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Background and aimIn 2016, England initiated the implementation of standardised tobacco packaging, introduced in conjunction with minimum pack sizes and other measures included in the 2014 European Tobacco Products Directive, over the course of a 1-year sell-off period ending in May 2017. These measures have been shown to have been associated with increases in tobacco prices and product diversity. We now investigate the association between implementation of the new legislation and smoking status in England.DesignSegmented regression analysis of repeated cross-sectional surveys using a generalised linear model with individual-level data to test for a change in trend and immediate step change.SettingEngland.ParticipantsParticipants in the Smoking Toolkit Study, which involves repeated, cross‐sectional household surveys of individuals aged 16 years and older in England. The sample included 278 219 individual observations collected between November 2006 and December 2019.InterventionImplementation of standardised packaging legislation (May 2016 and May 2017).MeasurementsIndividual-level current smoking status adjusted for implementation of tobacco control policies, cigarette price, seasonality and autocorrelation.FindingsThe implementation of standardised packaging was associated with a significant step reduction in the odds of being a smoker after May 2017 (OR: 0.93; 95% CI 0.87 to 0.99). The magnitude of the association was similar when modelling the step change in May 2016 at the start of the 1-year policy implementation period (OR: 0.90; 95% CI: 0.83 to 0.97).ConclusionsThis is the first independent study demonstrating that implementation of standardised packaging was associated with a reduction in smoking in England which occurred in anticipation of, rather than after, full policy implementation. It appears that the odds of being a smoker were affected by the prospect of the move to standardised packs and accompanying legislation.

BackgroundPlain packaging and minimum pack size legislation for tobacco products was introduced in the UK in May 2016, with a 1-year sell-off period until May 2017, during which both fully branded and plain packs of various sizes were legally available. This study investigates trends in prices of roll-your-own tobacco (RYO) before, during and after implementation of this legislation, and compares trends with those observed in the cigarette market.MethodsWe used Nielsen Scantrack data for the period from March 2013 to June 2018 to describe trends in UK inflation-adjusted prices and volumes of both RYO and cigarettes, and linear regression to estimate changes in prices associated with the introduction of plain packaging and the minimum pack sizes of 30 g RYO and 20 cigarettes.ResultsIn contrast to a downward trend in cigarette sales volumes, RYO volumes rose throughout the study period. By the time plain packs accounted for 75% or more of sales, the average price of products sold in equivalent pack sizes had increased, relative to average prices in the year before implementation and with adjustment for tax changes, from 34.9 to 38.8 pence per gram for RYO (mean difference 4.26, 95% CI 3.99 to 4.53 pence, 12% increase), and from 38.6 to 41.13 pence for cigarettes (mean difference 2.53, 95% CI 2.24 to 2.83 pence, 7% increase) per cigarette.ConclusionsNew legislation resulted in higher prices for RYO and manufactured cigarettes. However, sales volumes of RYO continued to increase throughout the study period, perhaps because RYO remains a less expensive means of smoking tobacco.

BackgroundReality television shows are popular with children and young adults; inclusion of tobacco imagery in these programmes is likely to cause smoking in these groups. Series 3 of the UK reality show Love Island, broadcast in 2017, attracted widespread media criticism for high levels of smoking depicted. We have quantified this tobacco content and estimated the UK population exposure to generic and branded tobacco imagery generated by the show.MethodsWe used 1-min interval coding to quantify actual or implied tobacco use, tobacco paraphernalia or branding, in alternate episodes of series 3 of Love Island, and Census data and viewing figures from Kantar Media to estimate gross and per capita tobacco impressions.ResultsWe coded 21 episodes comprising 1001 min of content. Tobacco imagery occurred in 204 (20%) intervals; the frequency of appearances fell significantly after media criticism. An identifiable cigarette brand, Lucky Strike Double Click, appeared in 16 intervals. The 21 episodes delivered an estimated 559 million gross tobacco impressions to the UK population, predominantly to women, including 47 million to children aged <16 and 44 million gross impressions of Lucky Strike branding, including 4 million to children <16.ConclusionDespite advertising legislation and broadcasting regulations intended to protect children from smoking imagery in UK television, series 3 of Love Island delivered millions of general and branded tobacco impressions both to children and adults in the UK. More stringent controls on tobacco content in television programmes are urgently needed.

Correspondence to Dr Alexander B Barker, Division of Epidemiology and Public Health, UK Centre for Tobacco and Alcohol Studies, Clinical Sciences Building, City Hospital, University of Nottingham, Nottingham NG7 2RD, UK; alexander.barker@nottingham.ac.uk Introduction Tobacco advertising and sponsorship in Formula 1 (F1) racing, which was banned in Europe by the 2005 EU Tobacco Advertising Directive1 and internationally by the Federation Internationale de l'Automobile since 2006,2 continues to this day through the Philip Morris sponsorship of Ferrari,3 thought to be worth $160 million (£124 million) annually.4 Although Marlboro advertising and related barcode alibis disappeared from Ferrari cars after 2010,5 during the 2018 championship, Philip Morris introduced a new marketing campaign, Mission Winnow, with text and logo branding on Ferrari cars and uniforms. In addition to the individual F1 race events, Channel 4 broadcast a range of qualifying race and pre-event and postevent programmes. Since we limited the present analysis to the broadcast programmes containing the actual race as specified by Channel 4 and did not code F1 races and related content broadcast in the UK through Sky Sports F1, our analysis probably underestimated the total numbers of Philip Morris tobacco impressions delivered through F1-related programming in the UK. Funding This work was supported by the Medical Research Council (grant number MR/K023195/1) and the UK Centre for Tobacco and Alcohol Studies, with core funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council and the Department of Health under the auspices of the UK Clinical Research Collaboration.

