Have Restrictions on Alcohol Advertising in Ireland Affected Awareness Among Adults? A Comparative Observational Study Using Nonprobability Repeat Cross-Sectional Surveys.

OBJECTIVE: Since November 2019, Ireland has restricted alcohol advertising at the cinema and outdoors (e.g., near schools) and banned alcohol advertising on public transport. Although awareness of such advertising had decreased 1 year after the restrictions, measures to limit COVID-19 transmission complicated interpretation. We examined (a) changes in awareness 2 years after restrictions, when COVID-19 mitigation measures had eased, and (b) how changes in Ireland compared with Northern Ireland, where the restrictions did not apply. METHOD: Repeat cross-sectional surveys were conducted with adults recruited from nonprobability online panels, with three waves in Ireland (October 2019 [before restrictions] and October 2020/2021 [after restrictions]; n = 3,029) and two in Northern Ireland (October 2020/2021; n = 1,011). Participants self-reported past-month awareness of 13 alcohol marketing activities, including public transport, cinema, and outdoor advertising (coded as any past-month awareness, no awareness, or not sure). RESULTS: In Ireland, the odds of reporting no past-month awareness (vs. any) were higher in both 2021 and 2020 versus 2019 for all restricted advertising activities (e.g., 2021 vs. 2019 for public transport: adjusted OR = 1.88, 95% CI [1.53, 2.32]). Interactions between wave and jurisdiction indicated that in 2021, compared with 2020, the odds of reporting no past-month awareness of public transport and cinema advertising (vs. any) were higher in Ireland than in Northern Ireland, despite increased opportunities for exposure in both jurisdictions through eased pandemic mitigation measures. There was no interaction for outdoor advertising, suggesting between-wave trends did not differ by jurisdiction. CONCLUSIONS: Ireland's restrictions have reduced past-month awareness of alcohol advertising at the cinema and on public transport but not outdoors. Continued monitoring is required.

Impact of standardised packaging in the UK on warning salience, appeal, harm perceptions and cessation-related behaviours: a longitudinal online survey.

INTRODUCTION: In the UK, since 20 May 2017, tobacco companies must sell cigarettes and rolling tobacco in standardised packs. METHODS: Three waves of a longitudinal online survey with smokers (≥16) before standardised packaging (wave 1 (W1): April to May 2016) and after standardised packaging (wave 2 (W2): September to November 2017; wave 3 (W3): May to July 2019). Of the 6233 smokers at W1, 4293 responded at W2 and 3175 at W3. We explored smokers' response to warning salience, appeal (appeal, quality, value, satisfaction and taste compared with a year ago), harm (harmfulness compared with a year ago, harm compared with other brands and whether some brands have more harmful substances), and quit plans, attempts and quitting. RESULTS: Compared with W1, the proportions noticing warnings first on packs, and rating cigarettes/rolling tobacco less appealing and worse value than a year ago, were higher at W2 and W3. Disagreeing that some brands contain more harmful substances was higher at W2. Interactions between social grade and survey wave for warning salience, and each appeal and harm outcome, were non-significant. Smokers switching from not noticing warnings first at W1 to noticing warnings first at W2, or who had a lower composite appeal score at W2, were more likely to plan to quit and to have made a quit attempt at W2. Smokers who switched to disagreeing that some brands contain more harmful substances at W2, after giving a different response at W1, were more likely to quit at W3. CONCLUSIONS: Standardised packaging appears to be having the intended impacts.

Expenditure on Paid-for Gambling Advertising During the National COVID-19 'Lockdowns': An Observational Study of Media Monitoring Data from the United Kingdom.

