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Background While tobacco smoking has declined among UK youth in recent decades, cannabis use has begun to show some growth. Given their interrelationship, growth in cannabis use may act as a barrier to continued reduction in youth smoking. This paper assesses recent tobacco and cannabis use trends in Wales, and their association, to explore whether change in cannabis use might have impacted youth tobacco smoking prevalence. Methods Repeat cross-sectional data on tobacco and cannabis use were obtained from biennial Welsh Student Health and Wellbeing surveys between 2013 and 2019. Data were pooled and analysed using logistic regression with adjustment for school-level clustering. Results No change in regular youth tobacco smoking was observed between 2013 and 2019. In contrast, current cannabis use increased during this time, and cannabis users had significantly greater odds of regular tobacco smoking. After adjusting for change in cannabis use, a significant decline in youth tobacco smoking was observed (OR 0.95; 95% confidence intervals: 0.92, 0.97). Conclusion Recent growth in cannabis use among young people in Wales may have offset prospective declines in regular tobacco smoking. Further reductions in youth smoking may require more integrated policy approaches to address the co-use of tobacco and cannabis among adolescents. [ABSTRACT FROM AUTHOR]

Introduction: Hypertension affects around 30% of the UK population and is the leading modifiable cause of cardiovascular disease1. Despite available evidence-based treatments, nonadherence to antihypertensive medication is prevalent. Health psychology theory suggests that beliefs about a condition and its treatment influence health-related behaviours such as medication adherence through the formation of 'illness representations', a lay perception of the health threat. Accurate illness representations and an increased belief in the necessity for medication are associated with greater medication adherence2. Visualisation of the internal process of an illness has been shown to support the accuracy of illness representations3. ViSTA-BP (Visualisation to Support Treatment Adherence for High Blood Pressure) is a digital intervention used within a healthcare consultation, enabling individuals to visualise and conceptualise hypertension and the resulting changes to the circulatory system using real-time animations. The purpose is to support medication adherence through the improved understanding of hypertension and increased perception of medication necessity. Aim: To explore the acceptability of a community pharmacy-based hypertension visualisation intervention (ViSTA-BP) with community pharmacists and patients. Methods: Acceptability of ViSTA-BP was investigated in a community pharmacy setting in South Wales by conducting semi-structured qualitative interviews with pharmacists and patients. Ethical approval was granted by NHS Research Ethics Committee Wales (REC) 5 (20/WA/0280) and Cardiff Metropolitan University Ethics Committee (PGR-3806). Template analysis, a form of qualitative thematic analysis, was used to guide data interpretation. The Theoretical Framework of Acceptability (TFA) provided a lens through which to investigate acceptability, considering affective attitude towards the intervention burden, intervention coherence, ethicality, opportunity costs, perceived effectiveness and self-efficacy. Patients were purposely selected, incorporating a range of locations, adherence and treatment beliefs, thus minimising bias. Results: Interviews were conducted with fifteen patients and eight pharmacists who provided feedback. Both groups demonstrated a positive attitude towards ViSTA-BP. Patients were both interested in and reassured by the intervention. They showed good intervention coherence, articulating an increased understanding of hypertension and suggesting patient groups that could benefit from ViSTA-BP. Pharmacists felt ViSTA-BP illustrated the necessity for medication, demonstrating that hypertension could be managed effectively. Patients and pharmacists were positive about ViSTA-BP's potential for effectiveness. Patients felt it provided context for their understanding of hypertension and could prompt action. Pharmacists liked the visual elements, with ViSTA-BP providing a useful addition to their consultation 'toolkit'. Patients felt that ViSTA-BP fits well within a community pharmacy setting. Intervention accessibility and facilitator knowledge were key; patients found the intervention duration acceptable. Pharmacists felt that ViSTA-BP fits within their current practice. However, the evolving role of the community pharmacy workforce and time pressures from competing workloads created uncertainty regarding the future feasibility of ViSTA-BP within this setting. Discussion/Conclusion: Both patients and pharmacists were positive about ViSTA-BP, acknowledging the potential effectiveness of the personalised interactive visual to engage the viewer and conceptualise hypertension through visual-based communication. However, pharmacists' perceptions of future roles supported by the community pharmacy contractual framework in Wales and staff time constraints provide potential barriers to future implementation. References: 1. McDonnell BJ, Rees E, Cockcroft JR, Beaney T, Clayton B, Kieu P Le, et al. May Measurement Month 2019: an analysis of blood pressure screening results from the United Kingdom and Republic of Ireland. Eur Hear Journal, Suppl. 2021;23(supplement B):B147–50. 2. Hagger MS, Orbell S. The common sense model of illness self-regulation: a conceptual review and proposed extended model. Health Psychol Rev [Internet]. 2022;16(3):347–77. Available from: https://doi.org/10.1080/17437199.2021.1878050 3. Jones ASK, Ellis CJ, Nash M, Stanfield B, Broadbent E. Using Animation to Improve Recovery from Acute Coronary Syndrome: A Randomized Trial. Ann Behav Med. 2016 Feb 1;50(1):108–18. [ABSTRACT FROM AUTHOR]

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.

