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Background While tobacco smoking has declined among UK youth in recent decades, cannabis use has begun to show some growth. Given their interrelationship, growth in cannabis use may act as a barrier to continued reduction in youth smoking. This paper assesses recent tobacco and cannabis use trends in Wales, and their association, to explore whether change in cannabis use might have impacted youth tobacco smoking prevalence. Methods Repeat cross-sectional data on tobacco and cannabis use were obtained from biennial Welsh Student Health and Wellbeing surveys between 2013 and 2019. Data were pooled and analysed using logistic regression with adjustment for school-level clustering. Results No change in regular youth tobacco smoking was observed between 2013 and 2019. In contrast, current cannabis use increased during this time, and cannabis users had significantly greater odds of regular tobacco smoking. After adjusting for change in cannabis use, a significant decline in youth tobacco smoking was observed (OR 0.95; 95% confidence intervals: 0.92, 0.97). Conclusion Recent growth in cannabis use among young people in Wales may have offset prospective declines in regular tobacco smoking. Further reductions in youth smoking may require more integrated policy approaches to address the co-use of tobacco and cannabis among adolescents. [ABSTRACT FROM AUTHOR]

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. Plain language summary 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. Scientific summary Background Smoking is a leading cause of preventable death and health inequalities in the United Kingdom (UK), and internationally. E-cigarettes are a popular means for smokers to quit. Emerging evidence suggests that E-cigarettes can be highly effective in helping smokers quit and many people argue that e-cigarettes should be endorsed to support smoking cessation, as e-cigarettes are likely significantly less harmful than tobacco. However, the increasing popularity of e-cigarettes has led to debates surrounding potential positive, and negative public health impacts. Although there is growing consensus that e-cigarettes are less harmful than tobacco, there is also consensus that e-cigarettes are not harmless and, hence, that use of e-cigarettes among non-smokers, particularly young people, should be prevented. Although there has been concern about direct harms to non-smoking young people, most concerns centre on how e-cigarettes might affect smoking uptake. Since the 1990s, the prevalence of young people’s smoking in the UK has steadily declined following two decades of regulation of tobacco markets. At the centre of concerns around e-cigarettes is an argument that these gains may be reversed, by their acting as a gateway to nicotine addiction and tobacco use, or through renormalising smoking by mimicking it’s action. Different positions on e-cigarettes are reflected in divergent international approaches to regulation. Some countries ban their sale, whereas other countries have few specific regulations. England and Wales introduced age of sales regulations in 2015, followed by Scotland in 2017. Unsuccessful attempts in Wales were made in 2015 to introduce legislation prohibiting e-cigarette use in public spaces where smoking is banned. In May 2016, Tobacco Products Directive (TPD) regulations were introduced in European Union (EU) member states. The TPD regulations included a suite of regulations for tobacco, many of which brought EU nations in line with UK regulations. In the UK, the TPD regulations occurred alongside introduction of plain packaging for tobacco cigarettes. The TPD also included specific regulations for e-cigarettes, including bans on cross-border advertising from May 2016, with regulations on the products themselves introduced with a transitional period beginning in May 2016 and full implementation to be achieved by May 2017. Regulations included a warning on the packet that the products contain nicotine, which is a highly addictive substance, restrictions on nicotine strength and mandatory declaration of new products 6 months in advance of their introduction. The TPD regulations were a cause of concern for some people who argued that regulations might inhibit the usefulness of e-cigarettes as cessation tools. However, the rationale for TPD regulations included that young people’s use of e-cigarettes was growing and there were concerns that e-cigarettes mimic smoking and, hence, renormalise it. Regulation of e-cigarettes was motivated, in part, by reducing the appeal to young people. To date, the role of e-cigarettes in renormalising smoking, as well as the impact of e-cigarettes regulation on young people’s e-cigarette use, are not well understood. This study investigates the extent to which regulations have affected growth in young people’s use of e-cigarettes in England, Scotland and Wales, and explores broader questions about the impact of e-cigarettes on young people’s smoking perceptions and behaviour. Objectives 1.To investigate the role of e-cigarette regulation via the TPD in influencing trajectories in young people’s use of e-cigarettes via the following research questions: i.Did increased regulation of e-cigarettes interrupt prior growth in young people’s e-cigarette use? ii.How do young people perceive risks and social norms surrounding e-cigarettes: a.as a product in their own right? b.relative to tobacco? iii.How do young people interpret and respond to health warnings on e-cigarette packets? iv.To what extent, and in what ways, do young people continue to interact with e-cigarette marketing after the prohibition of cross-border advertising? 2.To examine trends in young people’s smoking behaviour over time, to test theoretical assumptions regarding whether or not e-cigarettes renormalise smoking and to examine whether or not declines in smoking continued following the suite of regulation introduced within and alongside TPD, via the following questions: i.Were declines in young people’s ever and current smoking significantly interrupted during the emergence of e-cigarettes? ii.Did the rate of decline in young people’s smoking change after additional regulation of tobacco and e-cigarettes in 2016? 3.To explore the implementation and context of TPD regulation via the following questions: i.To what extent was compliance with TPD in product sales achieved, and what are the barriers to, and facilitators and unintended consequences of implementation? ii.To what extent, and in what ways, did variations between UK countries in e-cigarette policy emerge during the study period? iii.What other changes to the regulatory context of tobacco and e-cigarettes occurred during the study period in the UK and across UK countries? Methods Our study was a mixed-method natural experimental evaluation. Quantitative components drew on repeat cross-sectional survey data from Wales (i.e. the Health Behaviour in School-aged Children Survey and School Health Research Network Survey), Scotland (i.e. the Scottish Schools Adolescent Lifestyle and Substance Use Survey) and England (i.e. the Smoking Drinking and Drug Use Survey). Study populations were nationally representative samples of young people aged 13–15 years (or from the equivalent school years, i.e. years 9 and 11 in Wales and England and S2 and S4 in Scotland). Process evaluation included interviews with young people, retailers, policy stakeholders and trading standards officers (TSOs), and observations of retail premises during and after the transitional phase for TPD implementation. The survey data from Wales were used for our primary statistical analysis, which assessed change in ever use of e-cigarettes following the introduction of the TPD regulations, using segmented regression analysis. The analysis included 91,687 young people who completed surveys between 2013 and 2019 in Wales, with surveys disaggregated into monthly estimates to provide 16 data points overall. More simple logistic regression analyses were used to examine whether or not trends in Wales were mirrored elsewhere in the UK, using Scottish and English data. Changes in young people’s smoking behaviour before and after emergence of e-cigarettes, but prior to their regulation within the TPD, were examined using a segmented regression analysis of a pooled three-country data set from 1998 to 2015 (n = 243,111). The analysis examined whether or not any changes in trend occurred after e-cigarettes began to grow in popularity from around 2011, but prior to their regulation. Analyses of change in trend for smoking following TPD and associated tobacco regulations extended these analyses to 2019 (n = 359,111), with 2016 modelled as the intervention point. For the process evaluation, qualitative interviews were conducted with 76 young people aged 14–15 years during the transitional phase, and 148 young people after full implementation in 2018. Interviews with 12 policy stakeholders, 13 TSOs and 27 e-cigarette retailers were conducted at a single point approximately a year after the date for full compliance. Observations of retail premises were conducted