation (ie, to increase affordability or brand positioning) may be confounded by retailer behaviour, and such deviation may increase consumer price sensitivity.

Participation with alcohol marketing and user-created promotion on social media, and the association with higher-risk alcohol consumption and brand identification among adolescents in the UK.

Aim: To explore participation with alcohol marketing (i.e. commenting on brand statuses) and user-created promotion on social media (i.e. photos of peers drinking) by young people in the United Kingdom (UK), and what association this has with higher-risk consumption and brand identification. Method: Online cross-sectional survey with 11-19-year olds in the UK (n = 3,399) (average age: 15 years old). Past-month participation was measured for five forms of alcohol marketing on social media and one form of user-created promotion (all Yes/No). Past-month awareness of nine wider alcohol marketing activities, social media apps used at least weekly, and ownership of branded merchandise were included as covariates. Outcomes included higher-risk consumption in current drinkers (≥5 AUDIT-C) and brand identification in all respondents (8 pictures with brand names removed). Results: Over one-in-ten respondents (13.2%) had participated with at least one form of marketing on social media or participated with user-created promotion (12.2%). For both, participation was greater in current drinkers and those of legal purchasing age. A logistic regression found that participation with two or more forms of marketing on social media (AOR = 1.96, p < .01) and participation with user-created promotion (AOR = 3.46, p < .001) were associated with higher-risk drinking. Respondents, on average, identified 2.58 (SD = 2.12) alcohol brands. A linear regression found participation with marketing on social media was not associated with brand identification (ß = 0.01, p = .42) but participation with user-created promotion was (ß = 0.05, p < .001). Conclusion: Social media provides opportunities for adolescents to participate with commercial marketing and user-created promotion and this is associated with higher-risk consumption and brand identification.

Adolescents' Perceptions of an On-cigarette Health Warning.

INTRODUCTION: In most countries, health warnings have been on cigarette packs for decades. We explored adolescents' perceptions of a health warning on cigarettes. METHODS: Data come from the 2014 wave of a cross-sectional in-home survey with 11- to 16-year olds (N = 1205) from across the UK, with participants recruited from the general population using random location quota sampling. Participants were shown an image of a standard cigarette which displayed the warning "Smoking kills" and asked whether they thought this would (not) put people off starting to smoke, (not) make people want to give up smoking, and whether all cigarettes should (not) have health warnings on them. RESULTS: Most (71%) thought that an on-cigarette warning would put people off starting, although this decreased with age. Never smokers were more likely than current smokers to think that it would put people off starting. Approximately half (53%) thought that an on-cigarette warning would make people want to give up smoking, with this higher for never smokers and experimenters/past smokers than for current smokers. Most (85%) supported a warning on all cigarettes. There was support among each smoking group, although this was higher for never smokers and experimenters/past smokers than for current smokers, and higher for those indicating that most of their close friends do not smoke than for those indicating that most of their close friends do smoke. CONCLUSIONS: The perception among adolescents that an on-cigarette warning could deter smoking, and the high support for a warning on all cigarettes, warrants further research. IMPLICATIONS: Research on dissuasive cigarettes is at a nascent stage. This is the first study to explore how adolescents perceive a health warning ("Smoking kills") on cigarettes. Almost three quarters of participants indicated that on-cigarette health warnings would deter people from starting to smoke, and 85% supported the inclusion of a warning on all cigarettes. While further research is clearly needed, these findings suggest that the inclusion of health warnings on cigarettes is considered appropriate by young people and may have a dissuasive effect.

Relationship between trying an electronic cigarette and subsequent cigarette experimentation in Scottish adolescents: a cohort study.

BACKGROUND: This study examines whether young never smokers in Scotland, UK, who have tried an e-cigarette are more likely than those who have not, to try a cigarette during the following year. METHODS: Prospective cohort survey conducted in four high schools in Scotland, UK during February/March 2015 (n=3807) with follow-up 1 year later. All pupils (age 11-18) were surveyed. Response rates were high in both years (87% in 2015) and 2680/3807 (70.4%) of the original cohort completed the follow-up survey. Analysis was restricted to baseline 'never smokers' (n=3001/3807), 2125 of whom were available to follow-up (70.8%). RESULTS: At baseline, 183 of 2125 (8.6%) never smokers had tried an e-cigarette and 1942 had not. Of the young people who had not tried an e-cigarette at baseline, 249 (12.8%) went on to try smoking a cigarette by follow-up. This compares with 74 (40.4%) of those who had tried an e-cigarette at baseline. This effect remained significant in a logistic regression model adjusted for smoking susceptibility, having friends who smoke, family members' smoking status, age, sex, family affluence score, ethnic group and school (adjusted OR 2.42 (95% CI 1.63 to 3.60)). There was a significant interaction between e-cigarette use and smoking susceptibility and between e-cigarette use and smoking within the friendship group. CONCLUSIONS: Young never smokers are more likely to experiment with cigarettes if they have tried an e-cigarette. Causality cannot be inferred, but continued close monitoring of e-cigarette use in young people is warranted.

How Tobacco Companies are Perceived Within the United Kingdom: An Online Panel.

