E-cigarette Use in Prisons With Recently Established Smokefree Policies: A Qualitative Interview Study With People in Custody in Scotland.

INTRODUCTION: E-cigarettes were one measure introduced to help people in custody (PiC) to prepare for and cope with implementation of comprehensive smokefree policies in Scottish prisons. Our earlier study explored experiences of vaping when e-cigarettes were first introduced and most participants were dual tobacco and e-cigarette users. Here we present findings of a subsequent study of vaping among a different sample of PiC when use of tobacco was prohibited in prison, and smokefree policy had become the norm. METHODS: Twenty-eight qualitative interviews were conducted with PiC who were current or former users of e-cigarettes in prison, 6-10 months after implementation of a smokefree policy. Data were managed and analyzed using the framework approach. RESULTS: PiC reported that vaping helped with mandated smoking abstinence. However, findings suggest that some PiC may be susceptible to heavy e-cigarette use potentially as a consequence of high nicotine dependence and situational factors such as e-cigarette product choice and availability in prisons; issues with nicotine delivery; prison regimes; and use of e-cigarettes for managing negative emotions. These factors may act as barriers to cutting down or stopping use of e-cigarettes by PiC who want to make changes due to dissatisfaction with vaping or lack of interest in continued use of nicotine, cost, and/or health concerns. CONCLUSIONS: E-cigarettes helped PiC to cope with smokefree rules, although concerns about e-cigarette efficacy, cost, and safety were raised. PiC may desire or benefit both from conventional smoking cessation programs and from interventions to support reduction, or cessation, of vaping. IMPLICATIONS: Findings highlight successes, challenges, and potential solutions in respect of use of e-cigarettes to cope with mandated smoking abstinence in populations with high smoking prevalence and heavy nicotine dependence. Experiences from prisons in Scotland may be of particular interest to health and/or justice services in other jurisdictions, with similar legislation on e-cigarettes to the United Kingdom, who are planning for institutional smokefree policies in their prisons or inpatient mental health settings in the future.

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.

How has the introduction of point-of-sale legislation affected the presence and visibility of tobacco retailing in Scotland? A longitudinal study.

BACKGROUND: Reducing the local availability of tobacco is identified as the 'next frontier' in tobacco control. This paper examines the roles of tobacco retail outlet density and tobacco visibility in changing exposure to tobacco retailing before and after the introduction of point-of-sale (POS) legislation in Scotland. METHODS: National tobacco retailer register data were analysed to examine time trends in tobacco retailer density (2012-2017). Results were stratified by local authority, neighbourhood deprivation and urbanity. Next, an annual retail audit using a POS tobacco visibility tool assessed changes in total product visibility in all retail outlets in four study communities between 2013 and 2017. A longitudinal survey (2013-2017) of 5527 adolescents aged 12-17 in the four study communities enabled the calculation of residential and journey-to-school measures of tobacco retailer exposure. Trends were stratified by deprivation, urbanity and socioeconomic status. RESULTS: Retail provision of tobacco declined following the introduction of the POS legislation in 2013. However, there were strong geographic differences; nationally, one-fifth of local authorities have increased provision since 2015. In the four study communities, tobacco retail provision was generally stable over the study period. Although product visibility of tobacco products reduced for adolescents there was growing socioeconomic disparity in the density of tobacco retailers and the visibility of tobacco storage. CONCLUSIONS: The POS ban reduced exposure to tobacco products in communities across Scotland. However, tobacco products remain widely available, and there is growing socioeconomic disparity in the availability and visibility of tobacco.

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.

Selling second best: how infant formula marketing works.

