A "step too far" or "perfect sense"? A qualitative study of British adults' views on mandating COVID-19 vaccination and vaccine passports.

BACKGROUND: Debate is ongoing about mandating COVID-19 vaccination to maximise uptake. Policymakers must consider whether to mandate, for how long, and in which contexts, taking into account not only legal and ethical questions but also public opinion. Implementing mandates among populations who oppose them could be counterproductive. METHODS: Qualitative telephone interviews (Feb-May 2021) with British adults explored views on vaccine passports and mandatory vaccination. Participants (n = 50) were purposively selected from respondents to a probability-based national survey of attitudes to COVID-19 vaccination, to include those expressing vaccine-hesitancy. Data were analysed thematically. FINDINGS: Six themes were identified in participants' narratives concerning mandates: (i) mandates are a necessary and proportionate response for some occupations to protect the vulnerable and facilitate the resumption of free movement; (ii) mandates undermine autonomy and choice; (iii) mandates represent an over-reach of state power; (iv) mandates could potentially create 'vaccine apartheid'; (v) the importance of context and framing; and (vi) mandates present considerable feasibility challenges. Those refusing vaccination tended to argue strongly against mandates. However, those in favour of vaccination also expressed concerns about freedom of choice, state coercion and social divisiveness. DISCUSSION: To our knowledge, this is the first in-depth UK study of public views on COVID-19 vaccine mandates. It does not assess support for different mandates but explores emotions, principles and reasoning underpinning views. Our data suggest that debate around mandates can arouse strong concerns and could entrench scepticism. Policymakers should proceed with caution. While surveys can provide snapshots of opinion on mandates, views are complex and further consultation is needed regarding specific scenarios.

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.

National survey of attitudes towards and intentions to vaccinate against COVID-19: implications for communications.

OBJECTIVES: To examine public views on COVID-19 vaccination and consider the implications for communications and targeted support. DESIGN: Cross-sectional study. SETTING: Online and telephone nationally representative survey in Great Britain, January to February 2021. PARTICIPANTS: 4978 adults. Survey response rate was 84%, among the 5931 panellists invited. MAIN OUTCOME MEASURES: Sociodemographic characteristics (age, gender, ethnicity, education, financial status), COVID-19 status, vaccine acceptance, trust in COVID-19 vaccination information sources, perceptions of vaccination priority groups and perceptions of importance of second dose. RESULTS: COVID-19 vaccine acceptance (83%) was associated with increasing age, higher level of education and having been invited for vaccination. Acceptance decreased with unconfirmed past COVID-19, greater financial hardship and non-white British ethnicity; black/black British participants had lowest acceptance. Overall, healthcare and scientific sources of information were most trusted. Compared with white British participants, other ethnicities had lower trust in healthcare and scientific sources. Those with lower educational attainment or financial hardship had lower trust in healthcare and scientific sources. Those with no qualifications had higher trust in media and family/friends. While trust was low overall in community or faith leaders, it was higher among those with Asian/Asian British and black/black British ethnicity compared with white British participants. Views of vaccine prioritisation were mostly consistent with UK official policy but there was support for prioritising additional groups. There was high support for having the second vaccine dose. CONCLUSIONS: Targeted engagement is needed to address COVID-19 vaccine hesitancy in non-white British ethnic groups, in younger adults, and among those with lower education, greater financial hardship and unconfirmed past infection. Healthcare professionals and scientific advisors should play a central role in communications and tailored messaging is needed for hesitant groups. Careful communication around vaccination prioritisation continues to be required.

'I Was Smoking a Lot More during Lockdown Because I Can': A Qualitative Study of How UK Smokers Responded to the Covid-19 Lockdown.

This study explored how Covid-19 lockdown restrictions affected people's daily smoking routines and behaviours, including adherence and modifications to pre-established smoking restrictions in the home. Semi-structured telephone interviews were conducted with smokers and non-smokers from smoking households 19 to 27 weeks after the first full UK lockdown ended in May 2020. A non-probability purposive sample representing 25 adults aged 21 or over living in households with at least 1 smoker were recruited to the study. A quota sampling strategy was used, according to age, gender, smoking status, family status, household composition, householder access to outdoor space, and change to work-life status. Most participants found lockdown increased the amount of time spent at home, where stresses associated with confinement, curtailment of social routines, removal of barriers and distractions to smoking due to home working, and feelings of boredom all contributed to increased smoking. Fewer factors were identified as reducing smoking during lockdown. Prominent examples included disruption to habitual smoking patterns and distraction from smoking associated with spending more time doing outdoor activities. Pressures placed on physical space and lack of privacy due to the confinement at home were responsible for displacement of smoking within the home, leading to breaking of smoke-free rules and family tensions, and in some cases to greater awareness amongst parents that their children smoked. Changes in daily routines associated with lockdown affected and displaced smoking behaviour both positively and negatively. Health improvement interventions could seek to harness positive changes in smoking associated with any future lockdown approaches. New home-working norms highlight the need for employers to support staff to reduce their smoking and to remain smoke-free.

Managing COVID-19 Transmission Risks in Bars: An Interview and Observation Study.