Background: In May 2016, along with the latest European Tobacco Products Directive (TPD), standardised packaging legislation was implemented in the UK. During the following 12-month transition period, both new and old types of packaging were allowed on the market. This study aimed to assess awareness of standardised packaging and other TPD changes in the UK population in March 2017, when both forms of packaging were in widespread use. Methods: We conducted two surveys—one in adults and one in young people—investigating awareness of plain packaging legislation. In young people, we also measured susceptibility to smoking using previously validated questions. We asked smokers whether they had recently changed the product they used and also whether they used any of the products that are banned by the new legislation. Results: In the adult survey, 73.5% (95% CI: 71.5–75.5%) of the participants were aware of the new legislation and 32.4% (95% CI: 30.3–34.5%) had noticed changes in tobacco packaging, this proportion being considerably higher among smokers (83.7%; 95% CI: 78.9–87.5%) than never smokers (20.7%; 95% CI: 18.2–23.4%). More than half (52.4%; 95% CI: 46.5–58.4%) were using pack sizes or shapes (typically less than 20 cigarettes or 30 g loose tobacco), that would become illegal after full TPD implementation, and 31.4% (95% CI: 26.2–37.1%) reported switching to a different product since October 2016, in most cases to a cheaper brand. Among young people, 20.2% (95% CI: 17.8–22.7%) reported that they had noticed standardised packaging, comprising 16.2% (95% CI: 13.7–19.0%) of non-susceptible never smokers, 25.6% (95% CI: 18.0–35%) of susceptible never smokers, and 49% (95% CI: 37.8–60.2%) of ever smokers. Conclusions: In the final stages of implementation, awareness of the introduction of standardised packs was highest among smokers. The TPD will cause nearly half of adult smokers to purchase larger packs, and may cause many smokers to switch to cheaper brands.

Background In Ghana, overweight and obesity prevalence among women (20-49 years) reached 50% in 2022, increasing from 40% in 2014. This study aims to understand what has driven previous trends in overweight and obesity among women of reproductive age in Ghana and to predict future trends that can help inform policy making and public health surveillance. Methods We used data from the Ghana Demographic and Health Survey (DHS) containing information on women of reproductive age (aged 15 to 49 years). Data collected between 2003 and 2022 provided cohorts born between 1953 and 2007. Age-period-cohort (APC) analysis was used to disentangle the effects of age, time, and generation on trends in the odds of obesity and overweight. Results The prevalence of overweight and obesity increases during the study period, especially with age, in all cohorts. In the APC analysis, the odds of obesity increase with age until age 42–43 years (odds ratio (OR): 9.37; 95% confidence interval (CI): 5.63–15.59, compared to 20–21 year olds) before levelling out. Accounting for age and birth cohort, the odds of overweight and obesity increase significantly over time between 2003 and 2015 (overweight OR: 1.76; 95% CI: 1.47–2.11, obesity OR: 2.27; 95% CI: 1.77–2.91), after which the effect levels out and appears to stabilise. There is no effect of birth cohort on the odds of overweight or obesity. Conclusions Although high, the increasing odds of obesity and overweight in Ghana appears to be stabilising. However, the increasing odds of obesity with age, suggest that an ageing population could mean that the prevalence will increase into the future. Plain Language Summary Overweight and obesity are increasing rapidly in Ghana, especially among women, leading to serious health problems. We wanted to understand why these rates are rising and predict future trends to help create effective health programs. We looked at health survey data from Ghanaian women aged 15–49 collected over two decades (2003-2022). We used a specialist method to see how age, time, and the generation a woman was born into influenced her weight status. We found an increase in overweight and obesity among Ghanaian women over time, particularly between 2003 and 2014. Women tend to gain weight as they age, but we found that changes over time were more important than generational differences. Early interventions could be crucial to promote healthier weight and prevent long-term health issues for women. Gray et al. examine the weight trends in women using data from the Ghana Demographic and Health Study. Findings reveal that obesity poses a more substantial public health challenge than being underweight and that increases in obesity with age, combined with an aging population, could lead to continued rises in obesity rates.

