Do Flavour Descriptions Influence Subjective Ratings of Flavoured and Unflavoured E-Liquids among Non-Smoking and Non-Vaping UK Adolescents?

INTRODUCTION: Youth use of electronic cigarettes (e-cigarettes) is rising globally and is associated with health harms. Flavour descriptions on e-liquid packaging may contribute to the appeal of e-cigarettes among youth. This study compared subjective ratings of e-liquid packaging flavour descriptions among non-smoking and non-vaping UK adolescents. METHODS: This was an online observational study in a UK sample of non-smoking and non-vaping adolescents aged 11-17 years. The primary analyses compared flavoured versus unflavoured descriptions and the secondary analyses compared candy/sweet flavour versus fruit flavour descriptions. Outcomes were packaging appraisal, packaging receptivity, perceived harm, and perceived audience. RESULTS: The survey was completed by 120 participants (74% female). Packaging appraisal ratings were higher for e-liquids with flavoured descriptions than unflavoured descriptions (mean difference 5.9, 95% CI 4.2 to 7.6, p<.001). Similarly, packaging receptivity ratings were higher for e-liquids with flavoured descriptions than unflavoured descriptions (mean difference 4.2, 95% CI 2.8 to 5.6, p<.001). Participants also perceived e-liquids with flavoured (versus unflavoured) descriptions as less 'grown-up' (mean difference -5.2, 95% CI -7.3 to -3.1, p<.001). However, ratings of perceived harm were similar for flavoured and unflavoured descriptions (mean difference -1.0, 95% CI -2.6 to 0.5, p=.189). CONCLUSIONS: Although this study found differences in subjective ratings of e-liquids with flavoured and unflavoured descriptions, non-smoking and non-vaping UK adolescents generally had low appraisal and receptivity for e-liquids and they perceived them as being 'grown-up' and harmful. IMPLICATIONS: Youth use of electronic cigarettes (e-cigarettes) is increasing globally, leading to concerns about health harms. This study compared adolescents' ratings of e-liquids with flavoured versus unflavoured descriptions and e-liquids with candy/sweet flavour versus fruit flavour descriptions. This study adds to previous studies that have compared adolescents' ratings of e-liquids with tobacco flavour versus non-tobacco flavour descriptions. Although packaging appraisal and receptivity ratings were higher (more positive) for e-liquids with flavoured versus unflavoured descriptions, overall, adolescents who do not smoke or vape had low appraisal and receptivity for e-liquids, and they perceived them as being 'grown-up' and harmful.

The impact of introducing alcohol-free beer options in bars and public houses on alcohol sales and revenue: A randomised crossover field trial.

AIMS: The study aimed to estimate the impact of introducing a draught alcohol-free beer, thereby increasing the relative availability of these products, on alcohol sales and monetary takings in bars and pubs in England. DESIGN: Randomised crossover field trial. SETTING: England. PARTICIPANTS: Fourteen venues that did not previously sell draught alcohol-free beer. INTERVENTION AND COMPARATOR: Venues completed two intervention periods and two control periods in a randomised order over 8 weeks. Intervention periods involved replacing one draught alcoholic beer with an alcohol-free beer. Control periods operated business as usual. MEASUREMENTS: The primary outcome was mean weekly volume (in litres) of draught alcoholic beer sold. The secondary outcome was mean weekly revenue [in GBP (£)] from all drinks. Analyses adjusted for randomised order, special events, season and busyness. FINDINGS: The adjusted mean difference in weekly sales of draught alcoholic beer was -20 L [95% confidence interval (CI) = -41 to +0.4], equivalent to a 4% reduction (95% CI = 8% reduction to 0.1% increase) in the volume of alcoholic draught beer sold when draught alcohol-free beer was available. Excluding venues that failed at least one fidelity check resulted in an adjusted mean difference of -29 L per week (95% CI = -53 to -5), equivalent to a 5% reduction (95% CI = 8% reduction to 0.8% reduction). The adjusted mean difference in weekly revenue was +61 GBP per week (95% CI = -328 to +450), equivalent to a 1% increase (95% CI = 5% decrease to 7% increase) when draught alcohol-free beer was available. CONCLUSIONS: Introducing a draught alcohol-free beer in bars and pubs in England reduced the volume of draught alcoholic beer sold by 4% to 5%, with no evidence of the intervention impacting net revenue.

