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Background E-cigarettes are a popular smoking-cessation tool. Although less harmful than tobacco, use of e-cigarettes by non-smokers should be prevented. There is concern about the use of e-cigarettes by young people and that e-cigarettes may renormalise smoking. In May 2016, Tobacco Products Directive regulations aimed to reduce e-cigarettes’ appeal to young people. Aims To examine the effects of the Tobacco Products Directive regulations on young people’s use of e-cigarettes, and the role of e-cigarettes in renormalising smoking. Design A mixed-method natural experimental evaluation combining secondary analyses of survey data, with process evaluation, including interviews with young people, policy stakeholders, retailers and trading standards observers, and observations of retail settings. Settings Wales, Scotland and England. Participants Survey participants were aged 13–15 years, living in England, Scotland or Wales and participated in routinely conducted surveys from 1998 to 2019. Process evaluation participants included 14- to 15-year-olds in England, Scotland and Wales, policy stakeholders, trading standards offices and retailers. Intervention Regulation of e-cigarettes, including bans on cross-border advertising, health warnings and restrictions on product strength. Comparison group Interrupted time series design, with baseline trends as the comparator. Main outcome measures The primary outcome was ever e-cigarette use. Secondary outcomes included regular use, ever and regular smoking, smoking attitudes, alcohol and cannabis use. Data capture and analysis Our primary statistical analysis used data from Wales, including 91,687 young people from the 2013–19 Health Behaviour in School-aged Children and School Health Research Network surveys. In Scotland, we used the Scottish Schools Adolescent Lifestyle and Substance Use Survey and in England we used the Smoking Drinking and Drug Use surveys. The process evaluation included interviews with 73 young people in 2017 and 148 young people in 2018, 12 policy stakeholders, 13 trading standards officers and 27 retailers. We observed 30 retail premises before and after implementation. Data were integrated using the Medical Research Council’s process evaluation framework. Results Ever smoking continued to decline alongside the emergence of e-cigarettes, with a slight slowing in decline for regular use. Tobacco Products Directive regulations were described by stakeholders as well implemented, and observations indicated good compliance. Young people described e-cigarettes as a fad and indicated limited interaction with the components of the Tobacco Products Directive regulations. In primary statistical analyses in Wales [i.e. short (to 2017) and long term (to 2019)], growth in ever use of e-cigarettes prior to Tobacco Products Directive regulations did not continue after implementation. Change in trend was significant in long-term analysis, although of similar magnitude at both time points (odds ratio 0.96). Data from England and Scotland exhibited a similar pattern. Smoking followed the opposite pattern, declining prior to the Tobacco Products Directive regulations, but plateauing as growth in e-cigarette use stalled. Limitations Alternative causal explanations for changes cannot be ruled out because of the observational design. Conclusions Young people’s ever and regular use of e-cigarettes appears to have peaked around the time of the Tobacco Products Directive regulations and may be declining. Although caution is needed in causal attributions, findings are consistent with an effect of regulations. Our analysis provides little evidence that e-cigarettes renormalise smoking. More recent data indicate that declines in smoking are plateauing. Future work International comparative work to understand differences in use of e-cigarettes, and tobacco, within varying regulatory frameworks is a priority. Study registration This study is registered as ResearchRegistry4336. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information. Plain language summary Much has been achieved in preventing young people smoking; however, e-cigarettes have emerged as a new issue. E-cigarettes can help smokers stop, but might also appeal to young people or make smoking look ‘normal’. Until recently, In the United Kingdom, there were not many rules for e-cigarettes. In 2016, new rules came in as part of the European Union Tobacco Products Directive regulations. The Tobacco Products Directive regulations limited advertising and included rules about how e-cigarettes should be labelled. In our study, we wanted to know if (1) e-cigarettes make young people think smoking is ‘normal’ and (2) people’s use of e-cigarettes changed after new rules. We included young people who took part in surveys in England, Scotland and Wales between 1998 and 2019. Overall, about 360,000 young people did one of the surveys and about 90,000 were included in our main analysis. We spoke with young people in 2017 and 2018. In addition, in 2018, we spoke with people involved in tobacco policy, trading standards officers and people who sold e-cigarettes. Young people held negative attitudes about smoking and said that friends disagreed with smoking. Young people approved of occasional social e-cigarette use, but not regular use. Stakeholders described a range of views on how e-cigarettes should be regulated. Retailers and trading standards officers said that some retailers did not get much information about Tobacco Products Directive regulations, but new rules were implemented well. The percentage of young people saying that they had tried e-cigarettes was growing, but the number had stopped growing after the new rules. Regular use remained low throughout. Our findings suggest that e-cigarettes are not making smoking look normal again and new rules may have helped stop growth in use of e-cigarettes by young people. Scientific summary Background Smoking is a leading cause of preventable death and health inequalities in the United Kingdom (UK), and internationally. E-cigarettes are a popular means for smokers to quit. Emerging evidence suggests that E-cigarettes can be highly effective in helping smokers quit and many people argue that e-cigarettes should be endorsed to support smoking cessation, as e-cigarettes are likely significantly less harmful than tobacco. However, the increasing popularity of e-cigarettes has led to debates surrounding potential positive, and negative public health impacts. Although there is growing consensus that e-cigarettes are less harmful than tobacco, there is also consensus that e-cigarettes are not harmless and, hence, that use of e-cigarettes among non-smokers, particularly young people, should be prevented. Although there has been concern about direct harms to non-smoking young people, most concerns centre on how e-cigarettes might affect smoking uptake. Since the 1990s, the prevalence of young people’s smoking in the UK has steadily declined following two decades of regulation of tobacco markets. At the centre of concerns around e-cigarettes is an argument that these gains may be reversed, by their acting as a gateway to nicotine addiction and tobacco use, or through renormalising smoking by mimicking it’s action. Different positions on e-cigarettes are reflected in divergent international approaches to regulation. Some countries ban their sale, whereas other countries have few specific regulations. England and Wales introduced age of sales regulations in 2015, followed by Scotland in 2017. Unsuccessful attempts in Wales were made in 2015 to introduce legislation prohibiting e-cigarette use in public spaces where smoking is banned. In May 2016, Tobacco Products Directive (TPD) regulations were introduced in European Union (EU) member states. The TPD regulations included a suite of regulations for tobacco, many of which brought EU nations in line with UK regulations. In the UK, the TPD regulations occurred alongside introduction of plain packaging for tobacco cigarettes. The TPD also included specific regulations for e-cigarettes, including bans on cross-border advertising from May 2016, with regulations on the products themselves introduced with a transitional period beginning in May 2016 and full implementation to be achieved by May 2017. Regulations included a warning on the packet that the products contain nicotine, which is a highly addictive substance, restrictions on nicotine strength and mandatory declaration of new products 6 months in advance of their introduction. The TPD regulations were a cause of concern for some people who argued that regulations might inhibit the usefulness of e-cigarettes as cessation tools. However, the rationale for TPD regulations included that young people’s use of e-cigarettes was growing and there were concerns that e-cigarettes mimic smoking and, hence, renormalise it. Regulation of e-cigarettes was motivated, in part, by reducing the appeal to young people. To date, the role of e-cigarettes in renormalising smoking, as well as the impact of e-cigarettes regulation on young people’s e-cigarette use, are not well understood. This study investigates the extent to which regulations have affected growth in young people’s use of e-cigarettes in England, Scotland and Wales, and explores broader questions about the impact of e-cigarettes on young people’s smoking perceptions and behaviour. Objectives 1.To investigate the role of e-cigarette regulation via the TPD in influencing trajectories in young people’s use of e-cigarettes via the following research questions: i.Did increased regulation of e-cigarettes interrupt prior growth in young people’s e-cigarette use? ii.How do young people perceive risks and social norms surrounding e-cigarettes: a.as a product in their own right? b.relative to tobacco? iii.How do young people interpret and respond to health warnings on e-cigarette packets? iv.To what extent, and in what ways, do young people continue to interact with e-cigarette marketing after the prohibition of cross-border advertising? 2.To examine trends in young people’s smoking behaviour over time, to test theoretical assumptions regarding whether or not e-cigarettes renormalise smoking and to examine whether or not declines in smoking continued following the suite of regulation introduced within and alongside TPD, via the following questions: i.Were declines in young people’s ever and current smoking significantly interrupted during the emergence of e-cigarettes? ii.Did the rate of decline in young people’s smoking change after additional regulation of tobacco and e-cigarettes in 2016? 