Introduction: There is a consensus that adolescents' participation in organized leisure-time activities (OLTAs) is pro-developmental and beneficial for youth mental health. While enjoyment in OLTA is commonly regarded as positive, the role of obligation in the context of adolescents' OLTA has been scarcely researched. The present study investigated how these theoretically contradictory experiences (enjoyment and/or obligation) in OLTA participation relate to adolescents' wellbeing and incidence of psychological complaints accounting for their possible co-occurrence., Methods: A nationally representative sample of 14,128 eleven-fifteen-year-old adolescents (49.7% girls) drawn from the Czech 2021/2022 Health Behaviour in School-aged Children cross-sectional study was used. A series of multivariate regression analyses assessed how perceptions of obligation and enjoyment in OLTA related to wellbeing and occurrence of psychological complaints. A person-centered approach derived groups of respondents on the basis of their perceptions of obligation and enjoyment., Results: Regression analyses, controlled for sociodemographic and family environment factors, and dimensions of OLTA participation, indicated that adolescents enjoying their OLTA displayed more favourable mental wellbeing reports. In contrast, perceptions of obligation were only weakly associated with more frequent psychological complaints and not at all with wellbeing, unless adolescents also reported the lack of enjoyment., Conclusions: Enjoyment in OLTA plays a pivotal role in the association between OLTA participation and mental health, whereas the role of obligation is far less pronounced. In fact, if adolescents do not enjoy their participation, but feel obliged to participate, their self-assessed mental wellbeing is comparable to their peers not participating in OLTA at all., (© 2024 The Authors. Journal of Adolescence published by Wiley Periodicals LLC on behalf of Foundation for Professionals in Services to Adolescents.)

Background: Role models have been identified as a potential means to tackle the persisting low levels of physical activity among young girls. The aim of this research was to explore the involvement of community- and peer role models within the CHARMING (CHoosing Active Role Models to INspire Girls) intervention, an intervention which aims to increase and sustain physical activity among 9-10-year-old girls. The research questions were, is it feasible and acceptable to recruit role models? and what are the perceived barriers and facilitators to the inclusion of peer role models within the intervention?, Methods: A mixed methods process evaluation was embedded within a larger feasibility study, involving three secondary schools and four adjoining primary schools in South Wales, United Kingdom. One-to-one interviews were conducted with teachers (N = 10) across the seven schools and community role models (N = 10). Focus groups were conducted with 18 peer role models (older girls from adjoining secondary schools) and 18 girls aged 9-10-years who had participated in the intervention. Primary school teachers kept observation logs of each intervention session. A researcher completed observation logs of two random sessions per school. Qualitative data were analysed using thematic analysis with a combined deductive and inductive coding approach. Observation data were analysed using descriptive statistics. Data were triangulated and comparative analyses conducted across schools., Results: Twenty-three peer role models (aged 12-16-years) and 16 community role models participated in intervention delivery. Overall, the inclusion of both types of role models was shown as acceptable and feasible within the CHARMING intervention. Observation data highlighted key areas (i.e., intervention components delivered inconsistently) for further qualitative exploration. Six themes were identified during analyses; reach and access, communication, logistics, existing systems, interpersonal relationships, and perceived impacts. Themes were intertwined across the barriers and facilitators of recruitment and implementation. Areas for future improvement were highlighted., Conclusions: Findings can be used to optimise the CHARMING intervention and inform wider interventions or policies employing several role models across settings to promote physical activity among children., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background : Community pharmacies are well-placed to deliver well-being interventions; however, to date, nothing has been produced specifically for this setting. The aim of this study was to develop a positive psychology intervention suitable for a community pharmacy setting with the goal of increasing the well-being of community members. Methods : Intervention development consisted of three steps: Step 1-identify the evidence-base and well-being model to underpin the basis of the intervention (Version 1); Step 2-model the intervention and gather user feedback to produce Version 2, and Step 3-revisit the evidence-base and refine the intervention to produce Version 3. Results : Findings from nine studies (seven RCTs, one cross-sectional, one N-1 design plus user feedback were applied to model a 6-week ' Prescribing Happiness ( P - Hap )' intervention, underpinned by the PERMA model plus four other components from the positive psychology literature ( Three Good Things , Utilising Your Signature Strengths in New Ways , Best Possible Selves and Character Strengths ). A PERMA-based diary was designed to be completed 3 days a week as part of the intervention. Conclusions : This work is an important development which will direct the future implementation of interventions to support well-being in this novel setting. The next stage is to gain the perspectives of external stakeholders on the feasibility of delivering the P-Hap for its adoption into community pharmacy services in the future.

Background: Low physical activity levels in young children is a major concern. For children aged 0-5 years, engagement with opportunities to be physically active are often driven by the adults responsible for the child's care. This systematic review explores the barriers and facilitators to parents/caregivers engaging pre-school children in community-based opportunities for physical activity, within real-world settings, or as part of an intervention study. Methods: EBSCOhost Medline, CINHAL plus, EBSCOhost SPORTDiscus, Web of Science, ProQuest, and ASSIA were systematically searched for quantitative and qualitative studies published in English between 2015 and 16 May 2022. Data extracted from 16 articles (485 parents/carers; four countries) were quality-assessed using the Mixed Methods Assessment Tool and coded and themed via thematic analysis. Results: Nine themes (eight core, one minor) were identified and conceptualised into a socio-ecological model, illustrating factors over four levels: Individual-beliefs and knowledge (and parental parameters); Interpersonal-social benefits, social network, and family dynamic; Community-organisational factors and affordability; and Built and Physical Environment-infrastructure. Discussion: The findings provide valuable insights for practitioners and policy makers who commission, design, and deliver community-based physical activity opportunities for pre-school children. Developing strategies and opportunities that seek to address the barriers identified, as well as build on the facilitators highlighted by parents, particularly factors related to infrastructure and affordability, are imperative for physical activity promotion in pre-school children. The perspectives of fathers, socioeconomic and geographical differences, and the importance parents place on physical activity promotion all need to be explored further.