BACKGROUND: Despite the clear policy intent to contain it, the marketing of formula milk remains widespread, powerful and successful. This paper examines how it works. METHODS: The study comprised a mix of secondary analysis of business databases and qualitative interviews with marketing practitioners, some of whom had previously worked in formula marketing. RESULTS: The World Health Assembly Code aims to shield parents from unfair commercial pressures by stopping the inappropriate promotion of infant formula. In reality marketing remains widespread because some countries (e.g. the USA) have not adopted the Code, and elsewhere industry has developed follow-on and specialist milks with which they promote formula by proxy. The World Health Assembly has tried to close these loopholes by extending its Code to these products; but the marketing continues. The campaigns use emotional appeals to reach out to and build relationships with parents and especially mothers. Evocative brands give these approaches a human face. The advent of social media has made it easier to pose as the friend and supporter of parents; it is also providing companies with a rich stream of personal data with which they hone and target their campaigns. The formula industry is dominated by a small number of extremely powerful multinational corporations with the resources to buy the best global marketing expertise. Like all corporations they are governed by the fiduciary imperative which puts the pursuit of profits ahead of all other concerns. This mix of fiscal power, sophisticated marketing, and single-mindedness is causing great harm to public health. CONCLUSIONS: Formula marketing is widespread and using powerful emotional techniques to sell parents a product that is vastly inferior to breast milk. There is an urgent need to update and strengthen regulation.

Making hospital shops healthier: evaluating the implementation of a mandatory standard for limiting food products and promotions in hospital retail outlets.

BACKGROUND: The range of products stocked and their promotions in food retail outlets in healthcare settings can affect food choices by staff, patients and visitors. The innovative Scottish Healthcare Retail Standard (HRS) is a national mandatory scheme requiring all hospital food retail outlets to change the balance of food products stocked and their promotion to comply with nutritional criteria and promotional restrictions. The aim is to facilitate healthier food choices in healthcare settings. This study examined the implementation of HRS and the impact on foods stocked and promoted. METHODS: The study aimed to examine implementation process and changes to the retail environment in relation to food promotions and choice. A sample of hospital retail outlets (n = 17) including shops and trolley services were surveyed using a mixed methods design comprising: (a) structured observational audits of stock, layout and promotions (with a specific focus on chocolate and fruit product lines), and (b) face-to-face, semi-structured interviews with the shop manager or nominated members of staff (n = 32). Data were collected at Wave 1 (2016), at the beginning and during the early stages of HRS implementation; and Wave 2, 12 months later, after the HRS implementation deadline. RESULTS: All outlets, both commercial and not-for-profit, in the sample successfully implemented HRS. Implementation was reported to be more challenging by independent shop managers compared to chain store staff. Retail managers identified areas where more implementation guidance and support could have been provided. The number of chocolate product lines and promotions reduced substantially between Waves 1 and 2, but with no substantial increase in fruit product lines and promotions. Despite initial negative expectations of HRS's impact, managers identified some opportunities in the scheme and positive changes in the supply chain. CONCLUSIONS: Positive changes in food retail outlets occurred after hospital shops were required to implement HRS. By creating a consistent approach across hospital shops in Scotland, HRS changed the food retail environment for hospital staff, visitors and patients. HRS provides a regulatory template and implementation learning points for influencing retail environments in other jurisdictions and settings.

Parents' and carers' awareness and perceptions of UK supermarket policies on less healthy food at checkouts: A qualitative study.

BACKGROUND: In the retail environment strategic placement of food influences purchasing. Foods placed at checkouts have tended to be less healthy. In response to consumer concern some UK supermarkets voluntarily committed to removing less healthy food from their checkouts. We explored qualitatively the perceptions and experiences of parents and carers of younger children regarding food at supermarket checkouts, supermarket checkout food policies, and other supermarket stimuli which influences purchasing. METHODS: Twelve focus groups were conducted in urban central Scotland with 91 parents/carers of primary school aged children (aged 5-11 years). RESULTS: The availability of less healthy foods at checkouts was perceived as problematic, encouraging purchase requests by children and impulse buys by adults. Parents/carers were aware of a change in some supermarkets where less healthy foods had been replaced with healthier items and they were supportive of supermarket policies that placed restrictions on checkout food. Many parents/carers welcomed product-free checkouts, however the whole supermarket was perceived as manipulative and stimulating. CONCLUSION: Voluntary supermarket policies which clearly and consistently restrict the placement of less healthy foods at checkouts have been welcomed by parents/carers of young children. Given that marketing strategies throughout the whole supermarket were viewed as problematic, public health policymakers and advocacy groups may want to encourage supermarkets to develop broader policies to support healthier food purchasing.