3.To explore the implementation and context of TPD regulation via the following questions: i.To what extent was compliance with TPD in product sales achieved, and what are the barriers to, and facilitators and unintended consequences of implementation? ii.To what extent, and in what ways, did variations between UK countries in e-cigarette policy emerge during the study period? iii.What other changes to the regulatory context of tobacco and e-cigarettes occurred during the study period in the UK and across UK countries? Methods Our study was a mixed-method natural experimental evaluation. Quantitative components drew on repeat cross-sectional survey data from Wales (i.e. the Health Behaviour in School-aged Children Survey and School Health Research Network Survey), Scotland (i.e. the Scottish Schools Adolescent Lifestyle and Substance Use Survey) and England (i.e. the Smoking Drinking and Drug Use Survey). Study populations were nationally representative samples of young people aged 13–15 years (or from the equivalent school years, i.e. years 9 and 11 in Wales and England and S2 and S4 in Scotland). Process evaluation included interviews with young people, retailers, policy stakeholders and trading standards officers (TSOs), and observations of retail premises during and after the transitional phase for TPD implementation. The survey data from Wales were used for our primary statistical analysis, which assessed change in ever use of e-cigarettes following the introduction of the TPD regulations, using segmented regression analysis. The analysis included 91,687 young people who completed surveys between 2013 and 2019 in Wales, with surveys disaggregated into monthly estimates to provide 16 data points overall. More simple logistic regression analyses were used to examine whether or not trends in Wales were mirrored elsewhere in the UK, using Scottish and English data. Changes in young people’s smoking behaviour before and after emergence of e-cigarettes, but prior to their regulation within the TPD, were examined using a segmented regression analysis of a pooled three-country data set from 1998 to 2015 (n = 243,111). The analysis examined whether or not any changes in trend occurred after e-cigarettes began to grow in popularity from around 2011, but prior to their regulation. Analyses of change in trend for smoking following TPD and associated tobacco regulations extended these analyses to 2019 (n = 359,111), with 2016 modelled as the intervention point. For the process evaluation, qualitative interviews were conducted with 76 young people aged 14–15 years during the transitional phase, and 148 young people after full implementation in 2018. Interviews with 12 policy stakeholders, 13 TSOs and 27 e-cigarette retailers were conducted at a single point approximately a year after the date for full compliance. Observations of retail premises were conducted during and after the transitional phase for implementation of TPD regulations. Data were synthesised using an evaluation and integration framework based on Medical Research Council guidance for process evaluation, with data sources organised and presented chronologically to understand context prior to TPD, how this changed following implementation and finally, changes in young people’s e-cigarette use and smoking. Hence, presentation of results with data on the context into which TPD was fully introduced (i.e. pre-implementation trends in smoking and young people’s perceptions of vaping), followed by data from policy stakeholders, TSOs and retailers on implementation of legislation, before presenting data on mechanisms of change and post-legislation e-cigarette use and smoking outcomes. Results Segmented regression analyses of smoking trends between 1998 and 2015 indicated no significant changes in trend for ever smoking during the period 2011–15 [post-slope odds ratio (OR) 1.01, 95% confidence interval (CI) 0.99 to 1.03]. There was a marginally significant slowing in decline for regular smoking (post-slope OR 1.04, 95% CI 1.00 to 1.08), and this was greatest among subgroups for whom the level of decline pre 2010 was greatest, and was not unique to tobacco, with slowing decline also observed for other substance use behaviours. Negative attitudes towards smoking continued to harden after 2011, and at a faster rate than pre-2011 trends (post-slope OR 0.88, 95% CI 0.86 to 0.90). In group interviews shortly before the end of the transitional phase for TPD, young people differentiated between e-cigarettes and tobacco, preferring labels such as vaping, which removed association with cigarettes. Although smoking was strongly disapproved of, e-cigarette approval was more nuanced. Regular use was described as something smokers do. Young people described little interest in, or awareness of, whether or not products contained nicotine, with device characteristics, like flavours or the ability to do tricks at parties, described as more significant drivers of experimentation. Qualitative interviews with policy stakeholders and TSOs following implementation of TPD indicated mixed views about the extent to which e-cigarette regulation was supported. Stakeholders expressed simultaneously positive views of the role of e-cigarettes for smoking cessation, and some anxieties surrounding potential renormalisation and harms from e-cigarette use among young people. Marketing restrictions were largely seen as appropriate, and regulations were described by stakeholders as having been well implemented, despite challenges in communications. However, some aspects of regulation of the products themselves were seen as needing to be further refined. In interviews with retailers, some retailers argued that although some regulation was needed to prevent use by young people, regulating e-cigarettes as if they are tobacco products may lead to their being perceived as similar in terms of their health risks. In common with a positioning as separate from tobacco, specialist retailers expressed antipathy towards the tobacco industry and emphasised their role as helping people to quit smoking. Observations indicated that, during the transitional phase, implementation remained mixed, with retailers continuing to sell-off non-compliant old stock, but by the full compliance date all retailers observed were selling compliant products. Follow-up qualitative interviews with young people indicated continued tendency to distinguish between cigarettes and e-cigarettes. However, e-cigarette use was increasingly described as a fad that had begun to run its course. Although in qualitative interviews young people described little exposure to advertising, in surveys after implementation most young people reported seeing at least one form of advertising in the past month. Young people described limited interaction with components of TPD, such as device labelling, having often not seen devices inside their packets. Survey data from Wales indicated a growing tendency for young people to view e-cigarettes as being as risky as tobacco. Our primary statistical analysis of change in ever e-cigarette use following the implementation of TPD indicated that in Wales, the growth prior to TPD had plateaued or declined following implementation. Prior monthly growth in the odds of ever e-cigarette use had stalled around the time of TPD implementation, with evidence of a negative change in trend thereafter (OR 0.96, 95% CI 0.95 to 0.97). Change in trend was significant in only long-term analysis, although OR were of similar magnitude in short- (to 2017) and long-term (to 2019) analyses. Data from England and Scotland exhibited a similar pattern of rapid growth in experimentation prior to TPD regulations, with little or no increase thereafter. In all countries, the secondary outcome of regular e-cigarette use exhibited this similar pattern of growth prior to TPD regulations, with flattening or a slight decline thereafter. Regular use of e-cigarettes remained at ≤1% among never smokers throughout. Post TPD regulations, however, declines in young people’s smoking uptake followed the opposite change in trend to e-cigarettes. A significant positive change in trend for both ever (OR 1.09, 95% CI 1.06 to 1.11) and regular smoking (OR 1.13, 95% CI 1.09 to 1.18) indicated that as growth in e-cigarette use stalled so too did the decline in tobacco use. This was driven, in particular, by data from Wales and Scotland where estimates remained unchanged between the most recent surveys, with surveys in England still providing some indication of continued decline in young people’s smoking. Change in trend was also observed for other substances, indicating a broader social trend in slowing of decline in adolescent risk behaviours beyond smoking specifically, with stalling decline in ever tobacco use lagging behind the stalling decline for ever use of other substances. Conclusions Our primary aim was to understand the effects of TPD regulations on young people’s use of e-cigarettes. To achieve this, we first explored the context of young people’s smoking and e-cigarette use prior to the TPD regulations, during the implementation of TPD, and the mechanisms and outcomes that followed from implementation. The study provides limited evidence that e-cigarettes were renormalising smoking prior to the TPD regulations, although some forms of e-cigarette use itself appeared to be becoming normalised. Although stakeholders reported a range of perceptions of the TPD regulations, they were well implemented. Young people’s use of e-cigarettes peaked around the time of TPD implementation, with evidence that this became flat or declined across the nations of Great Britain. The disruption of the secular growth in e-cigarette use following TPD is consistent with an effect of the regulations, although caution is needed in causal attributions because of the observational nature of the study. Further support for a conclusion that this may be a causal effect is, however, provided by comparison to external data sources, which indicate that in other less-regulated environments, such as the USA, young people’s use of e-cigarettes continued to grow during the period where it appeared to peak in the UK. Although smoking continued to decline during the growth of e-cigarette use, there is evidence within more recent data sets that this decline has begun to stall. Recommendations for future research include the following: •Continued collection of survey data to monitor population trends in young people’s tobacco and e-cigarette use remain important. •Harmonised international data sets may be particularly valuable in enabling changes following new policies to be compared with an external comparator. •Although young people’s use of e-cigarettes was no longer growing, experimentation was still high at our latest measurements points, and understanding whether or not this diminishes, or further intervention is warranted, is important. •As regulation has diverged, international comparative research on variation in use trajectories according to differences in regulatory environment offers an opportunity to provide nuanced insights into optimal regulatory measures for limiting young people’s use of e-cigarettes, while maximising benefits for smoking cessation. •There are high levels of confusion among young people on harms of e-cigarettes relative to smoking. Research could seek to better understand how to reinforce the role of e-cigarettes as cessation devices, while discouraging use among non-smokers and acknowledging remaining ambiguity about long-term harms. •Further understanding how young people interact with e-cigarettes via the internet, including via social media platforms, is an important area for further research. •Although much has been achieved in reducing young people’s use of tobacco, there is some evidence that this progress may be beginning to stall. Further research is needed to reach the minority of young people who continue to take up smoking in contemporary society. Study registration This study is registered as ResearchRegistry4336. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.