OBJECTIVE: Licensed premises face particular challenges to operating safely within COVID-19 restrictions. Following a U.K. national lockdown from March 20, 2020, we studied business practices and behaviors in licensed premises to inform COVID-19 policies. To our knowledge, no previous study worldwide has examined these issues. METHOD: Before premises reopened in Scotland, we conducted in-depth telephone interviews (May-June 2020) with participants from hospitality trade associations, licensed premises, or in related roles (n = 18). Interviews focused on anticipated business practices and challenges relevant to minimizing COVID-19 transmission. Following reopening (July-August 2020), we conducted observations of relevant practices and behaviors in 29 bars purposively sampled for diversity, using a structured schedule. Interviews and observation reports were analyzed thematically. RESULTS: Interviewees generally sought clarity, flexibility, and balance in government guidance on reopening, and they cited commercial and practical challenges to doing so safely. Alcohol consumption was perceived as an additional but potentially manageable challenge. Most observed premises had made physical and operational modifications; however, practices were variable. Observed incidents of concern included close physical interaction between customers and with staff, frequently featuring alcohol intoxication and rarely effectively stopped by staff. CONCLUSIONS: Despite the efforts of bar operators and guidance from government, potentially significant risks of COVID-19 transmission persisted in a substantial minority of observed bars, especially when customers were intoxicated.

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.

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.

Correction: Barriers to bystander CPR in deprived communities: Findings from a qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0233675.].

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.

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.

Barriers to bystander CPR in deprived communities: Findings from a qualitative study.

STUDY AIM: Rates of out of hospital cardiac arrest are higher in deprived communities. Bystander Cardiopulmonary Resuscitation (BCPR) can double the chance of survival but occurs less often in these communities in comparison to more affluent communities. People living in deprived communities are, therefore, doubly disadvantaged and there is limited evidence to explain why BCPR rates are lower. The aim of this paper is to examine the barriers to administering BCPR in deprived communities. METHOD: Mixed method qualitative study with ten single sex focus groups (n = 61) conducted in deprived communities across central Scotland and 18 semi-structured interviews with stakeholders from the UK, Europe and the USA. RESULTS: Two key themes related to confidence and environmental factors were identified to summarise the perceived barriers to administering BCPR in deprived communities. Barriers related to confidence included: self-efficacy; knowledge and awareness of how, and when, to administer CPR; accessing CPR training; having previous experience of administering BCPR; who required CPR; and whether the bystander was physically fit to give CPR. Environmental barriers focused on the safety of the physical environment in which people lived, and fear of reprisal from gangs or the police. CONCLUSIONS: Barriers to administering BCPR identified in the general population are relevant to people living in deprived communities but are exacerbated by a range of contextual, individual and environmental factors. A one-size-fits-all approach is not sufficient to promote 'CPR readiness' in deprived communities. Future approaches to working with disadvantaged communities should be tailored to the local community.

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.

'It's like sludge green': young people's perceptions of standardized tobacco packaging in the UK.

BACKGROUND AND AIMS: Standardized tobacco packaging was introduced in the United Kingdom in May 2016, together with larger graphic warnings. This study explored young Scottish people's awareness of and perceptions about standardized tobacco packaging in the United Kingdom. DESIGN: Qualitative study using 16 focus groups conducted February-March 2017. SETTING: Four schools in Scotland based in areas of differing socio-economic status (high versus medium/low) and two levels of urbanity (large urban versus small town/other urban). PARTICIPANTS: Eighty-two S2 (13-14 years) and S4 (15-16 years) students who were smokers or at-risk non-smokers. MEASUREMENTS: Focus groups explored perceptions of standardized packaging and health warnings. The qualitative data underwent thematic analysis. FINDINGS: Views about standardized packaging were generally negative. Packs were described as being unattractive, drab and less appealing than non-standardized versions. The new health warnings generated negative affective, often aversive, responses. These varied depending on the image's perceived 'gruesomeness' and authenticity. Most participants thought that the impact would be greatest on young non/occasional smokers. There were divergent views about whether established smokers would be affected. CONCLUSIONS: The introduction of standardized tobacco packaging and new larger graphic health warnings in the United Kingdom seems have reduced the perceived attractiveness of cigarette packs among young people in the United Kingdom who smoke or are at elevated risk of becoming smokers, disrupting positive brand imagery (the brand heuristic), increasing the salience of health warnings and contributing to denormalizing smoking.

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.

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.

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.

Evaluating possible intended and unintended consequences of the implementation of alcohol minimum unit pricing (MUP) in Scotland: a natural experiment protocol.

INTRODUCTION: Scotland is the first country to carry out a national implementation of minimum unit pricing (MUP) for alcohol. MUP aims to reduce alcohol-related harms, which are high in Scotland compared with Western Europe, and to improve health equalities. MUP is a minimum retail price per unit of alcohol. That approach targets high-risk alcohol users. This work is key to a wider evaluation that will determine whether MUP continues. There are three study components. METHODS AND ANALYSIS: Component 1 sampled an estimated 2800 interviewees at a baseline and each of two follow-ups from four Emergency Departments in Scotland and Northern England. Research nurses administered a standardised survey to assess alcohol consumption and the proportion of attendances that were alcohol-related.Component 2 covered six Sexual Health Clinics with similar timings and country allocation. A self-completion survey gathered information on potential unintended effects of MUP on alcohol source and drug use.Using a natural experiment design and repeated cross-sectional audit, difference between Scotland (intervention) and North England (control) will be tested for outcomes using regression adjusting for differences at baseline. Differential impacts by age, gender and socioeconomic position will be investigated.Component 3 used focus groups with young people and heavy drinkers and interviews with stakeholders before and after MUP implementation. The focus groups will allow exploration of attitudes, experiences and behaviours and the potential mechanisms by which impacts arise. The interviews will help characterise the implementation process. ETHICS AND DISSEMINATION: Study components 1 and 2 have been ethically approved by the NHS, and component 3 by the University of Stirling. Dissemination plans include peer-reviewed journal articles, presentations, policy maker briefings and, in view of high public interest and the high political profile of this flagship policy, communication with the public via media engagement and plain language summaries. TRIAL REGISTRATION NUMBER: ISRCTN16039407; Pre-results.

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.

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.