Impacts of EU Tobacco Products Directive regulations on use of e-cigarettes in adolescents in Great Britain: a natural experiment evaluation.

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.

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.

Should I Stay or Should I Go? A Qualitative Exploration of Stigma and Other Factors Influencing Opioid Agonist Treatment Journeys.

(1) The harm-reduction benefits of opioid agonist treatment (OAT) are well-established; however, the UK government's emphasis on "recovery" may be contributing to a high proportion of people leaving treatment and low retention rates. We wanted to develop a rich and nuanced understanding of the factors that might influence the treatment journeys of people who use OAT. (2) We explored factors at each level of the socioecological system and considered the ways these interact to influence treatment journeys in OAT. We carried out semi-structured interviews with people who use OAT (n = 12) and service providers (n = 13) and analysed data using reflexive thematic analysis. (3) We developed three themes representing participant perceptions of treatment journeys in OAT. These were: (1) The System is Broken; (2) Power Struggles; and (3) Filling the Void. (4) Conclusions: The data suggest that prioritisation of treatment retention is important to preserve the harm-reduction benefits of OAT. Stigma is a systemic issue which presents multiple barriers to people who use OAT living fulfilling lives. There is an urgent need to develop targeted interventions to address stigma towards people who use OAT.

Effects of media representations of drug related deaths on public stigma and support for harm reduction.

BACKGROUND: Drug related deaths (DRD) are at historically high levels in the United Kingdom (UK), but some approaches that have the potential to reduce risk of mortality remain controversial. Public support makes an important contribution to drug policy development but there are high levels of public stigma towards people who use drugs (PWUD), and this is partly shaped by media representations. We investigated whether depiction of the characteristics of decedents represented in news articles about DRD was associated with differences in stigmatising attitudes and support for harm reduction policy. METHODS: We undertook a cross-sectional online study with a randomised design, conducted with a nationally representative sample (UK). Participants (N = 1280) were randomly presented with one of eight simulated news stories that reported on a DRD that differed with respect to drug (ecstasy or heroin), and the gender (male or female) and age (younger or older) of the decedent. Data were analysed using MANOVA. RESULTS: Data were obtained for 1248 participants (51.0% female; mean age 45.7±15.4). Stigma was higher towards depictions of male, older, and heroin deaths (all p < .001). Harm reduction support was higher in those participants seeing older compared to younger subjects (p = .035), and the older ecstasy decedent compared to younger decedent (p = .029). CONCLUSION: Presentation of some types of DRD are associated with higher public stigma towards the decedent than others. Those groups developing agenda-setting activities designed to reduce stigma or foster public support for harm reduction policies should consider the different ways in which audiences may respond to the depiction and framing of DRD in news media.

A Pilot Randomised Trial Investigating the Effects of Including Efficacy Messaging on Tobacco Warning Labels.