Background Increasing the availability of non-alcoholic options is a promising population-level intervention to reduce alcohol consumption, currently unassessed in naturalistic settings. This study in an online retail context aimed to estimate the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and purchasing of alcohol. Methods and results Adults (n = 737) residing in England and Wales who regularly purchased alcohol online were recruited between March and July 2021. Participants were randomly assigned to one of 3 groups: '25% non-alcoholic/75% alcoholic'; '50% non-alcoholic/50% alcoholic'; and '75% non-alcoholic/25% alcoholic,' then selected drinks in a simulated online supermarket, before purchasing them in an actual online supermarket. The primary outcome was the number of alcohol units selected (with intention to purchase); secondary outcomes included actual purchasing. A total of 607 participants (60% female, mean age = 38 years [range: 18 to 76]) completed the study and were included in the primary analysis. In the first part of a hurdle model, a greater proportion of participants in the '75% non-alcoholic' group did not select any alcohol (13.1%) compared to the '25% non-alcoholic' group (3.4%; 95% confidence interval [CI] -2.09, -0.63; p < 0.001). There was no evidence of a difference between the '75% non-alcoholic' and the '50% non-alcoholic' (7.2%) groups (95% CI 0.10, 1.34; p = 0.022) or between the '50% non-alcoholic' and the '25% non-alcoholic' groups (95% CI -1.44, 0.17; p = 0.121). In the second part of a hurdle model in participants (559/607) selecting any drinks containing alcohol, the '75% non-alcoholic' group selected fewer alcohol units compared to the '50% non-alcoholic' (95% CI -0.44, -0.14; p < 0.001) and '25% non-alcoholic' (95% CI -0.54, -0.24; p < 0.001) groups, with no evidence of a difference between the '50% non-alcoholic' and '25% non-alcoholic' groups (95% CI -0.24, 0.05; p = 0.178). Overall, across all participants, 17.46 units (95% CI 15.24, 19.68) were selected in the '75% non-alcoholic' group; 25.51 units (95% CI 22.60, 28.43) in the '50% non-alcoholic' group; and 29.40 units (95% CI 26.39, 32.42) in the '25% non-alcoholic' group. This corresponds to 8.1 fewer units (a 32% reduction) in the '75% non-alcoholic' compared to the '50% non-alcoholic' group, and 11.9 fewer alcohol units (41% reduction) compared to the '25% non-alcoholic' group; 3.9 fewer units (13% reduction) were selected in the '50% non-alcoholic' group than in the '25% non-alcoholic' group. For all other outcomes, alcohol selection and purchasing were consistently lowest in the '75% non-alcoholic' group. Study limitations include the setting not being entirely naturalistic due to using a simulated online supermarket as well as an actual online supermarket, and that there was substantial dropout between selection and purchasing. Conclusions This study provides evidence that substantially increasing the proportion of non-alcoholic drinks-from 25% to 50% or 75%-meaningfully reduces alcohol selection and purchasing. Further studies are warranted to assess whether these effects are realised in a range of real-world settings. Trial registration ISRCTN: 11004483; OSF: https://osf.io/qfupw., Author(s): Natasha Clarke 1,2,*, Anna K. M. Blackwell 3,4, Jennifer Ferrar 3, Katie De-Loyde 3, Mark A. Pilling 1, Marcus R. Munafò 3, Theresa M. Marteau 1,*, Gareth J. Hollands [...]