Objectives: Using the Health Belief Model as a conceptual framework, we investigated the association between attitudes towards COVID-19, COVID-19 vaccinations, and vaccine hesitancy and change in these variables over a 9-month period in a UK cohort., Methods: The COPE study cohort (n = 11,113) was recruited via an online survey at enrolment in March/April 2020. The study was advertised via the HealthWise Wales research registry and social media. Follow-up data were available for 6942 people at 3 months (June/July 2020) and 5037 at 12 months (March/April 2021) post-enrolment. Measures included demographics, perceived threat of COVID-19, perceived control, intention to accept or decline a COVID-19 vaccination, and attitudes towards vaccination. Logistic regression models were fitted cross-sectionally at 3 and 12 months to assess the association between motivational factors and vaccine hesitancy. Longitudinal changes in motivational variables for vaccine-hesitant and non-hesitant groups were examined using mixed-effect analysis of variance models., Results: Fear of COVID-19, perceived susceptibility to COVID-19, and perceived personal control over COVID-19 infection transmission decreased between the 3- and 12-month surveys. Vaccine hesitancy at 12 months was independently associated with low fear of the disease and more negative attitudes towards COVID-19 vaccination. Specific barriers to COVID-19 vaccine uptake included concerns about safety and efficacy in light of its rapid development, mistrust of government and pharmaceutical companies, dislike of coercive policies, and perceived lack of relaxation in COVID-19-related restrictions as the vaccination programme progressed., Conclusions: Decreasing fear of COVID-19, perceived susceptibility to the disease, and perceptions of personal control over reducing infection-transmission may impact future COVID-19 vaccination uptake., (© 2022 The Authors. British Journal of Health Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.)

Purpose: This study aims to identify distinct typologies of joint family activities and the associations with mental health and wellbeing among adolescents across four countries from the World Health Organization European region., Methods: The 2017/2018 data from adolescents from Armenia (n = 3,977, M age  = 13.5 ± 1.6 years, 53.4% female), Czechia (n = 10,656, M age  = 13.4 ± 1.7, 50.1% female), Russia (n = 4,096, M age  = 13.8 ± 1.7, 52.4% female), and Slovakia (n = 3,282, M age  = 13.4 ± 1.5, 51.0% female) were collected in schools. The respondents self-reported their participation in joint family leisure-time activities, life satisfaction, psychological and somatic complaints, as well as a range of demographic and family situational factors. Stratified by countries, latent class analysis identified typologies of joint family activities, and logistic regression models explored cross-sectional associations with life satisfaction, and psychological and somatic complaints., Results: Three typologies were identified across each of the four countries, distinguished by low, moderate, and high levels of family engagement. Adolescents with higher family engagement generally reported greater life satisfaction and fewer psychological complaints compared to those with lower family engagement. Russian adolescents in the high family engagement typology reported fewer somatic complaints compared to those with low family engagement. In addition, adolescents from Czechia and Russia showing moderate family engagement also reported fewer psychological complaints compared to those in the low family engagement typology., Discussion: Our findings from four countries suggest that adolescents with high family engagement have greater life satisfaction and fewer psychological complaints, pointing toward a need for interventions to support family engagement among adolescents. Further research is needed to fully explore underlying mechanisms., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: In the UK, there is evidence that girls' physical activity tends to decline to a greater extent than boys as they enter adolescence. 'Role models' could play a vital role in inspiring girls to become or remain physically active. The CHARMING Programme is a primary school-based community linked role-model programme, co-developed in 2016, with children, parents, schools and wider stakeholders. It involves different types of physical activity delivered for 1-h each week by a community provider and peer role models (e.g. older girls from secondary schools) joining in with the sessions. The programme ultimately aims to increase and sustain physical activity levels among 9-10-year-old girls. This study aims to assess the feasibility and acceptability of the CHARMING Programme and of evaluating it using a randomised trial., Methods: This study is a feasibility cluster randomised controlled trial, with embedded process evaluation and health economic evaluation. Approximately 90 Year 5 (i.e. 9-10-year-old) girls will be recruited across six primary schools in Mid-South Wales. Participating schools will be allocated to the programme: control on a 2:1 basis; four intervention schools will run the CHARMING Programme and two will continue with usual practice. A survey and accelerometer will be administered at baseline and repeated at 12 months. Interviews and focus groups will be conducted post-intervention delivery. The primary aim is to assess feasibility of a future randomised trial via the recruitment of schools, participants and role models; randomisation; retention; reach; data collection completion rates; programme adherence; and programme fidelity, views on intervention acceptability and programme barriers and facilitators. Secondary aims are to evaluate established physical activity outcome measures for children plus additional health economic outcomes for inclusion in a future full-scale trial., Discussion: The results of this study will inform decisions on whether and how to proceed to a full-scale evaluation of the effectiveness and cost-effectiveness of the CHARMING Programme to improve or sustain physical activity., Trial Registration: ClinicalTrials.gov ISRCTN36223327. Registered March 29, 2021., (© 2021. The Author(s).)