Learning from the implementation of Universal Free School Meals in Scotland using Normalisation Process Theory: Lessons for policymakers to engage multiple stakeholders.

In 2014/15, Universal Free School Meals (UFSM) were introduced in Scotland and England for children in their first three years of primary school. This study examined the implementation of UFSM in Scotland using Normalisation Process Theory (NPT), a middle-range theory of implementation, to identify areas of learning for policymakers wishing to introduce or extend similar policies. NPT is predominantly used to evaluate interventions or new technologies in healthcare settings. Qualitative data were collected across Scotland using a case study approach shortly after implementation (n = 29 school-level stakeholders) and in the following school year (n = 18 school-level stakeholders and n = 19 local authority-level stakeholders). Observations of lunchtime in each school were conducted at both timepoints. Data were analysed using a thematic framework approach using NPT constructs and sub-constructs. Results suggested education and catering stakeholders experiences of implementation diverged most around the NPT concepts of coherence, cognitive participation, and reflexive monitoring. Lack of coherence around the purpose and long-term benefits of UFSM appeared to reduce education stakeholders' willingness to engage with the policy beyond operational issues. In contrast, catering stakeholders identified a direct benefit to their everyday work and described receiving additional resources to deliver the policy. Overall, participants described an absence of monitoring data around the areas of greatest salience for education stakeholders. This study successfully used NPT to identify policy learning around school meals. Policymakers must increase the salience of such intersectoral policies for all relevant stakeholders involved before policy implementation, and plan adequate monitoring to evaluate potential long-term benefits.

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 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.

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.

Tobacco companies' use of retailer incentives after a ban on point-of-sale tobacco displays in Scotland.

INTRODUCTION: Incentives have been used by tobacco companies for many years to encourage retailers to sell and promote their products. However, few studies have examined the use of retailer incentives in countries with a ban on the open display of tobacco products in stores. METHODS: As part of the DISPLAY(Determining the Impact of Smoking Point of Sale Legislation Among Youth) study, annual qualitative interviews were conducted with 24 small retailers in four Scottish communities. This article focuses on data collected in June to July 2015 and June to July 2016 after a ban on the open display of tobacco was fully implemented in Scotland. RESULTS: Retailers described being offered and benefiting from a range of financial and other incentives, typically offered via tobacco company representatives ('reps'). Most of the retailers received tobacco manufacturer support for converting their storage unit to be compliant with the new regulations, and several participated in manufacturer 'loyalty' or 'reward' schemes. Incentives were additionally offered for maintaining stock levels and availability, positioning brands in specified spaces in the public-facing storage units (even though products were covered up), increasing sales, trialling new products and participating in specific promotions, such as verbally recommending specific brands to customers. CONCLUSIONS: Even in a market where the open display of tobacco is prohibited, tobacco companies continue to incentivise retailers to sell and promote their brands and have developed new promotional strategies. For countries that have implemented tobacco display bans, or are considering doing so, one option to combat these practices would be to ban promotional communications between manufacturers and retailers.

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.

Delivery of alcohol brief interventions in community-based youth work settings: exploring feasibility and acceptability in a qualitative study.