INTRODUCTION: Smokers can respond defensively to health risk communication such as on-pack warning labels, potentially reducing their effectiveness. Theory suggests that risk perception together with self-efficacy reduces defensive responses and predicts target behaviors. Currently, tobacco warning labels globally predominantly target risk and do not explicitly consider efficacy. AIMS: This study explores the effectiveness of combining Australian tobacco warning labels with efficacy content to increase quitting intentions. METHODS: RCT in 83 smokers over 3 weeks. After a seven-day baseline phase (smoking from usual tobacco packaging), participants were randomized to one of two adhesive labels groups for the remaining 14 days: Standard health warning labels (HWLs) featuring enhanced efficacy messages (experimental group) or unmodified standard HWLs (control group). Participants attached these labels to their tobacco packaging and recorded their cognitions and smoking behavior once daily using Smartphones. Multilevel structural equation modeling was used to test theorized effects of the labels on self-efficacy, risk perception, and intentions to quit. RESULTS: There was no effect of exposure to efficacy messages on either self-efficacy, risk perceptions, or intentions to quit. However, self-efficacy and risk perceptions were positively associated with quitting intentions at the within-person level. CONCLUSIONS: The predictive relationships between self-efficacy, risk perception, and intention to quit were supported, however, supplementing standard warning labels with efficacy messages had no effect on these cognitions. Whether this is due to conditioned avoidance of HWLS, characteristics of the messages, or limitations imposed by format are unclear. IMPLICATIONS: Self-efficacy and risk perception predict intentions to quit smoking. Adding efficacy content to tobacco health warnings may have the potential to bolster these cognitions but more research is required to determine the contexts in which this would be effective and who would be likely to benefit. The time course by which exposure to efficacy content might influence cessation self-efficacy and downstream quitting intentions also needs to be investigated.

Exercising body but not mind: A qualitative exploration of attitudes to combining physical activity and mindfulness practice for mental health promotion.

Background: Physical activity and mindfulness meditation can be effective for maintaining good mental wellbeing, with early-stage research suggesting even greater effectiveness in tandem. Literature is lacking on the perceptions and acceptability of these practices, particularly in a preventative context. The study aimed to explore attitudes toward mental health and its maintenance through physical activity and mindfulness meditation in the university student population. Methods: Semi-structured qualitative interviews were conducted with a sample of 16 students from 10 United Kingdom universities (M age = 23 years, SD = 3.22) recruited through social media and stratified to have varied wellbeing symptoms, physical activity levels, and experience with mindfulness meditation. Reflexive thematic analysis was used to elicit meaning from the data. Results: Four main themes were constructed. Participants held a "Dualist view of health," in which mental and physical aspects were seen as distinct but connected, and prioritized physical health maintenance. The "Low-point paradox," where engagement is most difficult during the time of greatest need, was identified as a crucial psychological barrier across health behaviors. "Unfamiliarity with mindfulness practice" was common, as were misconceptions inhibiting practice. Finally, participants were intrigued by combining physical activity and mindfulness, supposing that "Whole is greater than the sum of its parts," with mutual reinforcement of the two techniques cited as biggest motivating factor. Conclusion: Effective preventative mental health strategies for adults, including university students, should accommodate for common psychological barriers and facilitators to health maintenance behaviors, including misconceptions surrounding mindfulness, to increase acceptability. Combining physical activity and mindfulness meditation is one promising preventative approach that warrants further investigation.

The Effect of Conflicting Public Health Guidance on Smokers' and Vapers' E-cigarette Harm Perceptions.