Changes in gambling advertising during national COVID-19 'lockdowns', when stay-at-home rules restricted participation in certain gambling activities, provides important context to variance in gambling behaviour during these periods. This study describes expenditure on paid-for gambling advertising during three national lockdowns, compares expenditure to pre-pandemic estimates, and compares changes in expenditure by subsector. Data come from an observational study of weekly expenditure on paid-for gambling advertising in the United Kingdom (n = 135 weeks; beginning 2019 to mid-2021), focusing on three COVID-19 lockdowns: (1) March-May 2020; (2) November-December 2020; and (3) January-March 2021. We descriptively analysed how total advertising expenditure in each lockdown (£GBP, inflation-adjusted) compared to the same time points in 2019, both overall and by subsector (bookmakers, lotteries, online bingo, online casino and poker, gaming, pools, mobile content). Gambling advertising expenditure during lockdown one was 38.5% lower than 2019 (£43.5 million[m] vs. £70.7 m, respectively), with decreases across all subsectors (range: -81.7% [bookmakers] to -2.8% [online bingo]). Total advertising expenditure in lockdown two was 49.3% higher than 2019 (£51.7 m vs. £34.6 m), with increases for 5/7 subsectors (range: -31.6% [mobile content] to + 103.8% [bookmakers]). In lockdown three, advertising expenditure was 5.9% higher than 2019 (£91.2 m vs. £86.1 m), with increases for 4/7 subsectors (range: -92.4% [pools] to + 49.2% [mobile content]). Reductions in advertising expenditure in lockdown one are congruent with self-reported reductions in overall gambling also observed during this period. Further research is needed to determine whether increased advertising expenditure in lockdowns two and three correlates with increased gambling, overall and for specific subsectors.

Response to a novel, weight self-awareness plan used in a multi-component lifestyle intervention programme to reduce breast cancer risk factors in older women-Secondary analysis from the ActWELL trial.

BACKGROUND: The ActWELL randomised controlled trial assessed the effectiveness of a weight management programme delivered by volunteer lifestyle coaches (LCs) in women attending breast clinics. The intervention focused on caloric intake and physical activity, utilising behavioural change techniques including a weight awareness plan (WAP). The current work is a secondary analysis of the ActWELL data and aims to examine the response to the weight self-awareness plan (used as part of the intervention programme). METHODS: The LCs invited participants (n = 279) to undertake an implementation intention discussion to formulate a self-weighing (SW) plan. Bodyweight scales were offered, and recording books provided. The physical activity component of the intervention focused on a walking plan assessed by accelerometers. The LCs contacted participants by telephone monthly and provided personalised feedback. Mann-Whitney tests and chi-squared analysis were used to examine the effect of SW on weight change. A qualitative evaluation utilising semi-structured interviews was also undertaken. RESULTS: Most participants (96.4%) agreed to set a weekly SW goal and 76 (27%) requested scales. At 12 months, 226 (81%) returned for follow up. The median (interquartile range) weight change for those who self- reported at least one weight (n = 211) was -2.3 kg (-5.0 to 0.0) compared to -1.2 kg (-5.0 to 0.03) in those who did not (n = 14). Participants who reported weights on more than eight occasions (39%) were significantly more likely (p = 0.012) to achieve 5% weight loss compared to those who weighed less often. Low numbers of accelerometers were returned that did not allow for significance testing. Qualitative data (n = 24) indicated that many participants found the WAP helpful and motivating. CONCLUSIONS: Greater adherence to the WAP initiated by volunteer coaches is associated with achieving 5% weight loss.

A "step too far" or "perfect sense"? A qualitative study of British adults' views on mandating COVID-19 vaccination and vaccine passports.

BACKGROUND: Debate is ongoing about mandating COVID-19 vaccination to maximise uptake. Policymakers must consider whether to mandate, for how long, and in which contexts, taking into account not only legal and ethical questions but also public opinion. Implementing mandates among populations who oppose them could be counterproductive. METHODS: Qualitative telephone interviews (Feb-May 2021) with British adults explored views on vaccine passports and mandatory vaccination. Participants (n = 50) were purposively selected from respondents to a probability-based national survey of attitudes to COVID-19 vaccination, to include those expressing vaccine-hesitancy. Data were analysed thematically. FINDINGS: Six themes were identified in participants' narratives concerning mandates: (i) mandates are a necessary and proportionate response for some occupations to protect the vulnerable and facilitate the resumption of free movement; (ii) mandates undermine autonomy and choice; (iii) mandates represent an over-reach of state power; (iv) mandates could potentially create 'vaccine apartheid'; (v) the importance of context and framing; and (vi) mandates present considerable feasibility challenges. Those refusing vaccination tended to argue strongly against mandates. However, those in favour of vaccination also expressed concerns about freedom of choice, state coercion and social divisiveness. DISCUSSION: To our knowledge, this is the first in-depth UK study of public views on COVID-19 vaccine mandates. It does not assess support for different mandates but explores emotions, principles and reasoning underpinning views. Our data suggest that debate around mandates can arouse strong concerns and could entrench scepticism. Policymakers should proceed with caution. While surveys can provide snapshots of opinion on mandates, views are complex and further consultation is needed regarding specific scenarios.