Introduction Youth use of electronic cigarettes (e-cigarettes) is rising globally and is associated with health harms. Flavor descriptions on e-liquid packaging may contribute to the appeal of e-cigarettes among youth. This study compared subjective ratings of e-liquid packaging flavor descriptions among nonsmoking and non-vaping UK adolescents. Aims and Methods This was an online observational study in a UK sample of nonsmoking and non-vaping adolescents aged 11–17 years. The primary analyses compared flavored versus unflavored descriptions and the secondary analyses compared sweet flavor versus fruit flavor descriptions. Outcomes were packaging appraisal, packaging receptivity, perceived harm, and perceived audience. Results The survey was completed by 120 participants (74% female). Packaging appraisal ratings were higher for e-liquids with flavored descriptions than unflavored descriptions (mean difference 5.9, 95% CI: 4.2 to 7.6, p  < .001). Similarly, packaging receptivity ratings were higher for e-liquids with flavored descriptions than unflavored descriptions (mean difference 4.2, 95% CI: 2.8 to 5.6, p  < .001). Participants also perceived e-liquids with flavored (vs. unflavored) descriptions as less "grown-up" (mean difference −5.2, 95% CI: −7.3 to −3.1, p  < .001). However, ratings of perceived harm were similar for flavored and unflavored descriptions (mean difference −1.0, 95% CI: −2.6 to.5, p  = .189). Conclusions Although this study found differences in subjective ratings of e-liquids with flavored and unflavored descriptions, nonsmoking and non-vaping UK adolescents generally had low appraisal and receptivity for e-liquids and they perceived them as being "grown-up" and harmful. Implications Youth use of electronic cigarettes (e-cigarettes) is increasing globally, leading to concerns about health harms. This study compared adolescents' ratings of e-liquids with flavored versus unflavored descriptions and e-liquids with sweet flavor versus fruit flavor descriptions. This study adds to previous studies that have compared adolescents' ratings of e-liquids with tobacco flavor versus non-tobacco flavor descriptions. Although packaging appraisal and receptivity ratings were higher (more positive) for e-liquids with flavored versus unflavored descriptions, overall, adolescents who do not smoke or vape had low appraisal and receptivity for e-liquids, and they perceived them as being "grown-up" and harmful. [ABSTRACT FROM AUTHOR]