BACKGROUND: E-cigarettes are increasingly being viewed, incorrectly, as more harmful than cigarettes. This may discourage smokers from switching to e-cigarettes. One potential explanation for these increasingly harmful attitudes is conflicting information presented in the media and online, and from public health bodies. AIMS AND METHODS: In this prospectively registered online study, we aimed to examine the impact of conflicting public health information on smokers' and vapers' e-cigarette harm perceptions. Daily UK smokers who do not vape (n = 334) and daily UK vapers (n = 368) were randomized to receive either: (1) a consistent harm reduction statement from two different public health bodies (Harm Reduction), (2) a consistent negative statement about e-cigarette harms from two different public health bodies (Negative), (3) a harm reduction statement from one public health body and a negative statement from another (Conflict), and (4) a statement of the risks of smoking followed by a harm reduction statement from one public health body and a negative statement from another (Smoking Risk + Conflict). Participants then answered questions regarding their perceptions of e-cigarette harm. RESULTS: The Negative condition had the highest e-cigarette harm perceptions, significantly higher than the Smoking Risk + Conflict condition (MD = 5.4, SE = 1.8, p < .016, d = 0.3 [CI 0.73 to 10.04]), which did not differ from the Conflict condition (MD = 1.5, SE = 1.8, p = .836, d = 0.1 [CI -3.14 to 6.17]). The Conflict condition differed from the Harm Reduction condition, where harm perceptions were lowest (MD = 5.4, SE = 1.8, p = .016, d = 0.3 [CI 0.74 to 10.07]). CONCLUSIONS: These findings are the first to demonstrate that, compared to harm reduction information, conflicting information increases e-cigarette harm perceptions amongst vapers, and smokers who do not vape. IMPLICATIONS: This research provides the first empirical evidence that conflicting information increases smokers' and vapers' e-cigarette harm perceptions, compared to harm reduction information. This may have a meaningful impact on public health as e-cigarette harm perceptions can influence subsequent smoking and vaping behavior. Conflicting information may dissuade smokers, who have the most to gain from accurate e-cigarette harm perceptions, from switching to e-cigarettes. These findings indicate that public health communications that are consensus-based can lower harm perceptions of e-cigarettes, and have the potential to reduce morbidity and mortality attributable to tobacco smoking.

Are you tripping comfortably? Investigating the relationship between harm reduction and the psychedelic experience.

BACKGROUND: Alongside a recent revival in the use of psychedelics in clinical settings, there have been increases in the prevalence of recreational use, with many using psychedelics to deal with difficult emotions or to improve well-being. While clinical research is conducted in carefully controlled settings, this is not necessarily the case for recreational use. In this mixed methods online survey study, we aimed to develop an understanding of frequently used psychedelic harm reduction practices in recreational settings and how their use relates to the psychedelic experience. We also aimed to characterise users' first and most recent psychedelic trips to understand how harm reduction changes with experience. METHODS: Participants (n = 163) recounted their first and most recent psychedelic experience by providing details about the harm reduction practices they employed and completing the Challenging Experience Questionnaire (CEQ) and Emotional Breakthrough Inventory (EBI). We also asked open-ended questions for a more in-depth qualitative understanding of their views on psychedelic harm reduction. RESULTS: Using ANOVA, we observe greater use of harm reduction practices for participants' most recent versus first psychedelic experience and that use of these practices is positively associated with EBI scores and negatively associated with CEQ scores (particularly for the first experience). Participants engaged in a wide range of harm reduction practices and we provide details of those which are most commonly used and those which are deemed most important by experienced users. Our qualitative analysis indicated that participants were largely positive about psychedelics and many recounted profound positive experiences. While specifics of the drug they were taking was important for aspects of harm reduction, participants largely focused on the importance of ensuring a good "set and setting" for enhancing positive effects. CONCLUSIONS: Our research helps us understand how engagement in harm reduction may increase with experience. Our mixed methods data shed light on the perceived importance of different harm reduction practices and examine their association with the psychedelic experience itself. Together, our research has important implications for the development of psychedelic harm reduction advice and provides opportunities for future research to explore the importance of these different practices in more detail.

Cross-sectional online survey of the impact of new tobacco health warnings in Colombia.