during and after the transitional phase for implementation of TPD regulations. Data were synthesised using an evaluation and integration framework based on Medical Research Council guidance for process evaluation, with data sources organised and presented chronologically to understand context prior to TPD, how this changed following implementation and finally, changes in young people’s e-cigarette use and smoking. Hence, presentation of results with data on the context into which TPD was fully introduced (i.e. pre-implementation trends in smoking and young people’s perceptions of vaping), followed by data from policy stakeholders, TSOs and retailers on implementation of legislation, before presenting data on mechanisms of change and post-legislation e-cigarette use and smoking outcomes. Results Segmented regression analyses of smoking trends between 1998 and 2015 indicated no significant changes in trend for ever smoking during the period 2011–15 [post-slope odds ratio (OR) 1.01, 95% confidence interval (CI) 0.99 to 1.03]. There was a marginally significant slowing in decline for regular smoking (post-slope OR 1.04, 95% CI 1.00 to 1.08), and this was greatest among subgroups for whom the level of decline pre 2010 was greatest, and was not unique to tobacco, with slowing decline also observed for other substance use behaviours. Negative attitudes towards smoking continued to harden after 2011, and at a faster rate than pre-2011 trends (post-slope OR 0.88, 95% CI 0.86 to 0.90). In group interviews shortly before the end of the transitional phase for TPD, young people differentiated between e-cigarettes and tobacco, preferring labels such as vaping, which removed association with cigarettes. Although smoking was strongly disapproved of, e-cigarette approval was more nuanced. Regular use was described as something smokers do. Young people described little interest in, or awareness of, whether or not products contained nicotine, with device characteristics, like flavours or the ability to do tricks at parties, described as more significant drivers of experimentation. Qualitative interviews with policy stakeholders and TSOs following implementation of TPD indicated mixed views about the extent to which e-cigarette regulation was supported. Stakeholders expressed simultaneously positive views of the role of e-cigarettes for smoking cessation, and some anxieties surrounding potential renormalisation and harms from e-cigarette use among young people. Marketing restrictions were largely seen as appropriate, and regulations were described by stakeholders as having been well implemented, despite challenges in communications. However, some aspects of regulation of the products themselves were seen as needing to be further refined. In interviews with retailers, some retailers argued that although some regulation was needed to prevent use by young people, regulating e-cigarettes as if they are tobacco products may lead to their being perceived as similar in terms of their health risks. In common with a positioning as separate from tobacco, specialist retailers expressed antipathy towards the tobacco industry and emphasised their role as helping people to quit smoking. Observations indicated that, during the transitional phase, implementation remained mixed, with retailers continuing to sell-off non-compliant old stock, but by the full compliance date all retailers observed were selling compliant products. Follow-up qualitative interviews with young people indicated continued tendency to distinguish between cigarettes and e-cigarettes. However, e-cigarette use was increasingly described as a fad that had begun to run its course. Although in qualitative interviews young people described little exposure to advertising, in surveys after implementation most young people reported seeing at least one form of advertising in the past month. Young people described limited interaction with components of TPD, such as device labelling, having often not seen devices inside their packets. Survey data from Wales indicated a growing tendency for young people to view e-cigarettes as being as risky as tobacco. Our primary statistical analysis of change in ever e-cigarette use following the implementation of TPD indicated that in Wales, the growth prior to TPD had plateaued or declined following implementation. Prior monthly growth in the odds of ever e-cigarette use had stalled around the time of TPD implementation, with evidence of a negative change in trend thereafter (OR 0.96, 95% CI 0.95 to 0.97). Change in trend was significant in only long-term analysis, although OR were of similar magnitude in short- (to 2017) and long-term (to 2019) analyses. Data from England and Scotland exhibited a similar pattern of rapid growth in experimentation prior to TPD regulations, with little or no increase thereafter. In all countries, the secondary outcome of regular e-cigarette use exhibited this similar pattern of growth prior to TPD regulations, with flattening or a slight decline thereafter. Regular use of e-cigarettes remained at ≤1% among never smokers throughout. Post TPD regulations, however, declines in young people’s smoking uptake followed the opposite change in trend to e-cigarettes. A significant positive change in trend for both ever (OR 1.09, 95% CI 1.06 to 1.11) and regular smoking (OR 1.13, 95% CI 1.09 to 1.18) indicated that as growth in e-cigarette use stalled so too did the decline in tobacco use. This was driven, in particular, by data from Wales and Scotland where estimates remained unchanged between the most recent surveys, with surveys in England still providing some indication of continued decline in young people’s smoking. Change in trend was also observed for other substances, indicating a broader social trend in slowing of decline in adolescent risk behaviours beyond smoking specifically, with stalling decline in ever tobacco use lagging behind the stalling decline for ever use of other substances. Conclusions Our primary aim was to understand the effects of TPD regulations on young people’s use of e-cigarettes. To achieve this, we first explored the context of young people’s smoking and e-cigarette use prior to the TPD regulations, during the implementation of TPD, and the mechanisms and outcomes that followed from implementation. The study provides limited evidence that e-cigarettes were renormalising smoking prior to the TPD regulations, although some forms of e-cigarette use itself appeared to be becoming normalised. Although stakeholders reported a range of perceptions of the TPD regulations, they were well implemented. Young people’s use of e-cigarettes peaked around the time of TPD implementation, with evidence that this became flat or declined across the nations of Great Britain. The disruption of the secular growth in e-cigarette use following TPD is consistent with an effect of the regulations, although caution is needed in causal attributions because of the observational nature of the study. Further support for a conclusion that this may be a causal effect is, however, provided by comparison to external data sources, which indicate that in other less-regulated environments, such as the USA, young people’s use of e-cigarettes continued to grow during the period where it appeared to peak in the UK. Although smoking continued to decline during the growth of e-cigarette use, there is evidence within more recent data sets that this decline has begun to stall. Recommendations for future research include the following: •Continued collection of survey data to monitor population trends in young people’s tobacco and e-cigarette use remain important. •Harmonised international data sets may be particularly valuable in enabling changes following new policies to be compared with an external comparator. •Although young people’s use of e-cigarettes was no longer growing, experimentation was still high at our latest measurements points, and understanding whether or not this diminishes, or further intervention is warranted, is important. •As regulation has diverged, international comparative research on variation in use trajectories according to differences in regulatory environment offers an opportunity to provide nuanced insights into optimal regulatory measures for limiting young people’s use of e-cigarettes, while maximising benefits for smoking cessation. •There are high levels of confusion among young people on harms of e-cigarettes relative to smoking. Research could seek to better understand how to reinforce the role of e-cigarettes as cessation devices, while discouraging use among non-smokers and acknowledging remaining ambiguity about long-term harms. •Further understanding how young people interact with e-cigarettes via the internet, including via social media platforms, is an important area for further research. •Although much has been achieved in reducing young people’s use of tobacco, there is some evidence that this progress may be beginning to stall. Further research is needed to reach the minority of young people who continue to take up smoking in contemporary society. 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.