Background: Today's primary school children have grown up in a climate of strong smoking restrictions, decreasing tobacco use, and the emergence of e-cigarettes. Children's exposure to tobacco declined substantially in years following the introduction of smoke-free legislation, with smoking uptake and perceived smoking norms declining. There is debate regarding whether emergence of e-cigarettes may interrupt trends in children's smoking perceptions, or offer a means for adults to limit children's exposure to tobacco. This study examines change in children's tobacco and e-cigarettes experimentation (ever use), exposure to secondhand smoking and vaping, and perceived smoking norms., Methods: Data from four, repeat cross-sectional surveys of Year 6 primary school pupils (age 10-11 years) in Wales in 2007, 2008, 2014 and 2019 (n = 6741) were combined. E-cigarette use and perceptions were included in 2014 and 2019 surveys. Analyses used binary logistic regression analyses, adjusted for school-level clustering., Results: Child tobacco experimentation and most indicators of exposure to tobacco smoke indicated a graded decreasing trend over time from 2007 to 2019. Exposure to e-cigarettes increased from 2014 to 2019, as did pupil awareness of e-cigarettes (OR = 2.56, 95%CI = 2.12-3.10), and parental use (OR = 1.26, 95%CI = 1.00-1.57). A decrease in child e-cigarette experimentation was not significant (OR = 0.80, 95%CI = 0.57-1.13). Children's normative perceptions for smoking by adults and children indicated a graded decrease over time (OR = 0.66, 95%CI = 0.54-0.80; OR = 0.69, 95%CI = 0.55-0.86; respectively from 2014 to 2019). However, fewer reported disapproval of people smoking around them in 2019 relative to 2014 (OR = 0.68, 95%CI = 0.53-0.88). Higher exposure to tobacco cigarettes and e-cigarettes in public places, cars and households were associated with favourable normative perceptions for tobacco smoking; however in models adjusted for exposure to both associations of e-cigarette exposure were attenuated., Conclusion: Children's experimentation with and exposure to tobacco, and their perceptions of smoking as a normative behaviour, have continued to decline alongside growth in exposure to e-cigarettes. Although a large majority of pupils reported they minded people smoking around them, there was some evidence of diminishing disapproval of secondhand smoke since 2007. Further research is needed to understand whether use of e-cigarettes in cars and homes is displacing prior smoking or being introduced into environments where smoking had been eliminated., (© 2021. The Author(s).)

Public perceptions of pandemic viral threats and government policies can influence adherence to containment, delay, and mitigation policies such as physical distancing, hygienic practices, use of physical barriers, uptake of testing, contact tracing, and vaccination programs. The UK COVID-19 Public Experiences (COPE) study aims to identify determinants of health behaviour using the Capability, Opportunity, Motivation (COM-B) model using a longitudinal mixed-methods approach. Here, we provide a detailed description of the demographic and self-reported health characteristics of the COPE cohort at baseline assessment, an overview of data collected, and plans for follow-up of the cohort. The COPE baseline survey was completed by 11,113 UK adult residents (18+ years of age). Baseline data collection started on the 13th of March 2020 (10-days before the introduction of the first national COVID-19 lockdown in the UK) and finished on the 13th of April 2020. Participants were recruited via the HealthWise Wales (HWW) research registry and through social media snowballing and advertising (Facebook®, Twitter®, Instagram®). Participants were predominantly female (69%), over 50 years of age (68%), identified as white (98%), and were living with their partner (68%). A large proportion (67%) had a college/university level education, and half reported a pre-existing health condition (50%). Initial follow-up plans for the cohort included in-depth surveys at 3-months and 12-months after the first UK national lockdown to assess short and medium-term effects of the pandemic on health behaviour and subjective health and well-being. Additional consent will be sought from participants at follow-up for data linkage and surveys at 18 and 24-months after the initial UK national lockdown. A large non-random sample was recruited to the COPE cohort during the early stages of the COVID-19 pandemic, which will enable longitudinal analysis of the determinants of health behaviour and changes in subjective health and well-being over the course of the pandemic., Competing Interests: The authors have declared that no competing interests exist.

Research has consistently shown that access to parks and gardens is beneficial to people's health and wellbeing. In this paper, we explore the role of both public and private green space in subjective health and wellbeing during and after the first peak of the COVID-19 outbreak that took place in the UK in the first half of 2020. It makes use of the longitudinal COVID-19 Public Experiences (COPE) study, with baseline data collected in March/April 2020 (during the first peak) and follow-up data collected in June/July 2020 (after the first peak) which included an optional module that asked respondents about their home and neighbourhood (n = 5,566). Regression analyses revealed that both perceived access to public green space (e.g. a park or woodland) and reported access to a private green space (a private garden) were associated with better subjective wellbeing and self-rated health. In line with the health compensation hypothesis for green space, private gardens had a greater protective effect where the nearest green space was perceived to be more than a 10-minute walk away. This interaction was however only present during the first COVID-19 peak when severe lockdown restrictions came into place, but not in the post-peak period when restrictions were being eased. The study found few differences across demographic groups. A private garden was relatively more beneficial for men than for women during but not after the first peak. The results suggest that both public and private green space are an important resource for health and wellbeing in times of crisis., (© 2021 The Authors.)