ObjectivesHigh levels of particulate pollution due to secondhand smoke (SHS) have previously been recorded in English prisons. As part of an evaluation to ascertain whether a new comprehensive smoke-free policy introduced in the first four prisons in England was successfully implemented, this study compares indoor air quality on prison wing landing locations three months before and three months after going smoke-free.DesignAn indoor air quality monitoring study, comparing SHS levels before and after a comprehensive smoke-free prison policy.SettingThe first four prisons in England to implement a comprehensive smoke-free policy.Primary and secondary measuresWe compared concentrations of airborne particulate matter <2.5 microns in diameter (PM₂.₅), as a marker for SHS, on wing landing locations three months before and three months after the smoke-free policy was implemented. Static battery operated aerosol monitors were used to sample concentrations of PM₂.₅ on wing landings.ResultsAfter discarding data from monitors that had been tampered with we were able to analyse paired data across four prisons from 74 locations, across 29 wing landing locations, for an average sampling time of five hours and eight minutes. When comparing samples taken three months before with the paired samples taken three months after policy implementation (paired for prison, day of the week, time of day, wing location and position of monitor), there was a 66% reduction in mean PM₂.₅ concentrations across the four prisons sampled, from 39 to 13 µg/m³ (difference 26 µg/m³, 95% CI 25 to 26 µg/m³).ConclusionPrison smoke-free policies achieve significant improvements in indoor air quality. A national smoke-free policy would therefore be an effective means of protecting prisoners and staff from harm due to SHS exposure in the prison environment.

Background: We estimate exposure of British adults and adolescents to tobacco and alcohol content from a sample of popular YouTube music videos. Methods: British viewing figures were generated from 2 representative online national surveys of adult and adolescent viewing of the 32 most popular videos containing content. 2068 adolescents aged 11–18 years (1010 boys, 1058 girls), and 2232 adults aged 19 +years (1052 male, 1180 female) completed the surveys. We used the number of 10 s intervals in the 32 most popular videos containing content to estimate the number of impressions. We extrapolated gross and per capita impressions for the British population from census data and estimated numbers of adults and adolescents who had ever watched the sampled videos. Results: From video release to the point of survey, the videos delivered an estimated 1006 million gross impressions of alcohol (95% CI 748 to 1264 million), and 203 million of tobacco (95% CI 151 to 255 million), to the British population. Per capita exposure was around 5 times higher for alcohol than for tobacco, and nearly 4 times higher in adolescents, who were exposed to an average of 52.1 (95% CI 43.4 to 60.9) and 10.5 (95% CI 8.8 to 12.3) alcohol and tobacco impressions, respectively, than in adults (14.1 (95% CI 10.2 to 18.1) and 2.9 (95% CI 2.1 to 3.6)). Exposure rates were higher in girls than in boys. Conclusions: YouTube music videos deliver millions of gross impressions of alcohol and tobacco content. Adolescents are exposed much more than adults. Music videos are a major global medium of exposure to such content.

ObjectivesExposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. We report a trial of a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking.DesignAn open-label, parallel, randomised controlled trial.SettingDeprived communities in Nottingham City and County, EnglandParticipantsCaregivers resident in Nottingham City and County in England who were at least 18 years old, the main caregiver of a child aged under 5 years living in their household, and reported that they were smoking tobacco inside their home.InterventionsWe compared a complex intervention combining personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care.Main outcomesThe primary outcome was change in air quality in the home, measured as average 16–24  hours levels of particulate matter of  < 2.5  µm diameter (PM2.5), between baseline and 12 weeks. Secondary outcomes included changes in maximum PM2.5, proportion of time PM2.5 exceeded WHO recommended levels of maximum exposure of 25  µg/mg3, child salivary cotinine, caregivers’ cigarette consumption, nicotine dependence, determination to stop smoking, quit attempts and quitting altogether during the intervention.ResultsArithmetic mean PM2.5 decreased significantly more (by 35.2 %; 95%  CI 12.7% to 51.9 %) in intervention than in usual care households, as did the proportion of time PM2.5 exceeded 25  µg/mg3, child salivary cotinine concentrations, caregivers’ cigarette consumption in the home, nicotine dependence, determination to quit and likelihood of having made a quit attempt.ConclusionsBy reducing exposure to SHS in the homes of children who live with smokers unable or unwilling to quit, this intervention offers huge potential to reduce children’s’ tobacco-related harm.Trial registration numberISRCTN81701383.This trial was funded by the UK National Institute for Health Research (NIHR): RP-PG-0608-10020

Abstract Background Exposure to tobacco and alcohol content in audio-visual media is a risk factor for smoking and alcohol use in young people. We report an analysis of tobacco and alcohol content, and estimates of population exposure to this content, in a sample of reality television programmes broadcast in the UK. Methods We used 1-minute interval coding to quantify tobacco and alcohol content in all episodes of five reality TV programmes aired between January and August 2018 (Celebrity Big Brother; Made in Chelsea; The Only Way is Essex; Geordie Shore and Love Island), and estimated population exposure using viewing data and UK population estimates. Results We coded 5219 intervals from 112 episodes. Tobacco content appeared in 110 (2%) intervals in 20 (18%) episodes, and alcohol in 2212 (42%) intervals and in all episodes. The programmes delivered approximately 214 million tobacco gross impressions to the UK population, including 47.37 million to children; and for alcohol, 4.9 billion and 580 million respectively. Conclusion Tobacco, and especially alcohol, content is common in reality TV. The popularity of these programmes with young people, and consequent exposure to tobacco and alcohol imagery, represents a potentially major driver of smoking and alcohol consumption.