Background: Research consistently finds poorer health and educational outcomes for children who have experienced out-of-home care relative to the general population. Few studies have explored differences between those in care and those in receipt of intervention from social services but not in care. Children receiving social services interventions often experience Adverse Childhood Experiences (ACEs), and deprivation, which are known to negatively impact outcomes. We aimed to estimate the association of different social services interventions with educational outcomes and hospital admissions, while adjusting for ACEs and deprivation., Methods: We linked retrospective, routinely collected administrative records from health, education, and social care to create a cohort via the Secure Anonymised Information Linkage (SAIL) databank in Wales, UK. We analysed data for children and household members (N = 30,439) across four different groups: [1] no social care intervention; [2] children in need but not in care (CIN); [3] children on the Child Protection Register but not in care (CPR); [4] children in care - i.e. removed from the family home and looked after by the local authority (CLA). Our primary outcome was education outcomes at age 16 years. Secondary outcomes were all cause emergency hospital admissions, and emergency admissions for external causes/injuries., Results: Children in receipt of social services intervention were more likely to not attain the expected level upon leaving statutory education at age 16 after adjusting for ACEs and other characteristics (for children who had been in out-of-home care (conditional OR: 1·76, (95%CI) 1·25 - 2·48), in need (2·51, 2·00-3·15) and those at risk (i.e., on the child protection register) (4·04, 2·44 - 6·68). For all-cause emergency admissions, all social care groups were at greater risk compared to children in the general population (children in care (conditional HR: 1·31, 1·01-1·68), children in need (1·62, 1·38 - 1·90), and children at risk (1·51, 1·11 - 2·04)., Conclusions: All groups receiving social service intervention experience poorer educational and health outcomes than peers in the general population. Children who remain with their home parents or caregivers but are identified as 'in need' or 'at risk' by social care practitioners require further research. Integrated support is needed from multiple sectors, including health, educational and social care., (© 2024. The Author(s).)

Objective: This study aims to create a national ethnicity spine based on all available ethnicity records in linkable anonymised electronic health record and administrative data sources., Design: A longitudinal study using anonymised individual-level population-scale ethnicity data from 26 data sources available within the Secure Anonymised Information Linkage Databank., Setting: The national ethnicity spine is created based on longitudinal national data for the population of Wales-UK over 22 years (between 2000 and 2021)., Procedure and Participants: A total of 46 million ethnicity records for 4 297 694 individuals have been extracted, harmonised, deduplicated and made available within a longitudinal research ready data asset., Outcome Measures: (1) Comparing the distribution of ethnicity records over time for four different selection approaches (latest, mode, weighted mode and composite) across age bands, sex, deprivation quintiles, health board and residential location and (2) distribution and completeness of records against the ONS census 2011., Results: The distribution of the dominant group (white) is minimally affected based on the four different selection approaches. Across all other ethnic group categorisations, the mixed group was most susceptible to variation in distribution depending on the selection approach used and varied from a 0.6% prevalence across the latest and mode approach to a 1.1% prevalence for the weighted mode, compared with the 3.1% prevalence for the composite approach. Substantial alignment was observed with ONS 2011 census with the Latest group method (kappa=0.68, 95% CI (0.67 to 0.71)) across all subgroups. The record completeness rate was over 95% in 2021., Conclusion: In conclusion, our development of the population-scale ethnicity spine provides robust ethnicity measures for healthcare research in Wales and a template which can easily be deployed in other trusted research environments in the UK and beyond., Competing Interests: Competing interests: KK is Director of the University Centre for Ethnic Health Research, Trustee of the South Asian Health Foundation, Chair of the Ethnicity subgroup of the UK Scientific Advisory Group for Emergencies (SAGE) and member of SAGE. RL is a member of the Welsh Government COVID-19 Technical Advisory Group. RKO is a member of the National Institute for Health and Care Excellence (NICE) Technology Appraisal Committee, a member of the NICE Decision Support Unit (DSU) and an associate member of the NICE Technical Support Unit (TSU). She has provided unrelated methodological advice as a paid consultant to the pharmaceutical industry. She reports teaching fees from the Association of British Pharmaceutical Industry (ABPI) and the University of Bristol., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

SARS-CoV-2 infection in children and young people (CYP) can lead to life-threatening COVID-19, transmission within households and schools, and the development of long COVID. Using linked health and administrative data, we investigated vaccine uptake among 3,433,483 CYP aged 5-17 years across all UK nations between 4th August 2021 and 31st May 2022. We constructed national cohorts and undertook multi-state modelling and meta-analysis to identify associations between demographic variables and vaccine uptake. We found that uptake of the first COVID-19 vaccine among CYP was low across all four nations compared to other age groups and diminished with subsequent doses. Age and vaccination status of adults living in the same household were identified as important risk factors associated with vaccine uptake in CYP. For example, 5-11 year-olds were less likely to receive their first vaccine compared to 16-17 year-olds (adjusted Hazard Ratio [aHR]: 0.10 (95%CI: 0.06-0.19)), and CYP in unvaccinated households were less likely to receive their first vaccine compared to CYP in partially vaccinated households (aHR: 0.19, 95%CI 0.13-0.29)., (© 2024. The Author(s).)

Introduction: Research has investigated the association between time spent online and mental well-being, however the nuances between specific online behaviors and well-being have been less explored. This research examines how specific online behaviors (i.e., how young people are engaging online and with whom), are associated with one another, and how these patterns of behaviors are related to well-being., Methods: We used the November 2020 and March 2021 Understanding Society COVID-19 Panel data. The sample consisted of 1432 adolescents aged 10-15 years, who participated in November 2020. Latent class analysis was used to explore patterns of online behaviors. We also investigated how sociodemographic characteristics differed across the classes, along with physical, social, and mental well-being as distal outcomes both cross-sectionally and longitudinally., Results: We identified four classes: "Avid users," "Scholars," "Midways," and the "Passengers." The avid users had the highest frequency of posting online content regularly, likewise the scholars also posted online content regularly, however the scholars were differentiated by their higher frequency of schoolwork and news intake online. The midways had more complex activity characterized by talking to friends often and having a social media account, but posted online content less frequently. The passengers were the least active online as they posted pictures and videos less (76% said "never") and only 63% had a social media account. The avid users had the lowest well-being cross-sectionally and longitudinally, and the midways had lower social well-being and appearance dissatisfaction., Conclusions: Online behaviors such as regularly posting or talking to internet-only friends could be related to lower well-being. Policymakers should consider both improving regulations online and building an evidence base to enable caregivers from all backgrounds to support young people., (© 2023 The Authors. Journal of Adolescence published by Wiley Periodicals LLC on behalf of Foundation for Professionals in Services to Adolescents.)