The importance of parent-child interaction (PCI) for language development has been well established. This has led many speech and language therapy (SLT) interventions to focus on modifying PCI as a means to improving children's early language delay. However, the success of such programs is mixed. The current review compares PCI, observed in naturally occurring contexts, with preschool children with language delay and age- or language-matched typically developing (TD) controls. A systematic review of the literature searched 10 databases for studies using a case-control design and extracted data concerning participants, matching, selection, design, assessments, measures, findings, statistics, and bias. Quality appraisal used the Critical Appraisal Skills Programme case-control checklist. The search identified 17,824 articles, which were reviewed against exclusion criteria. The final review included 9 studies, which were diverse in terms of matching, delay criteria, and PCI measure. A narrative synthesis was conducted. The evidence for PCI differences between children with language delay and TD peers was limited and any suggestion that parents were less responsive could be attributed to limited language skills of children with language delay. The findings question the assumption that communicative environments of children with language delay are different, although the evidence is from a small sample of children from middle-class families. Children with language delay may instead be less able to learn from their environment. The review highlights the gap in understanding the relationship between parent and child language use during PCI. The need for further, longitudinal research is emphasized, including children ranging in type and severity of delay, across diverse socioeconomic backgrounds.

Background and Aims: Smoking fewer cigarettes per day may increase the chances of stopping smoking. Capping the number of cigarettes per pack is a promising policy option, but the causal impact of such a change is unknown. This study aimed to test the hypothesis that lowering cigarette pack sizes from 25 to 20 reduces the number of cigarettes smoked. Design: This randomized controlled cross‐over trial had two 14‐day intervention periods with an intervening 7‐day period of usual behaviour. Participants purchased their own cigarettes. They were instructed to smoke their usual brand from either one of two sizes of pack in each of two 14‐day intervention periods: (a) 25 cigarettes and (b) 20 cigarettes. Participants were randomized to the order in which they smoked from the two pack sizes (a–b; b–a). Setting: Canada. Participants: Participants were adult smokers who smoked from pack sizes of 25, recruited between July 2020 and June 2021. Of 252 randomized, 240 (95%) completed the study and 236 (94%) provided sufficient data for the primary analysis. Measurements Cigarettes smoked per participant per day. Findings Participants smoked fewer cigarettes per day from packs of 20 cigarettes [n = 234, mean = 15.7 standard deviation (SD) = 7.1] than from packs of 25 (n = 235, mean = 16.9, SD = 7.1). After adjusting for pre‐specified covariates (baseline consumption and heaviness of smoking), modelling estimated that participants smoked 1.3 fewer cigarettes per day [95% confidence interval (CI) = −1.7 to −0.9], equivalent to 7.6% fewer (95% CI = −10.1 to −5.2%) from packs of 20 cigarettes. Conclusions: Smoking from packs of 20 compared with 25 cigarettes reduced the number of cigarettes smoked per day. [ABSTRACT FROM AUTHOR]