OBJECTIVES: This study aimed to explore the impact of a new set of six pictorial warnings introduced in 2018. DESIGN AND SETTING: Using a cross-sectional design, we examined awareness of the new warnings among Colombian smokers across two time points of data collection. PARTICIPANTS: Adult smokers (≥18 years of age), defined as having smoked at least 100 cigarettes in their lifetime and currently smoking at least one cigarette per week participated at time 1, prior to the introduction of the new health warnings in Colombia in 2018 (n=1985, 72% male), and at time 2, 12 months post introduction (n=1572, 69% male). PRIMARY OUTCOMES: At each time, we examined smokers' responses to warnings on packs (negative affect, thinking about warning messages and cognitive elaboration), attitudes toward smoking (perceived likelihood and severity of harm, self-efficacy, response efficacy and quit intentions), knowledge of the health risks of smoking and responses to the new warnings (negative affect, believability, thinking about the harms, reactance and perceived message effectiveness). RESULTS: Awareness of the warnings was low, with only 59% of smokers reporting having seen them at time 2. Between times, we observed a reduction in negative affect toward current warnings (p<0.001), reduced thinking about (p<0.001) and cognitive elaboration of the warning message (p<0.001), and an increase in perceived severity of warnings (p<0.001). When asked about the six new health warnings, we found a reduction in negative affect (p<0.07), cognitions related to harm (p<0.01), believability (p<0.03), reactance (p<0.01) and perceived message effectiveness (p<0.02) between times. CONCLUSIONS: Our data indicate that effectiveness was low prior to the introduction of the new health warnings and at 12 months post introduction. Tobacco control policy should seek to improve exposure to and noticeability of tobacco health warnings in Colombia.

Group VR experiences can produce ego attenuation and connectedness comparable to psychedelics.

With a growing body of research highlighting the therapeutic potential of experiential phenomenology which diminishes egoic identity and increases one's sense of connectedness, there is significant interest in how to elicit such 'self-transcendent experiences' (STEs) in laboratory contexts. Psychedelic drugs (YDs) have proven particularly effective in this respect, producing subjective phenomenology which reliably elicits intense STEs. With virtual reality (VR) emerging as a powerful tool for constructing new perceptual environments, we describe a VR framework called 'Isness-distributed' (Isness-D) which harnesses the unique affordances of distributed multi-person VR to blur conventional self-other boundaries. Within Isness-D, groups of participants co-habit a shared virtual space, collectively experiencing their bodies as luminous energetic essences with diffuse spatial boundaries. It enables moments of 'energetic coalescence', a new class of embodied intersubjective experience where bodies can fluidly merge, enabling participants to include multiple others within their self-representation. To evaluate Isness-D, we adopted a citizen science approach, coordinating an international network of Isness-D 'nodes'. We analyzed the results (N = 58) using 4 different self-report scales previously applied to analyze subjective YD phenomenology (the inclusion of community in self scale, ego-dissolution inventory, communitas scale, and the MEQ30 mystical experience questionnaire). Despite the complexities associated with a distributed experiment like this, the Isness-D scores on all 4 scales were statistically indistinguishable from recently published YD studies, demonstrating that distributed VR can be used to design intersubjective STEs where people dissolve their sense of self in the connection to others.

Nucleation increases the visual appeal of lager but does not alter overall likeability or drinking rate.

BACKGROUND: Glassware can be an effective vehicle to recruit customers, revive brands, build profits and increase alcohol consumption by capitalising on the immediacy of glassware to the point of consumption. The design of glassware can also contribute to harm reduction by slowing and reducing consumption. Nucleated bases have been added to lager glasses in recent years which allow carbon dioxide (CO2) to be more rapidly released and ascend through the solution. The aim of these studies was to investigate the effect of nucleated glasses on the likeability and drinking rate of lager in alcohol drinkers. METHODS: In Study 1, participants (n = 116) were asked to taste two glasses of lager (280 millilitres (ml) each) in separate 5-min taste tests and fill out a likeability questionnaire after each glass in a within-subjects design with one factor of glass (nucleated, non-nucleated). The primary outcome was the likeability of lager and the secondary outcome was volume consumption during taste tests. In Study 2, participants (n = 160) were asked to consume a pint of lager (568 ml) and fill out a likeability questionnaire in a between-subjects design with one factor of glass (nucleated, non-nucleated). The primary outcome was time taken to consume a pint of lager and secondary outcomes were the likeability of lager, mood and alcohol craving. RESULTS: There was no clear evidence that likeability of lager differed between nucleated and non-nucleated glasses in either study. In Study 1, a paired-samples t test found strong evidence that lager in nucleated glasses was more visually appealing (single item from likeability measure) than lager in non-nucleated glasses (mean difference (MD) = 10.2, 95% confidence interval (CI) 6.1, 14.2, p < 0.001). In Study 2, a linear regression found no clear evidence that lager was consumed at different rates from nucleated and non-nucleated glasses (nucleated: 16.9 min, non-nucleated: 16.3 min, MD: 0.6 min, 95% CI - 1.5, 2.7, p = 0.57). CONCLUSIONS: Nucleated lager glasses do not appear to alter the likeability or consumption (volume consumed in Study 1 or drinking rate in Study 2) of lager, although they do seem to increase the visual appeal and refreshment of lager. This may increase the number of drinking episodes by making the drinking experience more enjoyable which may lead to increased alcohol related harm.