Lockdown and licensed premises: COVID-19 lessons for alcohol policy.

INTRODUCTION: The COVID-19 pandemic necessitated unprecedented changes in alcohol availability, including closures, curfews and restrictions. We draw on new data from three UK studies exploring these issues to identify implications for premises licensing and wider policy. METHODS: (i) Semi-structured interviews (n = 17) with licensing stakeholders in Scotland and England reporting how COVID-19 has reshaped local licensing and alcohol-related harms; (ii) semi-structured interviews (n = 15) with ambulance clinicians reporting experiences with alcohol during the pandemic; and (iii) descriptive and time series analyses of alcohol-related ambulance callouts in Scotland before and during the first UK lockdown (1 January 2019 to 30 June 2020). RESULTS: COVID-19 restrictions (closures, curfews) affected on-trade premises only and licensing stakeholders highlighted the relaxation of some laws (e.g. on takeaway alcohol) and a rise in home drinking as having long-term risks for public health. Ambulance clinicians described a welcome break from pre-pandemic mass public intoxication and huge reductions in alcohol-related callouts at night-time. They also highlighted potential long-term risks of increased home drinking. The national lockdown was associated with an absolute fall of 2.14 percentage points [95% confidence interval (CI) -3.54, -0.74; P = 0.003] in alcohol-related callouts as a percentage of total callouts, followed by a daily increase of +0.03% (95% CI 0.010, 0.05; P = 0.004). DISCUSSION AND CONCLUSIONS: COVID-19 gave rise to both restrictions on premises and relaxations of licensing, with initial reductions in alcohol-related ambulance callouts, a rise in home drinking and diverse impacts on businesses. Policies which may protect on-trade businesses, while reshaping the night-time economy away from alcohol-related harms, could offer a 'win-win' for policymakers and health advocates.

National survey of attitudes towards and intentions to vaccinate against COVID-19: implications for communications.

OBJECTIVES: To examine public views on COVID-19 vaccination and consider the implications for communications and targeted support. DESIGN: Cross-sectional study. SETTING: Online and telephone nationally representative survey in Great Britain, January to February 2021. PARTICIPANTS: 4978 adults. Survey response rate was 84%, among the 5931 panellists invited. MAIN OUTCOME MEASURES: Sociodemographic characteristics (age, gender, ethnicity, education, financial status), COVID-19 status, vaccine acceptance, trust in COVID-19 vaccination information sources, perceptions of vaccination priority groups and perceptions of importance of second dose. RESULTS: COVID-19 vaccine acceptance (83%) was associated with increasing age, higher level of education and having been invited for vaccination. Acceptance decreased with unconfirmed past COVID-19, greater financial hardship and non-white British ethnicity; black/black British participants had lowest acceptance. Overall, healthcare and scientific sources of information were most trusted. Compared with white British participants, other ethnicities had lower trust in healthcare and scientific sources. Those with lower educational attainment or financial hardship had lower trust in healthcare and scientific sources. Those with no qualifications had higher trust in media and family/friends. While trust was low overall in community or faith leaders, it was higher among those with Asian/Asian British and black/black British ethnicity compared with white British participants. Views of vaccine prioritisation were mostly consistent with UK official policy but there was support for prioritising additional groups. There was high support for having the second vaccine dose. CONCLUSIONS: Targeted engagement is needed to address COVID-19 vaccine hesitancy in non-white British ethnic groups, in younger adults, and among those with lower education, greater financial hardship and unconfirmed past infection. Healthcare professionals and scientific advisors should play a central role in communications and tailored messaging is needed for hesitant groups. Careful communication around vaccination prioritisation continues to be required.

The impacts of including information about the number of carcinogens in smoke on standardized cigarette packs in the UK.

