Douglas Eadie

Minimum unit pricing for alcohol (MUP) came into effect on 1^st May 2018 in Scotland, raising the price of the cheapest shop-bought alcohol. Small retailers are a key source of alcohol for communities, often located in areas of high alcohol-related harm. We sought to examine their experiences of MUP implementation and impact. We conducted semi-structured interviews in-store with 20 small retailers in central Scotland at two time points: October – November 2017 (6–7 months pre-implementation); and October – November 2018 (5–6 months post-implementation). Prior to implementation, some retailers did not understand MUP, including how prices would link to product strength, or were concerned about anticipated implementation burden. Several expressed support for reducing ‘problem’ drinking or suggested that MUP would increase alcohol prices in supermarkets bringing them into line with small retailers. Despite initial concerns, small retailers reported minimal disruption following implementation of MUP, which was generally straightforward. Compliance was taken seriously and price calculations relatively manageable. Few/no negative reactions from customers were reported. Some felt that the measure enabled them to better compete with larger retailers/supermarkets. Concerns about MUP expressed by some trade bodies prior to implementation were largely not borne out in the experiences of small retailers.

Objectives: Policy responses to the COVID-19 pandemic in 2020 led to behaviour changes in the UK’s population, including a sudden shift towards working from home. These changes may have affected overall exposure to fine particulate matter (PM_2.5), an air pollutant and source of health harm. We report the results of a simulation model of a representative sample of the UK’s population, including workers and non-workers, to estimate PM_2.5 exposure before and during the pandemic. Methods: PM_2.5 exposure was simulated in April and August 2017–2020 for 10,000 individuals across the UK drawn from the 2011 nationwide census. These data were combined with data from the UK’s ambient PM_2.5 monitoring network, time use data and data on relevant personal behaviour before and during the first stage of the pandemic (such as changes in smoking and cooking). Results: The simulated exposures were significantly different between each year. Changes in ambient PM_2.5 resulted in regional and temporal variation. People living in homes where someone smoked experienced higher exposure than those in smoke-free homes, with an increase of 4 µg/m³ in PM_2.5 exposure in 2020. Conclusions: Changes in PM_2.5 exposure were minimal for most individuals despite the simulated increases in cooking activity. Those living in smoking homes (estimated to be around 11% of the UK population) experienced increased exposure to PM_2.5 during COVID lockdown measures and this is likely to have increased mortality and morbidity among this group. Government policy should address the risk of increased exposure to second-hand smoke in the event of future COVID-19-related restrictions.

Background: Prisons had partial exemption from the UK’s 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ have been very limited to date.Objective: The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service.Design: The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation).Setting: The study was set in Scotland’s prisons.Participants: Participants were people in custody, prison staff and providers/users of prison smoking cessation services.Intervention: Comprehensive smoke-free prison rules were implemented across all of Scotland’s prisons in November 2018.Main outcome measures: The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons.Data sources: The study utilised cross-sectional surveys of staff (total,n = 3522) and people in custody (total,n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups;n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits).Results: Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the ‘new normal’, were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the ‘with smoke-free’ policy period than in the ‘without’ policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold.Limitations: The ability to triangulate between different data sources mitigated limitations with constituent data sets.Conclusions: To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally.Future work: Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking.Study registration: This study is registered as Research Registry 4802.Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.