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., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. L. McKell, B. Hallingberg, J. Van Godwin, G. Moore, L. Bauld, O. Maynard and R. Brown report funds from NIHR Public Health Research. G. Moore also reports funds from UKCRC Consortium, Welsh Government via Health and Care Research Wales and Cardiff University, during the conduct of the study and grants from Cancer Research UK, NICE, NIHR, CRUK outside the submitted work. L. Bauld also reports grants from Medical Research Council, NIHR Public Health Research, Cancer Research UK and from UK Research Innovation, outside the submitted work. R. Brown also reports funding from Cardiff University during the conduct of the study, and grants from Cancer Research UK, outside the submitted work., (© 2021 Brown R. et al.)

To date no study has examined time trends in adolescent consumption of sugar-sweetened beverages and energy drinks, or modelled change in inequalities over time. The present study aimed to fill this gap by identifying historical trends among secondary school students in Wales, United Kingdom. The present study includes 11-16 year olds who completed the Health Behaviour in School-aged Children (HBSC) survey and the Welsh School Health Research Network (SHRN) survey between 1998 to 2017. Multinomial regression models were employed alongside tests for interaction effects. A total of 176,094 student responses were assessed. From 1998 to 2017, the prevalence of daily sugar-sweetened beverage consumption decreased (57% to 18%) while weekly consumption has remained constant since 2006 (49% to 52%). From 2013 to 2017, daily consumption of energy drinks remained stable (6%) while weekly consumption reports steadily decreased (23% to 15%). Boys, older children and those from a low socioeconomic group reported higher consumption rates of sugar-sweetened beverages and energy drinks. Consumption according to socioeconomic group was the only characteristic to show a statistically significant change over time, revealing a widening disparity between sugar-sweetened beverage consumption rates of those from low and high socioeconomic groups. Findings indicate a positive shift in overall consumption rates of both sugar-sweetened beverages and energy drinks. Adolescents from a low socioeconomic group however were consistently shown to report unfavourable sugar-sweetened beverages consumption when compared to peers from high socioeconomic group. Given the established longer term impacts of sugar-sweetened beverage and energy drink consumption on adolescent health outcomes, urgent policy action is required to reduce overall consumption rates, with close attention to equity of impact throughout policy design and evaluation plans., Competing Interests: The authors have declared that no competing interests exist.

Transition between primary and secondary school represents an important milestone in young people's development. While most young people look forward to this transition, it is a source of anxiety for many. Drawing on a nationally representative survey of 2218 children in 73 schools in Wales, this study aimed to understand the extent to which 10-11 year old children worried about and/or looked forward to their imminent transition to secondary school, the things they worried about and/or looked forward to, and how feelings about transition differed by socioeconomic status, as well as by emotional and behavioural difficulties. About a third of children reported being quite or very worried about transition to secondary school, while approximately two-thirds reported looking forward to it quite a bit or very much. These items were only moderately correlated, with many children both looking forward to and worrying about transition, or neither. Major sources of worry about transition centred around bullying and impact on existing friendships, while forming new friendships or joining existing friends in their new school were key things children looked forward to. Children from poorer backgrounds, attending poorer schools and reporting more emotional difficulties were significantly more likely to report worries about transition. Children from poorer families, and children reporting more emotional difficulties and behavioural difficulties, were less likely to look forward to transition. Interventions to support children in transition to secondary school need to be sensitive to the needs of children from poorer backgrounds and children with mental health difficulties., (© The Author(s) 2021.)

