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.

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.

'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.

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.

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.

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.

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.

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.

Are Retail Outlets Complying with National Legislation to Protect Children from Exposure to Tobacco Displays at Point of Sale? Results from the First Compliance Study in the UK.

BACKGROUND: From April 6th 2015, all small shops in the UK were required to cover up tobacco products at point of sale (POS) to protect children from exposure. As part of a larger 5-year study to measure the impact of the legislation in Scotland, an audit was conducted to assess level and nature of compliance with the ban immediately following its introduction. MATERIALS AND METHODS: A discreet observational audit was conducted 7-14 days post implementation which took measures of physical changes made to cover products, server/assistant practices, tobacco signage and advertising, and communication of price information. The audit was conducted in all small retail outlets (n = 83) selling tobacco in four communities in Scotland selected to represent different levels of urbanisation and social deprivation. Data were analysed descriptively. RESULTS: Compliance with the legislation was high, with 98% of shops removing tobacco from permanent display and non-compliance was restricted almost entirely to minor contraventions. The refurbishment of shops with new or adapted tobacco storage units resulted in the removal of nearly all commercial brand messages and images from POS, dropping from 51% to 4%. The majority of shops stored their tobacco in public-facing storage units (81%). Most shops also displayed at least one generic tobacco message (88%). CONCLUSIONS: Compliance with Scottish prohibitions on display of tobacco products in small retail outlets was high immediately after the legislation implementation date. However, although tobacco branding is no longer visible in retail outlets, tobacco storage units with generic tobacco messages are still prominent. This points towards a need to monitor how the space vacated by tobacco products is utilised and to better understand how the continuing presence of tobacco storage units influences people's awareness and understanding of tobacco and smoking. Countries with existing POS bans and who are considering such bans should pay particular attention to regulations regarding the use of generic signage and where within the retail setting tobacco stocks can be stored.

"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.

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.

Experience of wellness recovery action planning in self-help and mutual support groups for people with lived experience of mental health difficulties.

The main aim of this research was to assess the relevance and impact of wellness recovery action planning (WRAP) as a tool for self-management and wellness planning by individuals with mental health problems from pre-existing and newly formed groups, where the possibilities for continued mutual support in the development of WRAPs could be explored. Interviews and focus groups were conducted and pre-post recovery outcome measures completed (Recovery Assessment Scale and Warwick Edinburgh Mental Well Being Scale). 21 WRAP group participants took part in the research. The WRAP approach, used in groups and delivered by trained facilitators who could also share their lived experience, was very relevant and appeared to have a positive impact on many of the participants. The impact on participants varied from learning more about recovery and developing improved self-awareness to integrating a WRAP approach into daily life. The apparent positive impact of WRAP delivered in the context of mutual support groups indicates that it should be given serious consideration as a unique and worthwhile option for improving mental health. WRAP groups could make a significant contribution to the range of self-management options that are available for improving mental health and well-being.

Wellness Recovery Action Planning (WRAP) in self-help and mutual support groups.

OBJECTIVE: The aim of this research was to assess the relevance and impact of Wellness Recovery Action Planning (WRAP) in group settings, as a tool for self-management and wellness planning by individuals with mental-health problems. This paper reports on the impact on participants who trained as facilitators and delivered WRAP training to others within the organizations studied. METHOD: Eight WRAP facilitators took part in interviews and focus groups. RESULTS: The WRAP facilitators reported a positive impact on their well-being, from learning more about recovery, developing improved self-awareness, to integrating a WRAP approach into daily life. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Delivering WRAP training to groups can make a positive contribution to the well-being of facilitators themselves. Involving people with lived experience in the delivery of WRAP groups in this setting further promoted the recovery journey of facilitators.