INTRODUCTION: Little is known about how consumers perceive tobacco companies in the United Kingdom. METHODS: An online cross-sectional survey with those aged 16 years and over (N = 2253) explored perceptions of, and attitudes towards, tobacco companies. This included awareness of tobacco companies, views on tobacco companies' practices (targeting the most vulnerable, encouraging smoking to replace those who quit or die, making cigarettes more addictive) and values (honesty, ethics, interest in harm reduction), perceptions of regulation of tobacco companies (whether tobacco companies have the same marketing rights as other companies, should be allowed to promote cigarettes, be required to sell cigarettes in plain packs, and pay for associated health costs), and locus of responsibility for health problems caused by tobacco use. RESULTS: Prompted awareness of tobacco companies was high (68%). Almost a third of the sample had a negative perception of tobacco companies' practices, for example, they thought they made cigarettes more addictive. In terms of tobacco companies' values, less than a fifth considered tobacco companies honest, ethical, and interested in reducing the harm caused by cigarettes. Indeed, tobacco company executives were rated lower than the seven other professions asked about, except car salesman, in terms of ethics and honesty. More than half the sample supported greater regulation, for example, requiring tobacco companies to pay for health costs due to tobacco use. Most attributed responsibility for smoking-related health problems to smokers (88%) and tobacco companies (55%). CONCLUSIONS: The findings suggest that consumers are not fully informed about tobacco company practices. IMPLICATIONS: Few studies outside of North America have explored perceptions of tobacco companies' practices, values and regulation and responsibility for smoking-related illness. Adults surveyed within the United Kingdom considered tobacco companies dishonest, unethical and untrustworthy, but only a third of the sample thought that they encourage new smokers or have made cigarettes more addictive, and just over a half attributed most of the responsibility for smoking-related health problems to tobacco companies. As consumers do not appear fully informed about the role of tobacco companies in initiating and perpetuating the tobacco epidemic, tobacco industry denormalization campaigns may be of potential value.

Relationship between e-cigarette point of sale recall and e-cigarette use in secondary school children: a cross-sectional study.

BACKGROUND: There has been a rapid increase in the retail availability of e-cigarettes in the UK and elsewhere. It is known that exposure to cigarette point-of-sale (POS) displays influences smoking behaviour and intentions in young people. However, there is as yet no evidence regarding the relationship between e-cigarette POS display exposure and e-cigarette use in young people. METHODS: This cross sectional survey was conducted in four high schools in Scotland. A response rate of 87 % and a total sample of 3808 was achieved. Analysis was by logistic regression on e-cigarette outcomes with standard errors adjusted for clustering within schools. The logistic regression models were adjusted for recall of other e-cigarette adverts, smoking status, and demographic variables. Multiple chained imputation was employed to assess the consistency of the findings across different methods of handling missing data. RESULTS: Adolescents who recalled seeing e-cigarettes in small shops were more likely to have tried an e-cigarette (OR 1.92 99 % CI 1.61 to 2.29). Adolescents who recalled seeing e-cigarettes for sale in small shops (OR 1.80 99 % CI 1.08 to 2.99) or supermarkets (OR 1.70 99 % CI 1.22 to 2.36) were more likely to intend to try them in the next 6 months. CONCLUSIONS: This study has found a cross-sectional association between self-reported recall of e-cigarette POS displays and use of, and intention to use, e-cigarettes. The magnitude of this association is comparable to that between tobacco point of sale recall and intention to use traditional cigarettes in the same sample. Further longitudinal data is required to confirm a causal relationship between e-cigarette point of sale exposure and their use and future use by young people.

Young women smokers' response to using plain cigarette packaging: qualitative findings from a naturalistic study.

BACKGROUND: The aim of this study was to explore in-depth the response of young women smokers (18-35 years) to using dark brown 'plain' cigarette packs in naturalistic settings. METHODS: Participants were recruited in six towns and cities in Scotland to take part in a naturalistic study, where they used plain cigarette packs for a week. Participants completed a number of questionnaires during the study period (reported elsewhere), and a sub-sample participated in post-study telephone interviews to explore their experiences of using the plain packs. Of the 187 participants who completed the study, 23 were randomly selected to participate in the post-study interviews. Within the interviews a semi-structured topic guide was used to assess perceptions of the plain pack, feelings created by the pack, feelings about smoking, and avoidant and smoking behaviour. RESULTS: The brown (plain) packs were perceived negatively due to the colour, the undesirable image the pack conveyed, and the reaction from others. The plain packs were also associated with negative feelings, such as embarrassment, discomfort and guilt. Some participants also commented that they felt differently about the product, considered to be less enjoyable or more harmful, when using the plain packs, and were less interested in, or felt more negatively about, smoking. A number of participants said that they had engaged in avoidant behavior with the plain packs, such as hiding it, due to their negative thoughts about the packs and the reaction of others. Some participants also mentioned cessation-related behaviours when using the plain packs, such as forgoing cigarettes, stubbing cigarettes out early and thinking about quitting, largely due to the decreased enjoyment of smoking. CONCLUSIONS: The experience of using cigarettes in plain packs prompted a range of negative responses from young women smokers, who are a crucial target group for tobacco control interventions.