BACKGROUND: Alcohol Brief Interventions (ABIs) are increasingly being delivered in community-based youth work settings. However, little attention has been paid to how they are being implemented in such settings, or to their feasibility and acceptability for practitioners or young people. The aim of this qualitative study was to explore the context, feasibility and acceptability of ABI delivery in youth work projects across Scotland. METHODS: Individual, paired and group interviews were conducted with practitioners and young people in nine community projects that were either involved in the delivery of ABIs or were considering doing so in the near future. A thematic analysis approach was used to analyse data. RESULTS: ABIs were delivered in a diverse range of youth work settings including the side of football pitches, on the streets as part of outreach activities, and in sexual health drop-in centres for young people. ABI delivery differed in a number of important ways from delivery in other health settings such as primary care, particularly in being largely opportunistic and flexible in nature. ABIs were adapted by staff in line with the ethos of their project and their own roles, and to avoid jeopardising their relationships with young people. Young people reacted positively to the idea of having conversations about alcohol with youth project workers, but confirmed practitioners' views about the importance of these conversations taking place in the context of an existing trusting relationship. CONCLUSION: ABIs were feasible in a range of youth work settings with some adaptation. Acceptability to staff was strongly influenced by perceived benefits, and the extent to which ABIs fitted with their project's ethos. Young people were largely comfortable with such conversations. Future implementation efforts should be based on detailed consideration of current practice and contexts. Flexible models of delivery, where professional judgement can be exercised over defined but adaptable content, may be better appreciated by staff and encourage further development of ABI activity.

Health Behaviors and their Relationship with Disease Control in People Attending Genetic Clinics with a Family History of Breast or Colorectal Cancer.

The current work aimed to assess health behaviors, perceived risk and control over breast/colorectal cancer risk and views on lifestyle advice amongst attendees at cancer family history clinics. Participants attending the East of Scotland Genetics Service were invited to complete a questionnaire (demographic data, weight and height, health behaviors and psycho-social measures of risk and perceived control) and to participate in an in-depth interview. The questionnaire was completed by 237 (49 %) of attendees, ranging from 18 to 77 years (mean age 46 (±10) years). Reported smoking rates (11 %) were modest, most (54 %) had a BMI > 25 kg/m2, 55 % had low levels of physical activity, 58 % reported inappropriate alcohol intakes and 90 % had fiber intakes indicative of a low plant diet. Regression analysis indicated that belief in health professional control was associated with higher, and belief in fatalism with poorer health behavior. Qualitative findings highlighted doubts about the link between lifestyle and cancer, and few were familiar with the current evidence. Whilst lifestyle advice was considered interesting in general there was little appetite for non-tailored guidance. In conclusion, current health behaviors are incongruent with cancer risk reduction guidance amongst patients who have actively sought advice on disease risk. There are some indications that lifestyle advice would be welcomed but endorsement requires a sensitive and flexible approach, and the acceptability of lifestyle interventions remains to be explored.

"It Looks Like an Adult Sweetie Shop": Point-of-Sale Tobacco Display Exposure and Brand Awareness in Scottish Secondary School Students.

INTRODUCTION: As further restrictions have been placed on tobacco advertising and promotions, point-of-sale (PoS) displays of cigarettes in shops have become an increasingly important source of young people's exposure to tobacco products. This study explored the relationship between PoS displays of cigarettes and brand awareness among secondary school students in Scotland. METHODS: Cross-sectional school surveys (n = 1406) and focus groups (n = 86) were conducted with S2 (13-14 years) and S4 (15-16 years) students in four schools of differing socioeconomic status in 2013, prior to the PoS display ban in large shops. Adjusted negative binomial regression analysis examined associations between brand awareness and exposure variables (visiting tobacco retailers, noticing displays of tobacco products). RESULTS: Students visiting small shops more frequently (relative rate ratio [RRR] 1.19, 95% confidence interval [CI] 1.01-1.41) and those who noticed cigarette displays in small shops (RRR 1.24, 95% CI 1.03-1.51) and large supermarkets (RRR 1.15, 95% CI 1.01-1.30) had higher brand awareness. The focus groups supported these findings. Participants described PoS tobacco displays as being eye-catching, colorful and potentially attractive to young people. CONCLUSIONS: This mixed-methods study showed that higher cigarette brand awareness was significantly associated with regularly visiting small shops and noticing PoS displays in small and large shops, even when students' smoking status, smoking in their social networks, leisure activities, and demographics were included as confounding variables. This highlights the importance of PoS displays of tobacco products in increasing brand awareness, which is known to increase youth smoking susceptibility, and thus the importance of implementing PoS display bans in all shops. IMPLICATIONS: As increasing restrictions have been placed on tobacco promotion in many countries, PoS displays of cigarettes in shops have become an important source of young people's exposure to tobacco products and marketing. This mixed-methods study showed that prior to the PoS display ban in Scotland, and controlling for other factors, 13- and 15-year olds who regularly visited small shops and those who noticed PoS displays in small and large shops, had a higher awareness of cigarette brands. This highlights the importance of PoS displays in increasing youth brand awareness, which increases smoking susceptibility, and thus the need for comprehensive bans on PoS displays which cover all shops.