Background: Young people's experimentation with e-cigarettes has increased in recent years, although regular use remains limited. EU Tobacco Products Directive (TPD) regulations introduced packet warnings, advertising restrictions, and regulated nicotine strength from 2016, in part due to concerns regarding use by young people. This paper examines e-cigarette use trajectories before and after TPD., Methods: E-cigarette use data were obtained from School Health Research Network/Health Behaviour in School-aged Children surveys in Wales and Smoking Drinking and Drug Use surveys in England. Data from Wales were analysed using segmented logistic regression, with before and after regression analyses of English data. Semi-structured group interviews included young people aged 14-16 years in Wales, England and Scotland in 2017 and 2018., Results: In Wales, ever use of e-cigarettes increased over time, but under a range of assumptions, growth did not appear to continue post-TPD. A small and non-significant change in trend was observed post-implementation (OR=0.96; 95%CI=0.91 to 1.01), which increased in size and significance after adjusting for ever smoking (OR=0.93; 95%CI=0.88 to 0.98). There was little increase in regular e-cigarette use from 2015 to 2017 in Wales. However, ever and regular use increased from 2014 to 2016 in England. Young people in all nations described limited interactions with components of TPD, while describing e-cigarette use as a 'fad', which had begun to run its course., Conclusions: This study provides preliminary evidence that young people's e-cigarette experimentation may be plateauing in UK nations. The extent to which this arises from regulatory changes, or due to a fad having begun to lose its appeal among young people in the UK countries, remains unclear. These trends contrast to those observed in North America, where newer products whose EU market entry and marketing have been impacted by TPD, have gained traction among young people. Long-term monitoring of e-cigarette use trends and perceptions among young people remain vital., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Experimentation with e-cigarettes has grown rapidly among UK adolescents. To date, this topic has been primarily researched in secondary schools, with less understanding of development of attitudes and behaviours at an earlier age. This research reports qualitative data from interviews with pupils, parents, and teachers at 4 case study schools in Wales (N = 42). It draws on Bronfenbrenner's Ecological Systems Theory to consider how the intersection of systems surrounding primary school-age children and their interaction with these systems, shape knowledge, and attitudes towards e-cigarettes and tobacco. Findings indicate that consistent messaging on smoking from school and family was reflected in strong disapproval among pupils and clear understanding of harms. This was less evident for e-cigarettes, where messages were mixed and inconsistent between home and school, with concerns over what to tell children about e-cigarettes in light of mixed messages and absence of official guidance. Implications of findings for policy and teaching are discussed., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Objectives: To examine whether during a period of limited e-cigarette regulation and rapid growth in their use, smoking began to become renormalised among young people., Design: Interrupted time-series analysis of repeated cross-sectional time-series data., Setting: Great Britain PARTICIPANTS: 248 324 young people aged approximately 13 and 15 years, from three national surveys during the years 1998-2015., Intervention: Unregulated growth of e-cigarette use (following the year 2010, until 2015)., Outcome Measures: Primary outcomes were prevalence of self-reported ever smoking and regular smoking. Secondary outcomes were attitudes towards smoking. Tertiary outcomes were ever use of cannabis and alcohol., Results: In final models, no significant change was detected in the pre-existing trend for ever smoking (OR 1.01, CI 0.99 to 1.03). There was a marginally significant slowing in the rate of decline for regular smoking (OR 1.04, CI 1.00 to 1.08), accompanied by a larger slowing in the rate of decline of cannabis use (OR 1.21, CI 1.18 to 1.25) and alcohol use (OR 1.17, CI 1.14 to 1.19). In all models and subgroup analyses for smoking attitudes, an increased rate of decline was observed after 2010 (OR 0.88, CI 0.86 to 0.90). Models were robust to sensitivity analyses., Conclusions: There was a marginal slowing in the decline in regular smoking during the period following 2010, when e-cigarettes were emerging but relatively unregulated. However, these patterns were not unique to tobacco use and the decline in the acceptability of smoking behaviour among youth accelerated during this time. These analyses provide little evidence that renormalisation of youth smoking was occurring during a period of rapid growth and limited regulation of e-cigarettes from 2011 to 2015., Trial Registration Number: Research registry number: researchregistry4336., Competing Interests: Competing interests: LB declares a secondment post with Cancer Research UK and all other authors report no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: This study examines primary schoolchildren's perceptions of e-cigarettes and tobacco cigarettes, and associations with parental smoking, vaping and socioeconomic status., Methods: Survey of 2218 10-11-year-old children in 73 schools in Wales., Results: Overall, 36% reported that a parent figure smoked compared to 21% for vaping, with parental smoking lower in affluent families (OR = 0.72; 95% CI = 0.68 to 0.76). Overall, 1% had tried a cigarette, while 5% had tried an e-cigarette. Most said they would not smoke or vape in 2 years' time; susceptibility to vaping (20%) was higher than smoking (12%). Exposure to and perceptions of tobacco cigarettes were more positive for children of smokers. Having a parent who vaped was associated with exposure to and positive perceptions of e-cigarettes, but not smoking. Most children perceived e-cigarettes as used by adults to stop smoking (64%). Susceptibility to smoking (OR = 0.57; 95% CI = 0.41 to 0.79) and vaping (OR = 0.78; 95% CI = 0.62 to 0.99) were lower among children who perceived e-cigarettes as cessation aids., Conclusions: Parental smoking continues to be concentrated in poorer families. This study provides no evidence that parental vaping in the absence of smoking is associated with more positive perceptions of tobacco cigarettes. Communicating to children the role of e-cigarettes as cessation devices for smokers may help to limit their appeal to young people., Competing Interests: The authors declare no conflict of interest.

Purpose: The study of mental wellbeing requires reliable, valid, and practical measurement tools. One of the most widely used measures of mental wellbeing is the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Our aim was to examine the psychometric properties of SWEMWBS (a brief seven-item version) in a 'real-world' population sample of young people., Methods: We used data from the 2017 School Health Research Network Student Health and Wellbeing Survey, completed by 103,971 students in years 7 to 11 from 193 secondary schools in Wales. We first estimated polychoric correlation matrices for the whole sample and by school year, and undertook a principal components analysis to check for configural invariance. Subsequently, we used a multiple-groups structural equation model with successively greater constraints to test measurement invariance. To examine external construct validity, we calculated correlations between the SWEMWBS score and four covariates: life satisfaction, somatisation, school pressure and bullying victimisation., Results: Parallel analysis suggested that extraction of one factor was appropriate both overall and in each year group. Inspection of standardised loadings suggested that four items had progressively stronger correlations with the factor as students are older, but change in fit indices between models suggested that loadings and thresholds, but not residual variances, were invariant by age group. SWEMWBS scores were moderately correlated with measures of life satisfaction and somatisation, and weakly to moderately correlated with school pressure and bullying victimisation., Conclusions: This study adds to the growing evidence that SWEMWBS is appropriate for measuring mental wellbeing in young people and suggests that SWEMWBS is appropriate for tracking the development of wellbeing across adolescence.