BACKGROUND: Since May 2017, standardized packaging has been mandatory in the UK, with packs required to display an 'information message' explaining that there are more than 70 carcinogens in tobacco smoke. METHODS: Three waves of a longitudinal online survey in the UK with smokers pre-standardized packaging (Wave 1: April-May 2016) and followed up post-standardized packaging (Wave 2: September-November 2017, Wave 3: May-July 2019). Of the 6233 smokers at Wave 1, 4293 responded at Wave 2 and 3175 at Wave 3. We explored knowledge of the number of carcinogens in smoke, and whether knowing that smoke contains more than 70 carcinogens mediated change in the belief that the dangers of smoking are exaggerated (risk perception), stubbing out cigarettes, quit intentions and quitting. As the information message is larger on roll-your-own packs than on cigarette packs, as the packs are larger, we also explored whether there was any difference in knowing that smoke contains more than 70 carcinogens between exclusive cigarette smokers and exclusive roll-your-own smokers. RESULTS: Knowledge that there are over 70 carcinogens in smoke increased among smokers across waves, with the increase from Waves 1 to 3 greater for exclusive roll-your-own smokers than exclusive cigarette smokers (adjusted odds ratio=1.44; 95% CI 1.03-2.03). Knowledge that there are over 70 carcinogens in smoke mediated higher risk perception but not stubbing cigarettes out, quit intentions or quitting. CONCLUSIONS: The information message improved knowledge of how many carcinogens are in smoke, particularly among exclusive roll-your-own smokers, and this was linked to higher risk perception.

'I Was Smoking a Lot More during Lockdown Because I Can': A Qualitative Study of How UK Smokers Responded to the Covid-19 Lockdown.

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.

E-Cigarette Advertising in the UK: A Content Analysis of Traditional and Social Media Advertising to Observe Compliance with Current Regulations.

INTRODUCTION: The advertising of e-cigarettes in the UK is regulated through the revised EU Tobacco Products Directive and the Tobacco and Related Products Regulations, with further rules set out in the Advertising Standards Authority (ASA) Committees of Advertising (CAP) Code. Focusing on the ASA CAP Code Rules, we examined e-cigarette advertising regulation compliance in traditional advertising channels and on social media. METHODS: We conducted a content analysis of UK e-cigarette and related product advertising using a randomly selected sample (n = 130) of advertising in traditional channels and on Instagram which appeared between January and December 2019. All ads were independently double-coded to assess compliance with each CAP Code Rule. RESULTS: In traditional channels, our sample of advertising had largely good compliance. Only very small numbers of these ads appeared to be clearly in breach of any of the ASA rules (5% were in breach of Rule 22.7; 2% of Rule 22.9; and 1% of Rule 22.10). In contrast, we judged that all of the Instagram sample (n = 30) was in breach of Rule 22.12. For some rules, it was not possible to make definitive judgments about compliance, given uncertainty regarding how a rule should be interpreted and applied. CONCLUSIONS: We found overall good compliance for advertising in traditional channels, but assessed all of our social media advertising samples was in breach of regulations. Current guidance on e-cigarette advertising could be improved to facilitate e-cigarette advertising assessment and regulation. It would be beneficial to bring consumer perspectives into the assessment of regulation compliance. IMPLICATIONS: The regulation of e-cigarette advertising is a global concern. The UK Government has a statutory obligation to review the Tobacco and Related Products Regulations by May 2021. This study assessed compliance with current UK e-cigarette advertising regulations on placement and content. We identified areas where greater clarity is needed and outlined implications for future regulation.

Consumer Response to Standardized Tobacco Packaging in the United Kingdom: A Synthesis of Evidence from Two Systematic Reviews.

Standardized packaging of tobacco products has now been fully implemented in 15 countries. However, there is limited evidence, apart from in Australia, on how consumers have responded to the policy. Two systematic reviews explored consumer, tobacco industry and retailer response to standardized packaging in the United Kingdom (UK), which became mandatory for cigarettes (factory-made and hand-rolled) from May 2017, following a twelve-month transition period. In the first review, electronic databases were searched for published primary research from January 2016 to February 2019. The second review used the same methods, with searches conducted between February 2019 and September 2020. The current study conducted a narrative synthesis of the findings exploring consumer response from these two systematic reviews. Eleven studies met the inclusion criteria. Studies examined consumer response to on-pack warnings (n=7 studies), appeal of packs and smoking (n=4), perceptions of harm (n=5), and behavioral responses (n=8). There was consistent evidence that standardized packaging was associated with increased warning salience and effectiveness, and reduced appeal. Findings were mixed with respect to whether standardized packs were associated with increased perceptions of harm. Standardized packaging was generally thought to deter never or occasional smokers. Standardized packaging was associated with increased thoughts of quitting during the transition period, but no study directly explored cessation or relapse prevention. Some smokers switched to cheaper cigarettes. Standardized packaging in the UK seems to be reducing the appeal of packaging and smoking and making warnings more salient, but the behavioral impact is unclear. More consumer research is needed to assess longer-term behavioral response.