Introduction: Improving Access to Psychological Therapies (IAPTs) Services could offer smoking cessation treatment to improve physical and psychological outcomes for service users, but it currently does not. This study aimed to understand participants' views and experiences of receiving a novel smoking cessation intervention as part of the ESCAPE trial (intEgrating Smoking Cessation treatment As part of usual Psychological care for dEpression and anxiety). We used the Capability, Opportunity and Motivation Model of Behaviour (COM‐B) to understand the (i) acceptability of the integrated smoking cessation treatment, (ii) views of psychological well‐being practitioners' (PWPs) ability to deliver the smoking cessation treatment and (iii) positive and negative impacts of smoking cessation treatment. Methods: This was a qualitative study embedded within a feasibility randomized‐controlled trial (ESCAPE) in primary care services in the United Kingdom (IAPT). Thirty‐six participants (53% female) from both usual care and intervention arms of the ESCAPE trial, including both quitters and nonquitters, were interviewed using semi‐structured interviews. Data were analysed using a framework approach to thematic analysis, using the COM‐B as a theoretical frame. Results: Psychological Capability: Integrated smoking cessation treatment was acceptable and encouraged participants to reflect on their mental health. Some participants found it difficult to understand nicotine withdrawal symptoms. Motivation: Participants were open to change during the event of presenting to IAPT. Some described being motivated to take part in the intervention by curiosity, to see whether quitting smoking would help their mental health. Physical Opportunity: IAPT has a natural infrastructure for supporting integrated treatment, but there were some barriers such as session duration and interventions feeling segmented. Social Opportunity: Participants viewed PWPs as having good interpersonal skills to deliver a smoking cessation intervention. Conclusion: People with common mental illness generally accepted integrated smoking cessation and mental health treatment. Smoking cessation treatment fits well within IAPT's structure; however, there are barriers to implementation. Patient or Public Contribution: Before data collection, we consulted with people with lived experience of smoking and/or mental illness and lay public members regarding the aims, design and interview schedules. After analysis, two people with lived experience of smoking and mental illness individually gave feedback on the final themes and quotes. [ABSTRACT FROM AUTHOR]

Background and aims: Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial‐standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption. Design A between‐subjects randomised experiment with three groups was conducted: group 1: image‐and‐text HWL; group 2: text‐only HWL; group 3: no HWL. Setting: A commercial‐standard naturalistic shopping laboratory in the United Kingdom. Participants: Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home. Interventions: Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image‐and‐text HWL (n = 135); (ii) text‐only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non‐alcoholic drinks, and snacks. Measurement The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability. Findings There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image‐and‐text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text‐only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image‐and‐text HWL group, compared to the text‐only HWL group. Conclusions: In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour. [ABSTRACT FROM AUTHOR]

For years aged care nursing has been largely overlooked and marginalised from mainstream healthcare. COVID-19 brought both aged residential care and nursing into sharp focus for Aotearoa New Zealand. This paper provides a commentary on the work of executive nurses within the Nursing Leadership Group of the New Zealand Aged Care Association as COVID-19 spread into some ARC facilities in early 2020 and threatened the health and wellbeing of many residents and nurses. The group influenced the agenda and implementation of policies for Aged Residential Care and brought the voice of nursing and residents of aged care to the forefront at national and regional levels. [ABSTRACT FROM AUTHOR]

Health warning labels (HWLs) could reduce harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks. A systematic review with meta-analysis using Cochrane methods was conducted to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drink products displaying image-and-text (sometimes termed 'pictorial') and text-only HWLs. Fourteen randomised controlled trials were included, three for alcohol, eleven for food. For the primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared with no HWL (RR=0.74 (95%CI 0.68–0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger (although not statistically significant) effect on selection of image-and-text HWLs (RR=0.65 (95%CI 0.54–0.80)) than text-only HWLs (RR=0.79 (95%CI 0.74–0.85)). These findings suggest significant potential for HWLs to reduce selection of food and alcoholic drinks, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and naturalistic laboratory settings are needed to estimate the potential effects of food and alcohol HWLs. Study registration: PROSPERO 2018 (registration number: CRD42018106522). [ABSTRACT FROM AUTHOR]

INTRODUCTION From May 2016, the European Union introduced the Tobacco Products Directive (TPD) regulations, which included restrictions to advertising and new safety and labeling standards for e-cigarette products. This represented the first supranational policy regulating e-cigarette sales and marketing. This study explores perceptions of TPD and its implementation in Wales, Scotland and England, from perspectives of stakeholders involved in tobacco and e-cigarette policy and implementation in each nation. METHODS Semi-structured qualitative interviews were completed with 12 stakeholders from government and third sector organizations in the UK involved in tobacco control policy-making processes, and Trading Standards Officers from 13 UK local authorities. Data were analyzed thematically and a sub-sample double-coded. RESULTS Stakeholders held varying views of e-cigarettes, recognizing potential benefits and harms of both the products and the new policy actions. Nevertheless, most perceived TPD to be a positive step in introducing regulation for e-cigarettes. Compliance was perceived as high across nations, although stakeholders highlighted product adaptations to circumvent restrictions, and absence of controls on non-nicotine products. Budgetary and staffing limitations also meant that capacity to communicate new measures, and enforce change, was limited. This led to a gap occupied by industry representatives, who played a substantial role in preparing retailers for adoption of new measures. CONCLUSIONS TPD policy roll-out was largely perceived positively and as having been effectively implemented. However, contribution of industry to communication of new measures and absence of resourcing for effective communication perhaps introduced widespread innovations within regulations. While largely viewed positively, some refinements to device regulations were proposed. [ABSTRACT FROM AUTHOR]

The introduction to this special issue details each of the articles and situates the themes covered not only in relation to existing scholarship on the royal body, but to examples of the depiction of current British royalty in the media. We reflect, for instance, on the complex ideological constructions at work in the British press's depiction of Catherine [Middleton], Duchess of Cambridge in comparison to Meghan [Markle], Duchess of Sussex, and contrast the two royal women in order to highlight the distinctly racialized and gendered ways in which royal bodies are seen to occupy public space. In introducing the interdisciplinary approaches taken across the special issue and the depth and variety of discussion, we set out the importance of attending to the performativity of power and its multiply mediated and multiply constituted sites. [ABSTRACT FROM AUTHOR]