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.

Determining the impact of smoking point of sale legislation among youth (Display) study: a protocol for an evaluation of public health policy.

BACKGROUND: Tobacco advertising and product promotions have been largely banned in the UK but point of sale (POS) tobacco advertising is one of the few places where tobacco products may be legitimately advertised. POS displays have been shown to increase susceptibility to smoking, experimentation and initiation into smoking. These displays may also influence perceived prevalence of smoking and the perception that tobacco products are easily obtained and are a 'normal' product. A ban of POS tobacco advertising was introduced in Scotland in large tobacco retail outlets of over 280 m2 internal sales floor areas (mainly supermarkets) in April 2013 and will be extended to include smaller tobacco retail outlets in April 2015. However, the impact of POS bans on smoking attitudes, behaviours and prevalence has yet to be determined. METHODS/DESIGN: This study has a multi-modal before and after design and uses mixed methods to collect data, at baseline and then with longitudinal follow-up for 4 years, in four purposively selected communities. For the purposes of the study, community is defined as the catchment areas of the secondary schools selected for study. There are four main components to the on-going study. In each of the four communities, at baseline and in follow-up years, there will be: mapping and spatial analyses of tobacco retail outlets; tobacco advertising and marketing audits of tobacco retail outlets most used by young people; cross-sectional school surveys of secondary school pupils; and focus group interviews with purposive samples of secondary school pupils. The tobacco audit is supplemented by interviews and observations conducted with a panel of tobacco retailers recruited from four matched communities. DISCUSSION: This study examines the impact of the implementation of both a partial and comprehensive ban on point of sale (POS) tobacco advertising on attitudes to smoking, brand awareness, perceived ease of access to tobacco products and youth smoking prevalence. The results will be of considerable interest to policy makers both from the UK and other jurisdictions where they are considering the development and implementation of similar legislation.

A qualitative study of how young Scottish smokers living in disadvantaged communities get their cigarettes.

INTRODUCTION: Reducing access to cigarettes is an important element of youth smoking prevention strategies. This is particularly so in disadvantaged communities that have high rates of youth smoking. In 2010, Scotland banned proxy sales of tobacco products to under 18-year-olds who were getting older people to purchase cigarettes on their behalf. METHODS: A qualitative study using 24 small single-sex friendship groups. Eighty young people, mostly aged 14-16, of whom 57 were smokers, were recruited in 2012 from community youth groups in 3 socially disadvantaged areas of Scotland. RESULTS: Participants' main sources of cigarettes were proxy sales, family, and peers and friends. Younger smokers were more likely to purchase single cigarettes from older smokers at school and to steal cigarettes from family members. Older and regular smokers were more likely to obtain cigarettes through proxy purchases. Proxy purchases were often facilitated by problem drug users who were willing to buy cigarettes for a small monetary reward. Direct purchases in shops were less commonly reported but appeared to involve complicit action by some retailers. Few reported that they bought blackmarket cigarettes, although they were available in these communities. CONCLUSIONS: Young people in areas of deprivation are still able to circumvent the age-of-sale legislation on selling cigarettes. Even though proxy sales have been banned, they are an important source of cigarettes for disadvantaged young smokers.