Anticipated responses to a hypothetical minimum price for cigarettes and roll-your-own tobacco: an online cross-sectional survey with cigarette smokers and ex-smokers in the UK.

OBJECTIVES: As tobacco companies can circumvent tax increases, a minimum retail price per-cigarette/per-gram of roll-your-own tobacco presents an additional mechanism for governments to reduce smoking. We examined (1) anticipated responses to a hypothetical minimum price-per-cigarette/per-gram among smokers in the UK; (2) what demographic and smoker characteristics are associated with anticipated responses; and (3) whether minimum pricing may help ex-smokers stay quit. DESIGN: Cross-sectional survey (May-July 2019). SETTING: UK. PARTICIPANTS: Adult cigarette smokers (n=2412) and ex-smokers (n=700). MAIN OUTCOME MEASUREMENTS: Anticipated responses to a hypothetical minimum price of £10.00 for 20 cigarettes (£0.50 per-cigarette) and £13.50 for 30 grams of roll-your-own tobacco (£0.45 per-gram); approximately £0.10 per-cigarette/per-gram increases on the cheapest prices in leading UK supermarkets (January 2019). Smokers were presented with ten options (eg, 'Try to quit') and asked which they would do (Yes/No) and then which they would most likely do. Ex-smokers were asked to what extent the minimum prices would help them stay quit (A lot vs Lesser agreement). RESULTS: Among smokers, 55.6% said they would most likely smoke the same amount, 10.7% they would smoke less, 9.5% they would try to quit and 5.8% they would use e-cigarettes more often. Anticipated reactions were associated with demography and smoker characteristics, for example, C2DE (lower social grade) smokers were less likely than ABC1 (higher social grade) smokers to say they would smoke the same as they do now (ORAdj=0.74, 95% CI 0.62 to 0.88). Among ex-smokers, 38.5% said the minimum prices would help them stay quit 'A lot', more so among C2DE than ABC1 participants (ORAdj=1.80, 95% CI 1.30 to 2.49). CONCLUSIONS: In response to a hypothetical minimum price for cigarettes and roll-your-own tobacco, approximately a fifth of smokers in the UK indicated they would smoke less or quit and almost two-fifths of ex-smokers indicated the prices would help them stay quit.

The impact of the initial Covid-19 lockdown upon regular sports bettors in Britain: Findings from a cross-sectional online study.

BACKGROUND: In Britain, unprecedented restrictions on daily life associated with the Covid-19 pandemic included the suspension of professional sports events during the initial 'lockdown'. This provides opportunities to observe changes in sports bettors' behaviour when their primary form of activity is removed and assess the impact of Covid-19 related circumstances upon gambling. METHODS: In July 2020, we conducted an online cross-sectional survey of people who bet regularly (at least monthly) on sports before Covid-19 (n = 3866). Bi-variate analyses compared changes in gambling behaviours before and during the initial lockdown. Multi-variate logistic regression models explored associations between problem gambling (men) and moderate risk or problem gambling (MRPG) (women) with changes in Covid-19 related circumstances and changing gambling behaviours during Britain's initial 'lockdown' (March-June 2020). RESULTS: 29.8% of male sports bettors and 33.4% of female sports bettors stopped gambling altogether during the initial Covid-19 lockdown, though 17.3% of men and 16.5% of women started a new form of gambling during lockdown. Among men, adjusted odds ratios of problem gambling were higher among those starting a new gambling activity during lockdown (OR = 2.50 [95% CI 1.38-4.53]). Among women, adjusted odds ratios of MRPG were higher among those whose frequency of gambling on any activity increased during lockdown (OR = 4.21 [1.99-8.92] and among those shielding for health reasons. Poorer wellbeing was associated with problem gambling for men and MRPG for women. CONCLUSIONS: Those changing gambling behaviours during the initial Covid-19 lockdown (e.g. increasing gambling frequency or starting a new gambling activity) are potentially vulnerable to gambling harms.

A novel approach to increasing community capacity for weight management a volunteer-delivered programme (ActWELL) initiated within breast screening clinics: a randomised controlled trial.