Aims: Evidence from tobacco research suggests that health warning labels (HWLs) depicting the adverse consequences of consumption change smoking behaviours, with image‐and‐text (also known as 'pictorial' or 'graphic') HWLs most effective. There is an absence of evidence concerning the potential impact of HWLs placed on alcohol products on selection of those products. This study aimed to obtain a preliminary assessment of the possible impact of (i) image‐and‐text, (ii) text‐only, and (iii) image‐only HWLs on selection of alcoholic versus non‐alcoholic drinks. Design A between‐subjects randomised experiment with a 2 (image: present versus absent) × 2 (text: present versus absent) factorial design. Setting: The study was conducted on the online survey platform Qualtrics. Participants: Participants (n = 6024) were adults over the age of 18 who consumed beer or wine regularly (i.e. at least once a week), recruited through a market research agency. Interventions Participants were randomised to one of four groups varying in the HWL displayed on the packaging of alcoholic drinks: (i) image‐and‐text HWL; (ii) text‐only HWL; (iii) image‐only HWL; and (iv) no HWL. HWLs depicted bowel cancer, breast cancer and liver cancer, which were each displayed twice across six alcoholic drinks. Each group viewed six alcoholic and six non‐alcoholic drinks and selected one drink that they would like to consume. Measurements: The primary outcome was the proportion of participants selecting an alcoholic versus a non‐alcoholic drink. Findings Alcoholic drink selection was lower for all HWL types compared with no HWL (image‐and‐text: 56%; image‐only: 49%; text‐only: 61%; no HWL: 77%), with selection lowest for HWLs that included an image. Image‐and‐text HWLs reduced the odds of selecting an alcoholic drink compared with text‐only HWLs (OR = 0.80, 95% CI = 0.69, 0.92), but increased the odds of selecting an alcoholic drink compared with image‐only HWLs (OR = 1.34, 95% CI = 1.16, 1.55). Conclusions: Health warning labels communicating the increased risk of cancers associated with alcohol consumption reduced selection of alcoholic versus non‐alcoholic drinks in a hypothetical choice task in an online setting; labels displaying images had the largest effect. Their impact in laboratory and real‐world field settings using physical products awaits investigation. [ABSTRACT FROM AUTHOR]

Introduction: There is an absence of evidence regarding the impact of treating tobacco smoking and vaping equivalently in workplace policies. We aimed to describe and compare smoking and vaping policies in acute nonspecialist NHS Trusts (n = 131) and Higher Education Institutions (HEIs) (n = 131) in England.Methods: We conducted a census of smoking and vaping policies through organizational websites searches and direct requests for information. We recorded whether and where smoking and vaping were permitted.Results: Smoking was prohibited indoors in all organizations. No NHS Trust permitted smoking freely outdoors, in contrast with 60% of HEIs. In 27% of NHS Trusts and 33% of HEIs smoking was permitted in designated areas, while in 73% of NHS Trusts and 8% of HEIs smoking was prohibited anywhere on site. Vaping was prohibited indoors in all NHS Trusts and all but one HEI, but permitted freely outdoors in 18% of NHS Trusts and 75% of HEIs. Vaping was permitted in designated outdoor spaces in 23% of NHS Trusts: 21% had areas shared with smokers; 2% had separate vaping areas. Vaping was permitted in designated outdoor areas in 18% of HEIs, all of which were shared with smokers. Vaping was prohibited anywhere on site in 54% of NHS Trusts and 6% of HEIs.Conclusions: Policies vary considerably in whether vaping and smoking are treated equivalently. Smoking policies in most HEIs should be reviewed to include more effective tobacco control approaches. Evidence is needed on the impact of imposing shared or separate spaces on vapers and smokers.Implications: This report provides a comprehensive review of smoking and vaping policies in two types of organization across England. It highlights key discrepancies between current public health recommendations for vaping and existing workplace policies, which often lead to smokers and vapers sharing spaces. The report identifies the need for evidence on the impact of imposing shared spaces on smokers and vapers to inform workplace policies that maximize public health benefit. [ABSTRACT FROM AUTHOR]

Background: Very few countries regulate maximum cigarette pack size. Larger, non‐standard sizes are increasingly being introduced by the tobacco industry. Larger portion sizes increase food consumption; larger cigarette packs may similarly increase tobacco consumption. Here we consider the evidence for legislation to cap cigarette pack size to reduce tobacco‐related harm. Aims and analysis: We first describe the regulations regarding minimum and maximum pack sizes in the 12 countries that have adopted plain packaging legislation and describe the range of sizes available. We then discuss evidence for two key assumptions that would support capping pack size. First, regarding the causal nature of the relationship between pack size and tobacco consumption, observational evidence suggests that people smoke fewer cigarettes when using smaller packs. Secondly, regarding the causal nature of the relationship between reducing consumption and successful cessation, reductions in number of cigarettes smoked per day are associated with increased cessation attempts and subsequent abstinence. However, more experimental evidence is needed to infer the causal nature of these associations among general populations of smokers. Conclusion: Cigarette pack size is positively associated with consumption and consumption is negatively associated with cessation. Based on limited evidence of the causal nature of these associations, we hypothesize that government regulations to cap cigarette pack sizes would positively contribute to reducing smoking prevalence. [ABSTRACT FROM AUTHOR]