Objectives: We investigated SARS-CoV-2 infection trends, risk of SARS-CoV-2 infection and COVID-19 vaccination uptake among school staff, students and their household members in Wales, UK., Design: Seven-day average of SARS-CoV-2 infections and polymerase chain reaction tests per 1000 people daily, cumulative incidence of COVID-19 vaccination uptake and multi-level Poisson models with time-varying covariates., Setting: National electronic cohort between September 2020 and May 2022 when several variants were predominant in the UK (Alpha, Delta and Omicron)., Participants: School students aged 4 to 10/11 years (primary school and younger middle school, n  = 238,163), and 11 to 15/16 years (secondary school and older middle school, n  = 182,775), school staff in Wales ( n  = 47,963) and the household members of students and staff ( n  = 697,659)., Main Outcome Measures: SARS-CoV-2 infection and COVID-19 vaccination uptake., Results: School students had a sustained period of high infection rates compared with household members after August 2021. Primary schedule vaccination uptake was highest among staff (96.3%) but lower for household members (72.2%), secondary and older middle school students (59.8%), and primary and younger middle school students (3.3%). Multi-level Poisson models showed that vaccination was associated with a lower risk of SARS-CoV-2 infection. The Delta variant posed a greater infection risk for students than the Alpha variant. However, Omicron was a larger risk for staff and household members., Conclusions: Public health bodies should be informed of the protection COVID-19 vaccines afford, with more research being required for younger populations. Furthermore, schools require additional support in managing new, highly transmissible variants. Further research should examine the mechanisms between child deprivation and SARS-CoV-2 infection.

Transactional theory and the coercive family process model have illustrated how the parent-child relationship is reciprocal. Emerging research using advanced statistical methods has examined these theories, but further investigations are necessary. In this study, we utilised linked health data on maternal mental health disorders and explored their relationship with child problem behaviours via the Strengths and Difficulties Questionnaire for over 13 years. We accessed data from the Millennium Cohort Study, linked to anonymised individual-level population-scale health and administrative data within the Secure Anonymised Information Linkage (SAIL) Databank. We used Bayesian Structural Equation Modelling, specifically Random-Intercept Cross-Lagged Panel Models, to analyse the relationships between mothers and their children. We then explored these models with the addition of time-invariant covariates. We found that a mother's mental health was strongly associated over time, as were children's problem behaviours. We found mixed evidence for bi-directional relationships, with only emotional problems showing bi-directional associations in mid to late childhood. Only child-to-mother pathways were identified for the overall problem behaviour score and peer problems; no associations were found for conduct problems or hyperactivity. All models had strong between-effects and clear socioeconomic and sex differences. We encourage the use of whole family-based support for mental health and problem behaviours, and recommend that socioeconomic, sex and wider differences should be considered as factors in tailoring family-based interventions and support., (© 2023. The Author(s).)

Background: Socioeconomic differences in the impact of alcohol consumption on health have been consistently reported in the so-called "alcohol harm paradox" (i.e., individuals from higher socioeconomic backgrounds (SES) drink more alcohol than individuals from lower SES, but the latter accrue more alcohol-related harm). Despite the severe health risks of smoking however, there is a scarcity of studies examining a possible "smoking harm paradox" (SHP). We aim to fill this gap., Methods: We conducted a prospective cohort study with adolescents from the Norwegian Longitudinal Health Behaviour Study (NLHB). Our study used data from ages 13 to 30 years. To analyse our data, we used the random-intercept cross-lagged panel model (RI-CLPM) with smoking and self-reported health as mutual lagged predictors and outcomes as well as parental income and education as grouping variables. Parental income and education were used as proxies for adolescent socioeconomic status (SES). Smoking was examined through frequency of smoking (every day, every week, less than once a week, not at all). General health compared to others was measured by self-report., Results: Overall, we found inconclusive evidence of the smoking harm paradox, as not all effects from smoking to self-reported health were moderated by SES. Nevertheless, the findings do suggest that smoking predicted worse subjective health over time among individuals in the lower parental education group compared with those in the higher parental education group. This pattern was not found for parental income., Conclusions: While our results suggest limited evidence for a smoking harm paradox (SHP), they also suggest that the impact of adolescent smoking on later subjective health is significant for individuals with low parental education but not individuals with high parental education. This effect was not found for parental income, highlighting the potential influence of parental education over income as a determinant of subjective health outcomes in relation to smoking., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: From September 2021, Health Care Workers (HCWs) in Wales began receiving a COVID-19 booster vaccination. This is the first dose beyond the primary vaccination schedule. Given the emergence of new variants, vaccine waning vaccine, and increasing vaccination hesitancy, there is a need to understand booster vaccine uptake and subsequent breakthrough in this high-risk population., Methods: We conducted a prospective, national-scale, observational cohort study of HCWs in Wales using anonymised, linked data from the SAIL Databank. We analysed uptake of COVID-19 booster vaccinations from September 2021 to February 2022, with comparisons against uptake of the initial primary vaccination schedule. We also analysed booster breakthrough, in the form of PCR-confirmed SARS-Cov-2 infection, comparing to the second primary dose. Cox proportional hazard models were used to estimate associations for vaccination uptake and breakthrough regarding staff roles, socio-demographics, household composition, and other factors., Results: We derived a cohort of 73,030 HCWs living in Wales (78% female, 60% 18-49 years old). Uptake was quickest amongst HCWs aged 60 + years old (aHR 2.54, 95%CI 2.45-2.63), compared with those aged 18-29. Asian HCWs had quicker uptake (aHR 1.18, 95%CI 1.14-1.22), whilst Black HCWs had slower uptake (aHR 0.67, 95%CI 0.61-0.74), compared to white HCWs. HCWs residing in the least deprived areas were slightly quicker to have received a booster dose (aHR 1.12, 95%CI 1.09-1.16), compared with those in the most deprived areas. Strongest associations with breakthrough infections were found for those living with children (aHR 1.52, 95%CI 1.41-1.63), compared to two-adult only households. HCWs aged 60 + years old were less likely to get breakthrough infections, compared to those aged 18-29 (aHR 0.42, 95%CI 0.38-0.47)., Conclusion: Vaccination uptake was consistently lower among black HCWs, as well as those from deprived areas. Whilst breakthrough infections were highest in households with children., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Several SARS-CoV-2 vaccines have been shown to provide protection against COVID-19 hospitalization and death. However, some evidence suggests that notable waning in effectiveness against these outcomes occurs within months of vaccination. We undertook a pooled analysis across the four nations of the UK to investigate waning in vaccine effectiveness (VE) and relative vaccine effectiveness (rVE) against severe COVID-19 outcomes., Methods: We carried out a target trial design for first/second doses of ChAdOx1(Oxford-AstraZeneca) and BNT162b2 (Pfizer-BioNTech) with a composite outcome of COVID-19 hospitalization or death over the period 8 December 2020 to 30 June 2021. Exposure groups were matched by age, local authority area and propensity for vaccination. We pooled event counts across the four UK nations., Results: For Doses 1 and 2 of ChAdOx1 and Dose 1 of BNT162b2, VE/rVE reached zero by approximately Days 60-80 and then went negative. By Day 70, VE/rVE was -25% (95% CI: -80 to 14) and 10% (95% CI: -32 to 39) for Doses 1 and 2 of ChAdOx1, respectively, and 42% (95% CI: 9 to 64) and 53% (95% CI: 26 to 70) for Doses 1 and 2 of BNT162b2, respectively. rVE for Dose 2 of BNT162b2 remained above zero throughout and reached 46% (95% CI: 13 to 67) after 98 days of follow-up., Conclusions: We found strong evidence of waning in VE/rVE for Doses 1 and 2 of ChAdOx1, as well as Dose 1 of BNT162b2. This evidence may be used to inform policies on timings of additional doses of vaccine., (© The Author(s) 2022. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Background: The CVD-COVID-UK consortium was formed to understand the relationship between COVID-19 and cardiovascular diseases through analyses of harmonised electronic health records (EHRs) across the four UK nations. Beyond COVID-19, data harmonisation and common approaches enable analysis within and across independent Trusted Research Environments. Here we describe the reproducible harmonisation method developed using large-scale EHRs in Wales to accommodate the fast and efficient implementation of cross-nation analysis in England and Wales as part of the CVD-COVID-UK programme. We characterise current challenges and share lessons learnt., Methods: Serving the scope and scalability of multiple study protocols, we used linked, anonymised individual-level EHR, demographic and administrative data held within the SAIL Databank for the population of Wales. The harmonisation method was implemented as a four-layer reproducible process, starting from raw data in the first layer. Then each of the layers two to four is framed by, but not limited to, the characterised challenges and lessons learnt. We achieved curated data as part of our second layer, followed by extracting phenotyped data in the third layer. We captured any project-specific requirements in the fourth layer., Results: Using the implemented four-layer harmonisation method, we retrieved approximately 100 health-related variables for the 3.2 million individuals in Wales, which are harmonised with corresponding variables for > 56 million individuals in England. We processed 13 data sources into the first layer of our harmonisation method: five of these are updated daily or weekly, and the rest at various frequencies providing sufficient data flow updates for frequent capturing of up-to-date demographic, administrative and clinical information., Conclusions: We implemented an efficient, transparent, scalable, and reproducible harmonisation method that enables multi-nation collaborative research. With a current focus on COVID-19 and its relationship with cardiovascular outcomes, the harmonised data has supported a wide range of research activities across the UK., (© 2023. The Author(s).)