BACKGROUND: It is estimated that around 30% of breast cancers in post-menopausal women are related to lifestyle. The breast cancer-pooling project demonstrated that sustained weight loss of 2 to 4.5 kg is associated with an 18% lower risk of breast cancer, highlighting the importance of small changes in body weight. Our study aimed to assess the effectiveness a volunteer-delivered, community based, weight management programme (ActWELL) for women with a BMI > 25 kg/m2 attending NHS Scotland Breast Screening clinics. METHODS: A multicentre, 1:1 parallel group, randomised controlled trial was undertaken in 560 women aged 50 to 70 years with BMI > 25 kg/m2. On completion of baseline measures, all participants received a breast cancer prevention leaflet. Intervention group participants received the ActWELL intervention which focussed on personalised diet advice and pedometer walking plans. The programme was delivered in leisure centres by (the charity) Breast Cancer Now volunteer coaches. Primary outcomes were changes between groups at 12 months in body weight (kg) and physical activity (accelerometer measured step count). RESULTS: Two hundred seventy-nine women were allocated to the intervention group and 281 to the comparison group. Twelve-month data were available from 240 (81%) intervention and 227 (85%) comparison group participants. Coaches delivered 523 coaching sessions and 1915 support calls to 279 intervention participants. Mean weight change was - 2.5 kg (95% CI - 3.1 to - 1.9) in the intervention group and - 1.2 kg (- 1.8 to 0.6) in the comparison group. The adjusted mean difference was - 1.3 kg (95% CI - 2.2 to - 0.4, P = 0.003). The odds ratio for losing 5% weight was 2.20 (95% CI 1.4 to 3.4, p = 0.0005) in favour of the intervention. The adjusted mean difference in step counts between groups was 483 steps/day (95% CI - 635 to 1602) (NS). CONCLUSIONS: A community weight management intervention initiated at breast screening clinics and delivered by volunteer coaches doubled the likelihood of clinically significant weight loss at 12 months (compared with usual care) offering significant potential to decrease breast cancer risk. TRIAL REGISTRATION: Database of registration: ISCRTN. Registration number: 11057518 . Date trial registered:21.07.2017. Date of enrolment of first participant: 01.09.2017.

The Response of Smokers to Health Warnings on Packs in the United Kingdom and Norway Following the Introduction of Standardized Packaging.

INTRODUCTION: Standardized packaging was phased in between May 2016 and May 2017 in the United Kingdom and July 2017 and July 2018 in Norway. In both countries, the health warnings on packs prior to standardized packaging being implemented were from the former Tobacco Products Directive library of warnings (text warnings covering 43% of the pack front and pictorial warnings covering 53% of the pack reverse). The warnings on packs, postimplementation, were from the current Tobacco Products Directive library of warnings (novel pictorial warnings covering 65% of the pack front and reverse) for the United Kingdom but unchanged in Norway. AIMS AND METHODS: Longitudinal online surveys were conducted prior to standardized packaging (United Kingdom: April-May 2016; Norway: May-June 2017) and postimplementation (United Kingdom: September-November 2017 and May-July 2019; Norway: August-September 2018). We explored smokers' response to the on-pack warnings (salience, cognitive reactions, and behavioral reactions). RESULTS: In the United Kingdom, noticing warnings on packs, reading or looking closely at them, thinking about them, thinking about the health risks, avoidant behaviors, forgoing cigarettes, and being more likely to quit due to the warnings significantly increased from waves 1 to 2, and then decreased from waves 2 to 3, but remained higher than at wave 1. In Norway, noticing warnings, reading or looking closely at them, thinking about them, thinking about the health risks, and being more likely to quit due to the warnings significantly decreased from waves 1 to 2; avoidant behaviors and forgoing cigarettes remained unchanged. CONCLUSIONS: The inclusion of large novel pictorial warnings on standardized packs increases warning salience and effectiveness. IMPLICATIONS: Two longitudinal online surveys in the United Kingdom and Norway explored the impact of standardized packaging on warning salience and effectiveness. That warning salience and effectiveness only increased in the UK postimplementation, where standardized packaging was implemented alongside new larger pictorial warnings on the pack front and reverse, and not in Norway, where standardized packaging was introduced but older smaller text warnings (pack front) and pictorial warnings (pack reverse) were retained, highlights the importance of removing full branding and introducing stronger warnings simultaneously.