Background: Exercise referral schemes (ERSs) are recommended for patients with health conditions or risk factors. Evidence points to the initial effectiveness and cost-effectiveness of such schemes for increasing physical activity, but effects often diminish over time. Techniques such as goal setting, self-monitoring, and personalized feedback may support motivation for physical activity and maintenance of effects. Wearable technologies could provide an opportunity to integrate motivational techniques into exercise schemes. However, little is known about acceptability to exercise referral populations or implementation feasibility within exercise referral services., Objective: To determine the feasibility and acceptability of implementing an activity-monitoring device within the Welsh National ERS to inform a decision on whether and how to proceed to an effectiveness trial., Methods: We conducted a feasability randomized controlled trial with embedded mixed-methods process evaluation and an exploratory economic analysis. Adults (N=156) were randomized to intervention (plus usual practice; n=88) or usual practice only (n=68). Usual practice was a 16-week structured exercise program. The intervention group additionally received an accelerometry-based activity monitor (MyWellnessKey) and associated Web platform (MyWellnessCloud). The primary outcomes were predefined progression criteria assessing acceptability and feasibility of the intervention and proposed evaluation. Postal questionnaires were completed at baseline (time 0:T0), 16 weeks (T1), and 12 months after T0 (T2). Routine data were accessed at the same time-points. A subsample of intervention participants and scheme staff were interviewed following the initiation of intervention delivery and at T2., Results: Participants were on average aged 56.6 (SD 16.3) years and mostly female (101/156, 64.7%) and white (150/156, 96.2%). Only 2 of 5 progression criteria were met; recruitment and randomization methods were acceptable to participants, and contamination was low. However, recruitment and retention rates (11.3% and 67.3%, respectively) fell substantially short of target criteria (20% and 80%, respectively), and disproportionally recruited from the least deprived quintile. Only 57.4% of intervention participants reported receipt of the intervention (below the 80% progression threshold). Less than half reported the intervention to be acceptable at T2. Participant and staff interviews revealed barriers to intervention delivery and engagement related to the device design as well as context-specific technological challenges, all of which made it difficult to integrate the technology into the service. Routinely collected health economic measures had substantial missing data, suggesting that other methods for collecting these should be used in future., Conclusions: To our knowledge, this is the first study to evaluate short- and long-term feasibility and acceptability of integrating wearable technologies into community-based ERSs. The findings highlight device- and context-specific barriers to doing this in routine practice, with typical exercise referral populations. Key criteria for progression to a full-scale evaluation were not met., Trial Registration: ISRCTN Registry ISRCTN85785652; http://www.isrctn.com/ISRCTN85785652., (©Jemma Hawkins, Joanna M Charles, Michelle Edwards, Britt Hallingberg, Linda McConnon, Rhiannon Tudor Edwards, Russell Jago, Mark Kelson, Kelly Morgan, Simon Murphy, Emily J. Oliver, Sharon A. Simpson, Graham Moore. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 29.03.2019.)

Background: Evaluations of complex interventions in public health are frequently undermined by problems that can be identified before the effectiveness study stage. Exploratory studies, often termed pilot and feasibility studies, are a key step in assessing the feasibility and value of progressing to an effectiveness study. Such studies can provide vital information to support more robust evaluations, thereby reducing costs and minimising potential harms of the intervention. This systematic review forms the first phase of a wider project to address the need for stand-alone guidance for public health researchers on designing and conducting exploratory studies. The review objectives were to identify and examine existing recommendations concerning when such studies should be undertaken, questions they should answer, suitable methods, criteria for deciding whether to progress to an effectiveness study and appropriate reporting., Methods: We searched for published and unpublished guidance reported between January 2000 and November 2016 via bibliographic databases, websites, citation tracking and expert recommendations. Included papers were thematically synthesized., Results: The search retrieved 4095 unique records. Thirty papers were included, representing 25 unique sources of guidance/recommendations. Eight themes were identified: pre-requisites for conducting an exploratory study, nomenclature, guidance for intervention assessment, guidance surrounding any future evaluation study design, flexible versus fixed design, progression criteria to a future evaluation study, stakeholder involvement and reporting of exploratory studies. Exploratory studies were described as being concerned with the intervention content, the future evaluation design or both. However, the nomenclature and endorsed methods underpinning these aims were inconsistent across papers. There was little guidance on what should precede or follow an exploratory study and decision-making surrounding this., Conclusions: Existing recommendations are inconsistent concerning the aims, designs and conduct of exploratory studies, and guidance is lacking on the evidence needed to inform when to proceed to an effectiveness study., Trial Registration: PROSPERO 2016, CRD42016047843., Competing Interests: Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: This study investigates how the sexual health outcomes of a representative sample of students aged 15-16 in Wales vary according to the person delivering Sex and Relationships Education (SRE) in schools, students' access to on-site sexual health services and access to free condoms., Methods: Cross-sectional, self-report survey data were collected from students who participated in the 2015/16 School Health Research Network questionnaire in Wales. Data were analyzed from 59 schools, totalling 3781 students aged 15-16 (M = 15.7; SD = 0.3) who responded to questions about ever having had sex; age of sexual initiation and condom use at last intercourse. School level data were also collected, examining who delivers school SRE, provision of on-site, school 'drop-in' sexual health services and provision of free condoms for students. Binary and linear multi-level analyses explored the relationship between school level predictors and sexual health outcomes., Results: Compared to teachers, other modes of SRE delivery were associated with better sexual health outcomes, including remaining sexually inactive, later age of first intercourse and condom use. Providing on-site sexual health services did not significantly reduce the odds of having ever had sex or delaying first intercourse; but was associated with increased condom use. On-site condom provision was associated with lower condom use., Conclusions: SRE delivery by educators other than teachers is optimum to young people's sexual health outcomes. Further funding and coordination of on-site sexual health advice services are required. Longitudinal research is needed to identify the temporal sequence of sexual health practices and outcomes.