Standardised packs and larger health warnings: visual attention and perceptions among Colombian smokers and non-smokers.

AIMS: To measure how cigarette packaging (standardised packaging and branded packaging) and health warning size affect visual attention and pack preferences among Colombian smokers and non-smokers. DESIGN: To explore visual attention, we used an eye-tracking experiment where non-smokers, weekly smokers and daily smokers were shown cigarette packs varying in warning size (30%-pictorial on top of the text, 30%-pictorial and text side-by-side, 50%, 70%) and packaging (standardised packaging, branded packaging). We used a discrete choice experiment (DCE) to examine the impact of warning size, packaging and brand name on preferences to try, taste perceptions and perceptions of harm. SETTING: Eye-tracking laboratory, Universidad Nacional de Colombia, Bogotá, Colombia. PARTICIPANTS: Participants (n = 175) were 18 to 40 years old. MEASUREMENTS: For the eye-tracking experiment, our primary outcome measure was the number of fixations toward the health warning compared with the branding. For the DCE, outcome measures were preferences to try, taste perceptions and harm perceptions. FINDINGS: We observed greater visual attention to warning labels on standardised versus branded packages (F[3,167] = 22.87, P < 0.001) and when warnings were larger (F[9,161] = 147.17, P < 0.001); as warning size increased, the difference in visual attention to warnings between standardised and branded packaging decreased (F[9,161] = 4.44, P < 0.001). Non-smokers visually attended toward the warnings more than smokers, but as warning size increased these differences decreased (F[6,334] = 2.92, P = 0.009). For the DCE, conditional trials showed that increasing the warning size from 30% to 70% reduced preferences to try (odds ratio [OR] = 0.48, 95% CI = [0.42,0.54], P < 0.001), taste perceptions (OR = 0.61, 95% CI = [0.54,0.68], P < 0.001); and increased harm perceptions (OR = 0.78, 95% CI = [0.76,0.80], P < 0.001). Compared with branded packaging, standardised packaging reduced our DCE outcome measures with ORs ranging from OR = 0.25 (95% CI = [0.17,0.38], P < 0.001) to OR = 0.79 (95% CI = [0.67,0.93], P < 0.001) across two brands. These effects were more pronounced among non-smokers, males and younger participants. Unconditional trials showed similar results. CONCLUSIONS: Standardised cigarette packaging and larger health warnings appear to decrease positive pack perceptions and have the potential to reduce the demand for cigarette products in Colombia.

Implementation of e-cigarette regulation through the EU Tobacco Products Directive (2016) in Wales, Scotland and England from the perspectives of stakeholders involved in policy introduction and enforcement.

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.

Straight-sided beer and cider glasses to reduce alcohol sales for on-site consumption: A randomised crossover trial in bars.