Background: Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components. Objectives: This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use. Design: We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect. Setting: Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3). Participants: Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups. Intervention: Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. Results: The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas. Limitations: The short interval between policy announcement and implementation left limited time for pre-intervention data collection. Conclusions: Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context. Future work: Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts. Trial registration: Current Controlled Trials ISRCTN16039407. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Background Hesitancy about COVID-19 vaccination threatens comprehensive vaccination. It is important to examine vaccination acceptance when people are making real rather than hypothetical decisions, to identify whether targeted support is needed, and to identify implications for communications. Methods Cross-sectional online and telephone survey with probability-based sample (n=4,978) of British adults, conducted January-February 2021. Measures: socio-demographic characteristics (age, gender, ethnicity, education, financial status), COVID-19 status, vaccine acceptance, trust in COVID-19 vaccination information sources, perceptions of vaccination priority groups, and perceptions of importance of second dose. Findings Among 5,931 individuals invited, survey response rate was 84%. COVID-19 vaccine acceptance (83%) was associated with increasing age, higher level of education and having been invited for vaccination. Acceptance decreased with unconfirmed past COVID-19, greater financial hardship, and non-White British ethnicity; Black/Black British participants had lowest acceptance. Overall, healthcare and scientific sources of information were most trusted. Compared with White British participants, other ethnicities had lower trust in healthcare and scientific sources. Those with lower educational attainment or financial hardship had lower trust in healthcare and scientific sources. Those with no qualifications had higher trust in media and family/friends. While trust was low overall in community or faith leaders it was higher among those with Asian/Asian British and Black/Black British ethnicity compared with White British participants. Views of vaccine prioritisation were mostly consistent with UK official policy but there was support for prioritising additional groups. There was high support for having the second vaccine dose. Conclusions Targeted engagement is needed to address COVID-19 vaccine hesitancy in non-White British ethnic groups, in younger adults, and among those with lower education, greater financial hardship and unconfirmed past infection. Healthcare professionals and scientific advisors should play a central role in communications and tailored messaging is needed for hesitant groups. Careful communication around vaccination prioritisation continues to be required.

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

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

Background: Tobacco displays at point of sale have been shown to increase young people’s pro-smoking attitudes, susceptibility to smoking and smoking initiation. In Scotland, legislation that prohibited tobacco point-of-sale displays was implemented in large stores (i.e. those > 280 m²) in April 2013 and in small retailers in April 2015. Objective: To assess the impact of the point-of-sale tobacco display ban on young people’s exposure to tobacco advertising, their attitudes to smoking and smoking susceptibility, and their risk of smoking initiation. Design: Multimodal before-and-after study design using mixed methods to collect data at baseline (2013) and then longitudinally for 4 years. Setting: Four main study communities in the central belt of mainland Scotland, UK, purposively selected to reflect two levels of urbanity (urban vs. small town) and two levels of deprivation (high vs. medium/low). Four matched communities. Participants: In the main study communities, 94 tobacco retail outlets. All Secondary 2 (aged 13 years) and Secondary 4 (aged 15 years) pupils in 2013 and 2014 together with all Secondary 1 to Secondary 6 (aged 12–17 years) pupils in 2015–17. This included 6612 pupils who completed 14,344 questionnaires over 5 years. Three hundred and eighty-two participants in 80 focus groups who were recruited from Secondary 2 and Secondary 4 in 2013–17. In matched communities, 24 retail panel members in 2013–17. Main outcome measures: Tobacco product and tobacco storage visibility, density of retail outlets (the number of retailers in a pre-defined area such as a residential neighbourhood), tobacco product exposure, brand awareness, perceived accessibility of tobacco, pro-smoking attitudes, pro-smoking norms, smoking susceptibility and smoking initiation. Data platform and methods: The study had four components – a mapping and spatial analysis of retail outlets; a tobacco marketing audit, including retail panel interviews in matched communities; school surveys; and focus group discussions with secondary school pupils. Limitations: The study was based on a small number of communities and did not include communities in remote areas. Results: Compliance with the point-of-sale legislation in Scotland was high. This led to a large reduction in the visibility of tobacco products in retail outlets. However, when the results were stratified by socioeconomic status, declines in retailer density, weighted by total product visibility, were restricted to the least disadvantaged tertile of participants. Nevertheless, the implementation of the legislation was associated with a reduction in risk of both smoking susceptibility and smoking initiation in young people, as well as a reduction in the perceived accessibility of tobacco and in pro-smoking attitudes after both the partial and the comprehensive bans were introduced. Conclusions: The Scottish point-of-sale legislation has been successful in reducing the overall visibility of tobacco products and is associated with improvements in attitudinal and behavioural outcomes in young people. However, cues that tobacco is for sale are still highly visible, particularly in retail outlets in areas of deprivation. In addition, the increase in retailer density that was observed after 2015 increased inequalities in product visibility. There was also evidence that the emergence of e-cigarettes may have disrupted the full impact of the legislation. Future work: Our research indicates that further research is needed to examine the longitudinal relationships between tobacco outlet availability and product visibility inequalities; and the impact of e-cigarettes and standardised packaging on smoking initiation and prevalence. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.