There is a need for better understanding of the risk of thrombocytopenic, haemorrhagic, thromboembolic disorders following first, second and booster vaccination doses and testing positive for SARS-CoV-2. Self-controlled cases series analysis of 2.1 million linked patient records in Wales between 7th December 2020 and 31st December 2021. Outcomes were the first diagnosis of thrombocytopenic, haemorrhagic and thromboembolic events in primary or secondary care datasets, exposure was defined as 0-28 days post-vaccination or a positive reverse transcription polymerase chain reaction test for SARS-CoV-2. 36,136 individuals experienced either a thrombocytopenic, haemorrhagic or thromboembolic event during the study period. Relative to baseline, our observations show greater risk of outcomes in the periods post-first dose of BNT162b2 for haemorrhagic (IRR 1.47, 95%CI: 1.04-2.08) and idiopathic thrombocytopenic purpura (IRR 2.80, 95%CI: 1.21-6.49) events; post-second dose of ChAdOx1 for arterial thrombosis (IRR 1.14, 95%CI: 1.01-1.29); post-booster greater risk of venous thromboembolic (VTE) (IRR-Moderna 3.62, 95%CI: 0.99-13.17) (IRR-BNT162b2 1.39, 95%CI: 1.04-1.87) and arterial thrombosis (IRR-Moderna 3.14, 95%CI: 1.14-8.64) (IRR-BNT162b2 1.34, 95%CI: 1.15-1.58). Similarly, post SARS-CoV-2 infection the risk was increased for haemorrhagic (IRR 1.49, 95%CI: 1.15-1.92), VTE (IRR 5.63, 95%CI: 4.91, 6.4), arterial thrombosis (IRR 2.46, 95%CI: 2.22-2.71). We found that there was a measurable risk of thrombocytopenic, haemorrhagic, thromboembolic events after COVID-19 vaccination and infection., (© 2022. The Author(s).)

Objectives: Examine if pre-COVID-19 pandemic (prior March 2020) health-related behaviours during primary school are associated with (1) being tested for SARS-CoV-2 and (2) testing positive between 1 March 2020 and 31 August 2021., Design: Retrospective cohort study using an online cohort survey (January 2018 to February 2020) linked with routine PCR SARS-CoV-2 test results., Setting: Children attending primary schools in Wales (2018-2020), UK, who were part of the Health and Attainment of Pupils in a Primary Education Network (HAPPEN)_school network., Participants: Complete linked records of eligible participants were obtained for n=7062 individuals. 39.1% (n=2764) were tested (age 10.6±0.9; 48.9% girls) and 8.1% (n=569) tested positive for SARS-CoV-2 (age 10.6±1.0; 54.5% girls)., Main Outcome Measures: Logistic regression of health-related behaviours and demographics were used to determine the ORs of factors associated with (1) being tested for SARS-CoV-2 and (2) testing positive for SARS-CoV-2., Results: Consuming sugary snacks (1-2 days/week OR=1.24, 95% CI 1.04 to 1.49; 5-6 days/week OR=1.31, 95% CI 1.07 to 1.61; reference 0 days), can swim 25 m (OR=1.21, 95% CI 1.06 to 1.39) and age (OR=1.25, 95% CI 1.16 to 1.35) were associated with an increased likelihood of being tested for SARS-CoV-2. Eating breakfast (OR=1.52, 95% CI 1.01 to 2.27), weekly physical activity ≥60 min (1-2 days OR=1.69, 95% CI 1.04 to 2.74; 3-4 days OR=1.76, 95% CI 1.10 to 2.82; reference 0 days), out-of-school club participation (OR=1.06, 95% CI 1.02 to 1.10), can ride a bike (OR=1.39, 95% CI 1.00 to 1.93), age (OR=1.16, 95% CI 1.05 to 1.28) and girls (OR=1.21, 95% CI 1.00 to 1.46) were associated with an increased likelihood of testing positive for SARS-CoV-2. Living in least deprived areas (quintile 4 OR=0.64, 95% CI 0.46 to 0.90; quintile 5 OR=0.64, 95% CI 0.46 to 0.89) compared with the most deprived (quintile 1) was associated with a decreased likelihood., Conclusions: Associations may be related to parental health literacy and monitoring behaviours. Physically active behaviours may include coparticipation with others and exposure to SARS-CoV-2. A risk-versus-benefit approach must be considered in relation to promoting these health behaviours, given the importance of health-related behaviours such as childhood physical activity for development., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Coronavirus disease 2019 (COVID-19) has disproportionately affected people with mental health conditions., Aims: We investigated the association between receiving psychotropic drugs, as an indicator of mental health conditions, and COVID-19 vaccine uptake., Method: We conducted a cross-sectional analysis of a prospective cohort of the Northern Ireland adult population using national linked primary care registration, vaccination, secondary care and pharmacy dispensing data. Univariable and multivariable logistic regression analyses investigated the association between anxiolytic, antidepressant, antipsychotic, and hypnotic use and COVID-19 vaccination status, accounting for age, gender, deprivation and comorbidities. Receiving any COVID-19 vaccine was the primary outcome., Results: There were 1 433 814 individuals, of whom 1 166 917 received a COVID-19 vaccination. Psychotropic medications were dispensed to 267 049 people. In univariable analysis, people who received any psychotropic medication had greater odds of receiving COVID-19 vaccination: odds ratio (OR) = 1.42 (95% CI 1.41-1.44). However, after adjustment, psychotropic medication use was associated with reduced odds of vaccination (OR adj = 0.90, 95% CI 0.89-0.91). People who received anxiolytics (OR adj = 0.63, 95% CI 0.61-0.65), antipsychotics (OR adj = 0.75, 95% CI 0.73-0.78) and hypnotics (OR adj = 0.90, 95% CI 0.87-0.93) had reduced odds of being vaccinated. Antidepressant use was not associated with vaccination (OR adj = 1.02, 95% CI 1.00-1.03)., Conclusions: We found significantly lower odds of vaccination in people who were receiving treatment with anxiolytic and antipsychotic medications. There is an urgent need for evidence-based, tailored vaccine support for people with mental health conditions.