Background: Alcohol labeling provides a relatively low-cost, population-level approach to providing information about alcohol's content and harms.Method: We conducted an online between-subjects experiment with two tasks to examine the impact of alcohol labels (n = 1884). In one task, participants were randomized to view one of four different unit labels (including labels currently used by the alcohol industry and novel labels which provide more information about how the number of units relates to recommended drinking guidelines). We assessed participants' accuracy of estimating weekly serving limits of alcohol. In a second task, participants were randomized to view one of eight health warnings (which varied according to message content, specificity, and framing). We assessed the motivation to quit after viewing the health warning.Results: Accuracy of estimating weekly serving limits of alcohol was greater for participants who viewed novel unit labels compared to the industry standard labels. Motivation to drink less was higher amongst participants who had viewed both cancer and negatively framed messages, compared to mental health and positively framed messages.Conclusion: Existing unit labels used by the alcohol industry can be improved; the inclusion of unit information per serving and how these relate to low-risk drinking guidelines may be important for facilitating consumer understanding. Health warning labels should be included alongside units to provide consumers with information about the harms associated with alcohol and discourage riskier drinking behavior. [ABSTRACT FROM AUTHOR]

Increasing numbers of older New Zealanders are spending their last days of life in Aged Residential Care (ARC), traditionally rehabilitative-focused. Current trends suggest realignment towards a palliative approach to care is needed. While the New Zealand government has committed to providing quality palliative care, available to all irrespective of where they live, the need for a supportive partnership between regional ARC and specialist palliative care services has not been established. A pilot study was conducted by a specialist Supportive Education and Quality palliative care (SEQUAL) team in five ARC facilities within regional New Zealand. A clinical staff survey (n = 84) and facility desktop document review were undertaken to determine readiness, need for and level of support required to enhance primary palliative care for residents. Each of the five facilities was found to document few indicators for a palliative care approach in care philosophy or delivery plans. While the majority of clinical staff (Registered Nurses /Health Care Assistants), reported spending more than 50% of their time with residents in their final year of life, not all felt confident to do so. No palliative care education had been received by 42% (n=36) of respondents. Implementing a specialist palliative care partnership to support facility re-alignment of care philosophy, policies and procedural guidelines, with additional clinical staff palliative care education would provide a platform to implement a palliative care approach in regional ARC settings. This would signal the intent of the organisations to provide an individualised quality palliative care experience for residents. [ABSTRACT FROM AUTHOR]

An interview is presented with screenwriter Andrew Davies. Topics discussed include information on adapting a work of novel War and Peace (Tolstoy, 1863–69); adaptation of Victor Hugo's Les Misérables work in costume drama; and overlapping between his work and other British Broadcasting Corporation (BBC) programmes such as Happy Valley.

Despite a critical movement seen across the humanities described as the ‘corporeal turn’ (Elam 143) in Shakespeare studies alone, adaptation studies has been slow to situate the body as a site of major interpretive possibility. A constituent part of textual readings the body has, nonetheless, rarely been regarded as an adaptive site in and of itself; instead, it is viewed as a participant in the process of adaptation. The purpose of this paper is twofold. First, to demonstrate the validity of an actor-based approach to adaptation and secondly to further the call made by Deborah Cartmell and Imelda Whelehan amongst others to ascend the ‘aporias of fidelity’ by working to an intertextual or dialogical model (Cartmell and Whelehan 73). I thereby wish to explore Josie Rourke’s theatrical production of Coriolanus and the importance of her lead Tom Hiddleston’s body as a source of meaning, doing this through examining inter-related but frequently disparate fields such as star-theory and popular culture studies, as well as considering the qualities independently brought by the actor to character through physicality and intertextuality within the adaptive process. Through the presentation of Hiddleston’s body and its function as an adaptive site, we are thus able to view Rourke’s interaction with the visual culture of contemporary action cinema and the resonances this creates physically and thematically for Coriolanus’s depiction of the soldier-hero. [ABSTRACT FROM AUTHOR]

The article presents information on the seventh Annual Association of Adaptation Studies Conference held at the University of York in York. It is noted that the relationship between acts of authoring and the ongoing lives of adapted texts was reflected in the papers presented at the conference. Philosopher Kamilla Elliott presented her paper "12 Fallacies in Contemporary Adaptation Theory, 2012."

Pack size of tobacco products, including factory-made cigarettes and loose tobacco, is an important but neglected aspect of tobacco control policy. Understanding the nature of the relationship between pack size and consumption, as well as the underlying mechanisms, is key for informing effective policy and reducing smoking prevalence.

Background: We examined whether enhancing self-affirmation among a population of drinkers, prior to viewing threatening alcohol pictorial health warning labels, would reduce defensive reactions and promote reactions related to behaviour change. We also examined how health warning severity influences these reactions and whether there is an interaction between self-affirmation and severity.Methods: In this experimental human laboratory study, participants (n = 128) were randomised to a self-affirmation or control group. After the self-affirmation manipulation was administered, we tracked participants' eye movements while they viewed images of six moderately-severe and six highly-severe pictorial health warning labels presented on large beer cans. Self-reported responses to the pictorial health warning labels were then measured, including avoidance, reactance, effectiveness, susceptibility and motivation to drink less. Finally, participants reported their self-efficacy to drink less and their alcohol use.Results: There was no clear evidence that enhancing self-affirmation influenced any outcome. In comparison to moderately-severe health warnings, highly-severe health warnings increased avoidance and reactance and were perceived as more effective and increased motivation to drink less.Conclusions: These findings call into question the validity of the self-affirmation manipulation, which is purported to reduce defensive reactions to threatening warnings. We discuss possible explanations for this null effect, including the impact of participants' low perceived susceptibility to the risks shown on these pictorial health warning labels. Our finding that highly-severe health warnings increase avoidance and reactance but are also perceived as being more effective and more likely to motivate people to drink less will inform future health warning design and have implications for health warning label theory. [ABSTRACT FROM AUTHOR]