BACKGROUND: Straight-sided glasses can slow the rate of lager consumption in a laboratory setting compared with curved glasses. Slower drinking rates may lower overall alcohol consumption. Glass shape is therefore a potential target for intervention. The aim of this randomised crossover trial was to estimate the impact of serving draught beer and cider in straight-sided glasses, compared with usual, predominantly curved glasses, on alcohol sales for on-site consumption in bars. METHODS: Twenty-four bars in England completed two intervention periods (A) and two control periods (B) in a randomised order: 1) BABA; 2) BAAB; 3) ABBA; or 4) ABAB. Each period lasted two weeks and involved serving draught beer and cider in either straight-sided glasses (A) or the venue's usual glasses (≥75% curved; B). The primary outcome was the mean volume (in litres) of draught beer and cider sold weekly, compared between A and B periods using a paired-samples t-test on aggregate data. A regression model adjusted for season, order, special events, and busyness. FINDINGS: Mean weekly volume sales of draught beer and cider was 690·9 L (SD 491·3 L) across A periods and 732·5 L (SD 501·0 L) across B periods. The adjusted mean difference (A minus B) was 8·9 L per week (95% CI -45·5 to 63·3; p = 0·737). INTERPRETATION: This study provides no clear evidence that using straight-sided glasses, compared with usual, predominantly curved glasses, reduces the volume of draught beer and cider sold for on-site consumption in bars.

Tackling Smoker Misperceptions About E-cigarettes Using Expert Videos.

BACKGROUND: The pervasive misperception that e-cigarettes are equally or more harmful than combustible cigarettes is a barrier to current smokers switching to e-cigarettes. To tackle misperceptions, public health bodies are using informational videos, although their efficacy is unknown. METHODS: In our online study, current UK smokers who do not vape (n = 382) were randomized to view either: (1) a Cancer Research UK (CRUK) text-only video; (2) a video featuring leading e-cigarette experts (expert); or (3) a no video control condition, and then completed questions regarding e-cigarette harm perceptions. RESULTS: Compared to the control condition, participants in the CRUK condition, and especially those in the expert condition had more accurate harm perceptions of e-cigarettes and had more accurate knowledge of e-cigarette constituents. In the expert condition, 67% of individuals reported they would try an e-cigarette in a future quit attempt, compared with 51% in the CRUK condition and 35% in the control condition. CONCLUSIONS: Our findings are encouraging in the face of mounting evidence that e-cigarette misperceptions are increasing. Whilst misperceptions are often characterized as resistant to correction, we find that carefully designed public health information videos have the potential to promote a more accurate, informed view of e-cigarettes, and encourage intended e-cigarette use among UK smokers. Importantly, we find this among current smokers who do not vape, a group often reported as having the highest levels of misperceptions and as having the most to gain from accurate e-cigarette perceptions. IMPLICATIONS: There is mounting evidence that e-cigarette misperceptions are increasing, particularly among smokers who do not vape, a group who have most to gain from accurate information about e-cigarettes. Misperceptions are often characterized as difficult to change and there is relatively little research on how to correct e-cigarette misperceptions. Our research in the UK shows that, compared to controls, e-cigarette misperceptions can be corrected among those smokers who are shown carefully constructed expert videos. This work has important implications for the development and dissemination of these important messages.

Avoidance of tobacco health warnings? An eye-tracking approach.

AIMS: Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings. DESIGN: Study 1: smoking status × warning immediacy (short-term versus long-term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain-framed versus loss-framed) × warning format (text-only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking). SETTING: University of Bristol, UK, eye-tracking laboratory. PARTICIPANTS: Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26). MEASUREMENTS: For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation. FINDINGS: Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2  = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2  = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32, P = 0.12, ηp2  = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2  = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2  = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2  = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58, P = 0.30, ηp2  = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all Ps < 0.001, ηp2  > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2  = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2  = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41, P = 0.24, ηp2  = 0.02). CONCLUSIONS: Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.

Young people's use of e-cigarettes in Wales, England and Scotland before and after introduction of EU Tobacco Products Directive regulations: a mixed-method natural experimental evaluation.

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.