Background: Several countries restricted the administration of ChAdOx1 to older age groups in 2021 over safety concerns following case reports and observed versus expected analyses suggesting a possible association with cerebral venous sinus thrombosis (CVST). Large datasets are required to precisely estimate the association between Coronavirus Disease 2019 (COVID-19) vaccination and CVST due to the extreme rarity of this event. We aimed to accomplish this by combining national data from England, Scotland, and Wales., Methods and Findings: We created data platforms consisting of linked primary care, secondary care, mortality, and virological testing data in each of England, Scotland, and Wales, with a combined cohort of 11,637,157 people and 6,808,293 person years of follow-up. The cohort start date was December 8, 2020, and the end date was June 30, 2021. The outcome measure we examined was incident CVST events recorded in either primary or secondary care records. We carried out a self-controlled case series (SCCS) analysis of this outcome following first dose vaccination with ChAdOx1 and BNT162b2. The observation period consisted of an initial 90-day reference period, followed by a 2-week prerisk period directly prior to vaccination, and a 4-week risk period following vaccination. Counts of CVST cases from each country were tallied, then expanded into a full dataset with 1 row for each individual and observation time period. There was a combined total of 201 incident CVST events in the cohorts (29.5 per million person years). There were 81 CVST events in the observation period among those who a received first dose of ChAdOx1 (approximately 16.34 per million doses) and 40 for those who received a first dose of BNT162b2 (approximately 12.60 per million doses). We fitted conditional Poisson models to estimate incidence rate ratios (IRRs). Vaccination with ChAdOx1 was associated with an elevated risk of incident CVST events in the 28 days following vaccination, IRR = 1.93 (95% confidence interval (CI) 1.20 to 3.11). We did not find an association between BNT162b2 and CVST in the 28 days following vaccination, IRR = 0.78 (95% CI 0.34 to 1.77). Our study had some limitations. The SCCS study design implicitly controls for variables that are constant over the observation period, but also assumes that outcome events are independent of exposure. This assumption may not be satisfied in the case of CVST, firstly because it is a serious adverse event, and secondly because the vaccination programme in the United Kingdom prioritised the clinically extremely vulnerable and those with underlying health conditions, which may have caused a selection effect for individuals more prone to CVST. Although we pooled data from several large datasets, there was still a low number of events, which may have caused imprecision in our estimates., Conclusions: In this study, we observed a small elevated risk of CVST events following vaccination with ChAdOx1, but not BNT162b2. Our analysis pooled information from large datasets from England, Scotland, and Wales. This evidence may be useful in risk-benefit analyses of vaccine policies and in providing quantification of risks associated with vaccination to the general public., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests. AS is a member of the Scottish Government Chief Medical Officer’s COVID-19 Advisory Group and the New and Emerging Respiratory Virus Threats (NERVTAG) Risk Stratification Subgroup and AstraZeneca’s COVID-19 Thrombocytopenia Taskforce; all roles are remunerated to AS or his institution. AS and SS are members of the editorial board of PLOS Medicine. CRS declares funding from the MRC, NIHR, CSO and New Zealand Ministry for Business, Innovation and Employment and Health Research Council during the conduct of this study. SVK is co-chair of the Scottish Government’s Expert Reference Group on COVID-19 and ethnicity, is a member of the Scientific Advisory Group on Emergencies (SAGE) subgroup on ethnicity and acknowledges funding from a NRS Senior Clinical Fellowship, MRC and CSO. CR is a member of the Scottish Government Chief Medical Officer’s COVID-19 Advisory Group, SPI-M, MHRA Vaccine Benefit and Risk Working Group. HRS is an advisor to the Scottish Parliament’s COVID-19 Committee. RKO is a member of the National Institute for Health and Care Excellence (NICE) Technology Appraisal Committee. DB is employed by Queen’s University Belfast, the Public Health Agency and the Department of Health (Northern Ireland). DB is a member of several Northern Ireland and UK government COVID-19 advisory boards, including the Scientific Pandemic Influenza Group on Modelling and the UK Vaccine Effectiveness Expert Panel, and has represented Northern Ireland on the UK Scientific Advisory Group for Emergencies and its subgroups. SdeL through his University holds grants from AstraZeneca, Eli-Lilly, GSK, MSD, Sanofi and Seqirus. He has been advisory board members for Astra Zeneca, Sanofi and Seqirus. MW is a member of UK government COVID-19 advisory group, SPI-M, and a member of Scottish Government COVID-19 Advisory Group. All other authors report no conflicts of interest.

Background: While population estimates suggest high vaccine effectiveness against SARS-CoV-2 infection, the protection for health care workers, who are at higher risk of SARS-CoV-2 exposure, is less understood., Methods: We conducted a national cohort study of health care workers in Wales (UK) from 7 December 2020 to 30 September 2021. We examined uptake of any COVID-19 vaccine, and the effectiveness of BNT162b2 mRNA (Pfizer-BioNTech) against polymerase chain reaction (PCR) confirmed SARS-CoV-2 infection. We used linked and routinely collected national-scale data within the SAIL Databank. Data were available on 82,959 health care workers in Wales, with exposure extending to 26 weeks after second doses., Results: Overall vaccine uptake was high (90%), with most health care workers receiving theBNT162b2 vaccine (79%). Vaccine uptake differed by age, staff role, socioeconomic status; those aged 50-59 and 60+ years old were 1.6 times more likely to get vaccinated than those aged 16-29. Medical and dental staff, and Allied Health Practitioners were 1.5 and 1.1 times more likely to get vaccinated, compared to nursing and midwifery staff. The effectiveness of the BNT162b2 vaccine was found to be strong and consistent across the characteristics considered; 52% three to six weeks after first dose, 86% from two weeks after second dose, though this declined to 53% from 22 weeks after the second dose., Conclusions: With some variation in rate of uptake, those who were vaccinated had a reduced risk of PCR-confirmed SARS-CoV-2 infection, compared to those unvaccinated. Second dose has provided stronger protection for longer than first dose but our study is consistent with waning from seven weeks onwards., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: AS is a member of the Scottish Government Chief Medical Officer’s COVID-19 Advisory Group,the New and Emerging Respiratory Virus Threats (NERVTAG) Risk Stratification Subgroupand amember of AstraZeneca’s Thrombotic Thrombocytopenic Task Force; all roles are unremunerated.CR is a member of the Scottish Government Chief Medical Officer’s COVID-19 Advisory Group, the Scientific Pandemic Influenza Group on Modelling and the Medicines & Healthcare products RegulatoryAgency’s Vaccine Benefit and Risk Working Group.DTB is employed by the Public Health Agency, Northern Ireland, and the Department of Health, Northern Ireland.MP is employed by the Vaccine Preventable Disease Programme at Public Health Wales and is involved in the COVID-19 vaccine roll out for Wales.SVK is co-chair of the Scottish Government’s Expert Reference Group on COVID-19 andethnicity, is a member of the Scientific Advisory Group on Emergencies (SAGE) subgroup on ethnicity and acknowledges funding from a NRS Senior Clinical Fellowship, MRC and CSO.RF is a member of is a member of the Scientific Advisory Group on Emergencies (SAGE) Social Care Working Group (SCWG).RO is a member of the National Institute for Health and Care Excellence (NICE) Technology Appraisal Committee (TAC) and has provided methodological advice outside of the submitted work toCogentiaHealthcare Consulting Ltd, F. Hoffmann-La Roche Ltd,the National Institute for Health and Care Excellence (NICE) Decision Support Unit, the University of Bristol, and the Association of the British Pharmaceutical Industry (ABPI).RAL is a member of the Welsh Government COVID19 Technical Advisory Group.All other authors have declared no competinginterests., (Copyright © 2022. Published by Elsevier Ltd.)

