The research questions outlined in our original protocol1were necessarily broad and, as the project developed, these were refined. The structure of the report is as follows.
Following a discussion in Chapter 2 of the study design and research methods used, we present the main outcomes of the study in Chapters 3–8.
In Chapter 3 we focus on retailers’ implementation of and compliance with the POS legislation by answering the following questions:
l What were the characteristics of tobacco POS displays at baseline, prior to implementation of the POS legislation?
l What was the level of compliance with the legislation in large supermarkets and small shops?
In Chapter 4 we explore small retailers’ perspectives on the implementation and impact of the POS legislation by answering the following questions:
l What were small retailers’ expectations about the implementation and impact of the POS legislation?
l What were small retailers’ experiences of implementing the POS legislation?
l What were small retailers’ perceptions of the impact of the POS legislation on customers and the retail environment?
In Chapter 5 we report the findings on the impact of POS legislation on environmental exposure to POS displays. In addition to describing the development of a new visibility measure, we address the following questions:
l In our four DISPLAY communities, were there changes in exposure to tobacco products either at a community level or for young people in our sample following the implementation of POS legislation?
l Has there been a change in the national availability of tobacco products in Scotland between 2012 and 2017?
l To what extent do changes in the national availability of tobacco products vary between local authorities and by area-level indicators of socioeconomic deprivation and urban/rural status?
l What are the implications of these changes, at both a national and a local level, for social inequalities?
In Chapter 6 we examine the impact of the POS legislation on young people’s brand awareness, perceived accessibility of tobacco and pro-smoking attitudes. The questions addressed are:
l What was the relationship between POS displays of cigarettes and brand awareness prior to the introduction of the POS legislation in 2013?
l How did brand awareness change after the introduction of the partial and comprehensive POS bans?
l What were the trends in perceived tobacco accessibility, pro-smoking attitudes and pro-smoking norms between 2013 and 2017?
l To what extent did perceived tobacco accessibility, pro-smoking attitudes and pro-smoking norms change after the introduction of the partial and comprehensive POS bans?
l Did shop visit frequency influence the impact of the legislation on change in perceived tobacco accessibility?
l Were there any changes in the perceived availability of black-market tobacco associated with the POS legislation pro-smoking attitudes and pro-smoking norms?
INTRODUCTION
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In Chapter 7 we focus on the smoking-related outcomes– perceived smoking prevalence, smoking susceptibility and smoking initiation– and assess their relationship with the implementation of the POS legislation. The questions we answer are:
l Was the introduction of the partial and comprehensive POS display bans associated with a reduction in perceived youth and adult smoking prevalence?
l Did shop visit frequency have an influence on these associations?
l Was the introduction of comprehensive POS legislation associated with a reduction in smoking susceptibility in young people?
l Did shop visit frequency influence the association between introduction of comprehensive POS legislation and smoking susceptibility?
l Was the introduction of the comprehensive POS legislation associated with a reduction in the risk of smoking initiation in young people?
l Did shop visit frequency influence the association between POS legislation and risk of smoking initiation?
In the last of our outcome chapters, Chapter 8, we consider the impact of the increase in marketing and use of e-cigarettes and the introduction of standardised packaging, and answer the following questions:
l What are the patterns and trends in e-cigarette use among young people aged 12–17 years?
l What are the influences on developing social norms among adolescents around e-cigarettes and their use?
l Is there a relationship between exposure to e-cigarette promotions and e-cigarette use among young people aged 12–17 years?
l Is there a relationship between e-cigarette use and future smoking initiation in never-smokers aged 12–17 years?
l What is the level of awareness of standardised packs in young people aged 12–17 years?
l What are young people’s reactions to the new standardised packs and pictorial health warnings? Finally, in Chapter 9 we bring together and integrate the findings from across the study components and discuss them in the context of what is already known about the impact of legislation that bans tobacco displays at POS. We then go on to consider the strengths and weaknesses of the study and to consider the implications for future tobacco control policy and research.
DOI: 10.3310/phr08010 Public Health Research 2020 Vol. 8 No. 1
© Queen’s Printer and Controller of HMSO 2020. This work was produced by Haw et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Chapter 2 Study design
P
arts of this chapter have been adapted from the protocol for the study by Haw et al.1© 2014 Haw et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Setting
The study was conducted in four communities on mainland Scotland, UK.
Study design
We regarded the Scottish POS legislation as a complex intervention as it was intended to act on a variety of targets at both the community and the individual level and to have multiple outcomes in the retail environment both among young people and in the community.60The legislation was rolled out simultaneously across all areas of Scotland on the same day; hence an experimental design, such as a randomised controlled trial, to evaluate the legislation was not possible. Instead, we conducted a longitudinal study in four purposively selected communities using a multimodal before-and-after design and mixed methods to collect data.61Mixed methods were chosen to collect data as this allowed us to collect a range of quantitative and qualitative data and thus answer a much broader range of questions than would otherwise have been possible. This was necessary to make a comprehensive assessment of the effects of the POS legislation in the retail environment and on young people. The collection of qualitative data from both young people and tobacco retailers was intended to provide important contextual information with which to interpret some of the findings on outcomes.
For the purposes of the study,‘community’ was defined as the catchment areas of the secondary schools selected for study. Schools were purposively selected according to set criteria. Candidate schools were initially identified from those in the central belt of Scotland that had a school enrolment of> 1000 (about 46% of Scottish secondary schools fell into this category at the start of the study), were non-denominational and had an ethnic minority population of< 10%. An upper limit was placed on schools’ ethnic minority population because in Scotland ethnic minority pupils represent only 4% of the total Scottish secondary school population.62
Schools were then classified by level of social deprivation using the Scottish Index of Multiple Deprivation (SIMD).63
The estimate was based on the mean (population-weighted) of the deprivation scores for the data zones (a small-area statistical geography) that fell within the school catchment areas. The schools were also classified by level of urbanisation using the Scottish Government Urban/ Rural Classification, which combines measures of population and accessibility64to give six categories of urbanisation: large urban, other urban, accessible small town, remote small town, accessible rural areas and remote rural areas. In total, 61 schools met the size (pupil roll of> 1000) and ethnicity (< 10% non-white) criteria. Eight were then shortlisted that best met the deprivation (high vs. medium to low) and urbanisation (large urban vs. other urban/small town) criteria, as well as giving a reasonable spread within the central belt of Scotland. The team selected four first-choice schools and four second-choice schools. The final school sample consisted of three first-choice schools and one second-choice school. The fourth first-choice school declined to participate in the study because of pressure of work. Table 1 gives the characteristics of the catchment areas served by the study schools.
DOI: 10.3310/phr08010 Public Health Research 2020 Vol. 8 No. 1
© Queen’s Printer and Controller of HMSO 2020. This work was produced by Haw et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
There were four main components to the study:
l mapping and spatial analysis of the location and density of tobacco retail outlets
l marketing audits of tobacco retail outlets most used by young people, comprising observational audits in the study communities, and interviews with a panel of retailers in four matched communities
l cross-sectional school surveys of pupils, with embedded pupil cohorts
l focus group discussions with purposive samples of pupils.