Positive relationships with family, friends and school staff are consistently linked with health and wellbeing during adolescence, though fewer studies explore how these micro-systems interact to influence adolescent health. This study tests the independent and interacting roles of family, peer and school relationships in predicting substance use, subjective wellbeing and mental health symptoms among 11-16 year olds in Wales. It presents cross-sectional analyses of the 2013 Health Behaviour in School-aged Children survey, completed by 9055 young people aged 11-16 years. Multilevel logistic regression analyses are used to test associations of family communication, family support, relationships with school staff, school peer connectedness, and support from friends, with tobacco use, cannabis use, alcohol use, subjective wellbeing and mental health symptoms. Positive relationships with family and school staff were consistently associated with better outcomes. Support from friends was associated with higher use of all substances, while higher school peer connectedness was associated with better subjective wellbeing and mental health. Better relationships with school staff were most strongly associated with positive subjective wellbeing, and fewer mental health symptoms where pupils reported less family support. Support from friends was associated with higher cannabis use and worse mental health among pupils with lower family support. Relationships with family and school staff may be important in protecting young people against substance use, and improving wellbeing and mental health. Interventions focused on student-staff relationships may be important for young people with less family support. Interventions based on peer support should be mindful of potential harmful effects for pupils with less support from family., Competing Interests: Compliance with Ethical StandardsThe HBSC survey was approved by the Cardiff University School of Social Sciences Research Ethics Committee. The authors have no conflicts to declare.

Background: The present study investigated associations between individual- and school-level predictors and young people's self-reported physical activity (total activity and moderate-to-vigorous activity) and sedentary behaviours., Methods: Individual-level data provided by the 2013/14 cross-sectional survey 'Health Behaviour in School-aged Children (HBSC) study in Wales' were linked to school-level data within the 'HBSC School Environment Questionnaire'. The final sample comprised 7,376 young people aged 11-16 years across 67 schools. Multilevel modelling was used to examine predictors of total physical activity, moderate-to-vigorous physical activity (MVPA) and sedentary behaviours (screen-based behaviours)., Results: Taking more physical activity (less than 5 days vs. 5 or more days per week), engaging in higher levels of MVPA (less than 4 hours vs. 4 or more hours per week) and reporting 2 or less hours of sedentary time were predicted by several individual level variables. Active travel to school positively predicted high levels of physical activity, however, gender stratified models revealed active travel as a predictor amongst girls only (OR:1.25 (95 % CI:1.05 - 1.49)). No school-level factors were shown to predict physical activity levels, however, a lower school socio-economic status was associated with a higher level of MVPA (OR:1.02 (95 % CI:1.01 - 1.03)) and a lower risk of sedentary behaviour (OR:0.97 (95 % CI:0.96 - 0.99)). A shorter lunch break (OR:1.33 (95 % CI:1.11 - 1.49)) and greater provision of facilities (OR:1.02 (95 % CI:1.00 - 1.05)) were associated with increased sedentary activity. Gender stratified models revealed that PE lesson duration (OR:1.18 (95 % CI:1.01 - 1.37)) and the provision of sports facilities (OR:1.03 (95 % CI:1.00 - 1.06)) were predictors of boy's sedentary behaviours only., Conclusion: Shorter lunch breaks were associated with increased sedentary time. Therefore, while further research is needed to better understand the causal nature of this association, extending lunch breaks could have a positive impact on sedentary behaviour through the provision of more time for physical activity. The findings also suggest that active travel could offer a mechanism for increasing physical activity levels particularly amongst girls. Particularly, the design and evaluation of interventions to promote physical activity during school hours should employ a comprehensive approach, including a focus on school policies and behaviours both in and out of school hours.

Background: There is a lack of research investigating organised activity participation and associated alcohol use in vulnerable groups., Aims: The purpose of this research was to test and compare associations between participation in organised activities and indicators of hazardous drinking between young offenders and young non-offenders., Methods: Two groups of 13-18 year-old males were recruited in Cardiff, UK: 93 young offenders and 53 non-offenders from secondary schools matched on estimated IQ, sex and socioeconomic status. Indicators of hazardous drinking were measured using the Fast Alcohol Screening Test (FAST). Organised activity participation and externalising behaviour was measured by the Youth Self Report. The Wechsler Abbreviated Scale of Intelligence was also administered., Results: Young offenders participated in fewer organised activities and had higher FAST scores than non-offenders. Young offenders and non-offenders significantly differed on mean FAST scores if they participated in no organised activities but not if they participated in at least one team sport. Externalising behaviour problems were unrelated to participation in organised activities., Conclusions: Although young offenders were less likely to have participated in organised activities, for them, participation in a team sport was associated with less hazardous drinking. Vulnerable youths who might benefit most from sporting activities actually access them the least. Future research should identify the different barriers to participation that they face., (© 2014 The Authors. Criminal Behaviour and Mental Health published by John Wiley & Sons, Ltd.)