Introduction: The novel coronavirus SARS-CoV-2, which emerged in December 2019, has caused millions of deaths and severe illness worldwide. Numerous vaccines are currently under development of which a few have now been authorised for population-level administration by several countries. As of 20 September 2021, over 48 million people have received their first vaccine dose and over 44 million people have received their second vaccine dose across the UK. We aim to assess the uptake rates, effectiveness, and safety of all currently approved COVID-19 vaccines in the UK., Methods and Analysis: We will use prospective cohort study designs to assess vaccine uptake, effectiveness and safety against clinical outcomes and deaths. Test-negative case-control study design will be used to assess vaccine effectiveness (VE) against laboratory confirmed SARS-CoV-2 infection. Self-controlled case series and retrospective cohort study designs will be carried out to assess vaccine safety against mild-to-moderate and severe adverse events, respectively. Individual-level pseudonymised data from primary care, secondary care, laboratory test and death records will be linked and analysed in secure research environments in each UK nation. Univariate and multivariate logistic regression models will be carried out to estimate vaccine uptake levels in relation to various population characteristics. VE estimates against laboratory confirmed SARS-CoV-2 infection will be generated using a generalised additive logistic model. Time-dependent Cox models will be used to estimate the VE against clinical outcomes and deaths. The safety of the vaccines will be assessed using logistic regression models with an offset for the length of the risk period. Where possible, data will be meta-analysed across the UK nations., Ethics and Dissemination: We obtained approvals from the National Research Ethics Service Committee, Southeast Scotland 02 (12/SS/0201), the Secure Anonymised Information Linkage independent Information Governance Review Panel project number 0911. Concerning English data, University of Oxford is compliant with the General Data Protection Regulation and the National Health Service (NHS) Digital Data Security and Protection Policy. This is an approved study (Integrated Research Application ID 301740, Health Research Authority (HRA) Research Ethics Committee 21/HRA/2786). The Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub meets NHS Digital's Data Security and Protection Toolkit requirements. In Northern Ireland, the project was approved by the Honest Broker Governance Board, project number 0064. Findings will be made available to national policy-makers, presented at conferences and published in peer-reviewed journals., Competing Interests: Competing interests: AS is a member of the Scottish Government Chief Medical Officer’s COVID-19 Advisory Group. RAL reports grants from MRC during the conduct of the study. SJS reports grants from Wellcome Trust, during the conduct of the study; grants from National Institute of Healthcare Research HTA, grants from Tommy's Charity and grants from Chief Scientist for Scotland, outside the submitted work. SdeL is Director of the Royal College of General Practitioners Research and Surveillance Centre. He has received grant funding through his University from AstraZeneca, Eli Lilly, GSK MSD, Seqirus and Takeda. He has been members of advisory boards for AstraZeneca, Sanofi, and Seqirus. DB is jointly employed by Queen’s University Belfast, the Public Health Agency and the Department of Health (Northern Ireland), and he is currently or has been a member of COVID-19 government advisory groups, including the Scientific Advisory Group for Emergencies (SAGE), its subgroups, and the UK Vaccine Effectiveness Expert Panel. All other authors report no conflicts of interest., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Parental substance use, that is alcohol and illicit drugs, can have a deleterious impact on child health and wellbeing. An area that can be affected by parental substance use is the educational outcomes of children. Current reviews of the literature in the field of parental substance use and children's educational outcomes have only identified a small number of studies, and most focus on children's educational attainment. To grasp the available literature, the method from Arksey and O'Malley (2005) was used to identify literature. Studies were included if they were empirical, after 1950, and focused on children's school or educational outcomes. From this, 51 empirical studies were identified which examined the relationship between parental alcohol and illicit drug use on children's educational outcomes. Five main themes emerged which included attainment, behavior and adjustment, attendance, school enjoyment and satisfaction, academic self-concept, along with other miscellaneous outcomes. This paper highlights the main findings of the studies, the gaps in the current literature, and the challenges presented. Recommendations are made for further research and interventions in the areas of parental substance use and child educational outcomes specifically, but also for broader areas of adversity and child wellbeing., Competing Interests: Conflicts of InterestEmily Lowthian has no relevant financial or non-financial interests to disclose., (© The Author(s) 2022.)

Purpose: Research demonstrates a strong socioeconomic gradient in health and well-being. However, many studies rely on unidimensional measures of socioeconomic status (SES) (e.g. educational qualifications, household income), and there is often a more limited consideration of how facets of SES combine to impact well-being. This paper develops a multidimensional measure of SES, drawing on family and school-level factors, to provide more nuanced understandings of socioeconomic patterns in adolescent substance use and mental well-being., Methods: Data from the Student Health and Wellbeing Survey from Wales, UK was employed. The sample compromised 22,372 students and we used latent class analysis to identify distinct groups using three measures of SES. These classes were then used to estimate mental well-being, internalizing symptoms, and substance use., Results: The five-class solution offered the best fit. Findings indicated distinct classes of families as follows: "nonworking," "deprived working families," "affluent families in deprived schools," "lower affluence," and "higher affluence." There was a clear relationship among the classes and mental well-being, internalizing symptoms, smoking, and cannabis use; alcohol was the exception to this., Conclusions: The identification of these classes led to a fuller understanding of the health and well-being effects of SES, showing clearer patterning in health behaviors that often is not captured in research. The implications for adolescent health and well-being are discussed, including considerations for future research., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Adverse childhood experiences (ACEs) are negatively associated with a range of child health outcomes. In this study, we explored associations between five individual ACEs and child mental health diagnoses or symptoms. ACEs included living with someone who had an alcohol-related problem, common mental health disorder or serious mental illness, or experienced victimisation or death of a household member., Methods: We analysed data from a population-level electronic cohort of children in Wales, UK, (N = 191,035) between the years of 1998 and 2012. We used Cox regression with discrete time-varying exposure variables to model time to child mental health diagnosis during the first 15 years of life. Child mental health diagnoses include five categories: (i) externalising symptoms (anti-social behaviour), (ii) internalising symptoms (stress, anxiety, depression), (iii) developmental delay (e.g. learning disability), (iv) other (e.g. eating disorder, personality disorders), and (v) any mental health diagnosis, which was created by combining externalising symptoms, internalising symptoms and other. Our analyses were adjusted for social deprivation and perinatal risk factors., Results: There were strong univariable associations between the five individual ACEs, sociodemographic and perinatal factors (e.g. gestational weight at birth) and an increased risk of child mental health diagnoses. After adjusting for sociodemographic and perinatal aspects, there was a remaining conditional increased risk of any child mental health diagnosis, associated with victimisation (conditional hazard ratio (cHR) 1.90, CI 95% 1.34-2.69), and living with an adult with a common mental health diagnosis (cHR 1.63, CI 95% 1.52-1.75). Coefficients of product terms between ACEs and deprivation were not statistically significant., Conclusion: The increased risk of child mental health diagnosis associated with victimisation, or exposure to common mental health diagnoses, and alcohol problems in the household supports the need for policy measures and intervention strategies for children and their families., (© 2021. The Author(s).)

To date no study has examined time trends in adolescent consumption of sugar-sweetened beverages and energy drinks, or modelled change in inequalities over time. The present study aimed to fill this gap by identifying historical trends among secondary school students in Wales, United Kingdom. The present study includes 11-16 year olds who completed the Health Behaviour in School-aged Children (HBSC) survey and the Welsh School Health Research Network (SHRN) survey between 1998 to 2017. Multinomial regression models were employed alongside tests for interaction effects. A total of 176,094 student responses were assessed. From 1998 to 2017, the prevalence of daily sugar-sweetened beverage consumption decreased (57% to 18%) while weekly consumption has remained constant since 2006 (49% to 52%). From 2013 to 2017, daily consumption of energy drinks remained stable (6%) while weekly consumption reports steadily decreased (23% to 15%). Boys, older children and those from a low socioeconomic group reported higher consumption rates of sugar-sweetened beverages and energy drinks. Consumption according to socioeconomic group was the only characteristic to show a statistically significant change over time, revealing a widening disparity between sugar-sweetened beverage consumption rates of those from low and high socioeconomic groups. Findings indicate a positive shift in overall consumption rates of both sugar-sweetened beverages and energy drinks. Adolescents from a low socioeconomic group however were consistently shown to report unfavourable sugar-sweetened beverages consumption when compared to peers from high socioeconomic group. Given the established longer term impacts of sugar-sweetened beverage and energy drink consumption on adolescent health outcomes, urgent policy action is required to reduce overall consumption rates, with close attention to equity of impact throughout policy design and evaluation plans., Competing Interests: The authors have declared that no competing interests exist.

(1) Background: This study examines the associations between risk behaviours and adolescent emotional and physical dating and relationship violence (DRV) victimisation and perpetration, and how these vary by gender. The risk behaviours explored include bullying, cyberbullying, sexting, alcohol, and cannabis use; (2) Methods: Cross-sectional self-report data from the School Health Research Network (SHRN) 2019 Student Health Wellbeing (SHW) survey of 48,397 students aged 11-16 from 149 schools across Wales were analysed using single and multiple-behaviour logistic regression models to explore the associations between each risk behaviour and emotional and physical DRV victimisation and perpetration; (3) Results: Bivariate analyses revealed a statistically significant association between DRV and all risk behaviours. In multivariate analyses, students who reported bullying, cyberbullying, sexting, and substance use, compared to those that had not, had significantly higher odds of experiencing and perpetrating emotional and physical DRV; and (4) Conclusions: Future studies on DRV should consider a mixed-methods approach to explore the context in which DRV and risk behaviours interrelate. Results from this study indicate the possibility that prevention and intervention programmes in school settings that seek to develop healthy school environments and peer-to-peer relationships, could inadvertently reduce the occurrence of future DRV and associated risk behaviours.

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., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Previous measures of parental substance use have often paid limited attention to the co-occurrence of alcohol and drugs, or to the between-parent dynamics in the use of substances. These shortcomings may have important implications for our understandings of the relationship between parental substance use and child wellbeing. Using data from the Avon Longitudinal Study of Parents and Children, a UK community-based cohort study from 1990 onwards (n = 9,451), we identified groups of parental substance use using latent class analysis. The 4-class solution offered the best fit, balancing statistical criteria and theoretical judgement. The results show distinct classes across the range of parental substance use, including very low users, low users, moderate users and heavy users. These classes suggest that substance use patterns among mothers are somewhat mirrored by those of their partners, while heavy use of alcohol by mothers and their partners is related to increased mothers drug use. We suggest that studies that investigate the effects of parental substance use on child wellbeing should pay greater attention to the dynamics of substance use by parental figures., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The effects of psychoactive substance abuse are not limited to the user, but extend to the entire family system, with children of substance abusers being particularly at risk. This meta-analysis attempted to quantify the longitudinal relationship between parental alcohol, tobacco, and drug use and child well-being, investigating variation across a range of substance and well-being indices and other potential moderators. We performed a literature search of peer-reviewed, English language, longitudinal observational studies that reported outcomes for children aged 0 to 18 years. In total, 56 studies, yielding 220 dependent effect sizes, met inclusion criteria. A multilevel random-effects model revealed a statistically significant, small detriment to child well-being for parental substance abuse over time (r = .15). Moderator analyses demonstrated that the effect was more pronounced for parental drug use (r = .25), compared with alcohol use (r = .13), tobacco use (r = .13), and alcohol use disorder (r = .14). Results highlight a need for future studies that better capture the effect of parental psychoactive substance abuse on the full breadth of childhood well-being outcomes and to integrate substance abuse into models that specify the precise conditions under which parental behavior determines child well-being.Registration: PROSPERO CRD42017076088.

Objectives: To examine whether during a period of limited e-cigarette regulation and rapid growth in their use, smoking began to become renormalised among young people., Design: Interrupted time-series analysis of repeated cross-sectional time-series data., Setting: Great Britain PARTICIPANTS: 248 324 young people aged approximately 13 and 15 years, from three national surveys during the years 1998-2015., Intervention: Unregulated growth of e-cigarette use (following the year 2010, until 2015)., Outcome Measures: Primary outcomes were prevalence of self-reported ever smoking and regular smoking. Secondary outcomes were attitudes towards smoking. Tertiary outcomes were ever use of cannabis and alcohol., Results: In final models, no significant change was detected in the pre-existing trend for ever smoking (OR 1.01, CI 0.99 to 1.03). There was a marginally significant slowing in the rate of decline for regular smoking (OR 1.04, CI 1.00 to 1.08), accompanied by a larger slowing in the rate of decline of cannabis use (OR 1.21, CI 1.18 to 1.25) and alcohol use (OR 1.17, CI 1.14 to 1.19). In all models and subgroup analyses for smoking attitudes, an increased rate of decline was observed after 2010 (OR 0.88, CI 0.86 to 0.90). Models were robust to sensitivity analyses., Conclusions: There was a marginal slowing in the decline in regular smoking during the period following 2010, when e-cigarettes were emerging but relatively unregulated. However, these patterns were not unique to tobacco use and the decline in the acceptability of smoking behaviour among youth accelerated during this time. These analyses provide little evidence that renormalisation of youth smoking was occurring during a period of rapid growth and limited regulation of e-cigarettes from 2011 to 2015., Trial Registration Number: Research registry number: researchregistry4336., Competing Interests: Competing interests: LB declares a secondment post with Cancer Research UK and all other authors report no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)