Prof Linda Bauld

Professor of Health Policy

University of Stirling

UKCTAS and Cancer Research UK

Are children using e-cigarettes?

Background

Public health concerns about children, young

people and e-cigarettes:

‘Gateway’ effect?

Marketing

Channels previously used for traditional cigarettes

Plus celebrity endorsements, online promotions and

social media

Growing number of e-cigarette product types, flavours

and product innovations

Investment in e-cigarette point-of-sale displays

‘Renormalisation’ of smoking?

Previous review

Review published by Public Health

England in May 2014

Identified 9 studies on use in

children (up to March 2014).

One UK study

In the studies we reviewed, with

the exception of one Polish survey,

ever use was reported by fewer

than one in ten children and was

concentrated in young people who

smoke

Update

Applied the same search

strategy in October 2014

to identify all published

peer-reviewed studies of

young people and e-

cigarettes

Also looked for ‘grey’

literature from the UK

We identified 23 new

studies/surveys, of

which 6 were grey

literature (i.e. not been or

unlikely to have been

peer-reviewed)

32 studies/surveys in all

These are English

language studies only.

Use in Great Britain

The only representative survey of young people

in the UK (GB only) is the work conducted by

YouGov for ASH in March 2013 and repeated

in March 2014

In 2013, 67% of 11-18 year olds had heard of

electronic cigarettes rising to 84% in 2014.

Of these, 5% had ever tried an e-cigarette in

2013 and 8% in 2014. Use was highly

concentrated in current smokers.

Which ONE of the following is closest to describing your experience of e-cigarettes?

Source: ASH (2014) YouGov survey, Base: All children aged 11 to 18 (2,068). Fieldwork dates: 21st

March to 1st April 2014

Don't want to say

I use them often (more than once a week)

I use them sometimes (more than once a month)

I have tried them once or twice

I have never used them

E-cigarette use by children in Great Britain

Not aware of e-cigarettes

Which comes first?

The GB survey asked

children about e-cig vs

tobacco cigarette

initiation

Source: ASH (2014) YouGov survey, Base: All children aged 11 to 18 who had heard of e-cigarettes

and tried them (n=157) Fieldwork dates: 21st March to 1st April 2014

I tried using an e-cigarette before I first tried smoking a real cigarette

I have never smoked a real cigarette but have tried an e-cigarette

I don't remember

I tried smoking a real cigarette before I first tried using an e-cigarette

What about other countries?

Data relating to ever use is available from 10

countries

Direct comparisons are very difficult with

published data because of:

Differences in age range (youngest in surveys=11,

oldest=19)

Differences in questions asked

Obtaining raw data from authors may allow for

some comparisons

Ever and current use

In surveys conducted between 2011 and 2014,

recorded ever use varied very significantly - from

5% to 62%

Amongst repeat cross sectional surveys there is a

consistent pattern of rising use between years

Except in one Polish study, rates of regular use

are much lower, commonly less than 10%.

Current use in never smokers also remains low

(the highest identified rate is 2%).

Survey comparisons

Some surveys reporting much lower levels of use amongst never smokers were excluded

from this table

Source: Dutra, K and Glanz, S (2014) High international electronic cigarette use among never

smoker adolescents, Journal of Adolescent Health, 595-597

E-cigarette/smoking by children: USA

Source: US CDC data from National Youth Tobacco Survey 2011 and 2012. Graph from Bates & Rodu

Repeat cross-sectional survey in Poland

Source: Goniewicz, M et al (2014) Rise in electronic cigarette use amongst adolescents in Poland, Journal of Adolescent Health, 55, 713-715

What about the ‘gateway’

Until we have reliable longitudinal data on

young people and e-cigarettes, theories about

these products being a ‘gateway’ to smoking are

just that – theories.

However we do need to recognise that a number

of young people in a range of countries are

exposed to nicotine for the first time by using an

e-cigarette.

Flavours

Concerns about E-liquid

flavours and youth appeal

have been raised

A number of studies and

consumer surveys have

looked at flavour preferences

in adult users.

As an example, a recent

survey of 800 vapers in

Germany, Austria and

Switzerland asked about

liquid flavour preferences. Source: PowerCigs (2014) www/powercigs-

shop.de. Online consumer survey October 2014.

Research Underway

Youth Tobacco Policy Survey (YTPS) funded by Cancer

Research UK

Monitors youth response to tobacco marketing and

tobacco control since 1999

2014, 7th wave

New e-cigarette questions

Survey is currently in the field

To develop questions we conducted 6 focus groups with

11-16 year olds in central Scotland (n=34) in April and

May 2014 (ethics approval and parental consent obtained).

Findings Initial discussions

E-cigarettes seen as a distinct product type but

Lack of terminology and language surrounding them

This poses problems for the survey

Knowledge often came from a

family member who had used

e-cigarettes to try to stop smoking

For adult smokers who

want to stop smoking

For situations where smoking prohibited

“at football games

you’re not allowed to

smoke real ones, you

see people with the

e-ones” (boy, 13-14)

“fake cigarettes”

“vapour stuff”

“electric type ones”

“adults”

“parents”

“people that smoke”

“Nobody young does

them”

Views on marketing

E-cigarette marketing

Some awareness of e-cig marketing but

Lack of engagement

Little brand awareness

Some. I’ve only heard it

once or twice, erm, a little

while ago, and it just says,

like I think there’s one

about nicotine as well (girl,

11-12) Sometimes you get like

adverts, is it SKYCIG or

something like that? It’s like

the fake cigarette, for er,

people to stop smoking (girl, 11-12)

Sports Sponsorship

E-cigarette companies sponsoring sports events, have you come across that at all?

- No

- No

- Erm

- None

No, you haven’t come across that. Would you expect these companies to be

sponsoring things like that?

- No, I wouldn’t expect it

- Not yet

- Not sporting events

- Because sport, like its not frowned upon but it’s like you don’t see an athlete

that smokes

- I don’t know if they’re allowed to sponsor anyway (boys, 15-16)

Sports Sponsorship, cont.

- I have seen them a lot

- Yeah, they sponsor something

- I think they do

The SKYCIG?

- Yeah

- I think at the football you see them

- And the packets

OK, and you thought you’d seen that one before as well, can you remember

where?

- I think I just seen it (sighs) I can’t remember, I think that’s one that’s always

at the tills, I’m not sure though

Packaging and Flavours

Once exposed to different product/pack styles:

Younger participants surprised by the range of flavours

Some e-cigarettes shown did seem to increase appeal for

participants:

Sweet and fruity flavours

Bright colours

‘Pen’-type devices

Rated by some as ‘fun’, ‘cool’, ‘stylish’, ‘for people who have

never smoked’, ‘for someone like me’, ‘tempted to try’.

They might want to try it if

they want to smoke….

like your friends smoke,

you wouldn’t want to start

(smoking) because they

can be more addictive than

these can be (girl, 11-12)

For fun or something… for

somebody that’s kind of

like starting but they don’t

want to like get really

addicted (boy, 11-12)

Who are e-cigarettes for?

None of them are meant for us are they? (laughing)

Not really

We’re not smokers

They’re not designed for us, they’re designed for people that need help to

stop smoking

But then candyfloss might be for them (never smoker)

The candyfloss could be used by people…

The candyfloss and the chocolate one

They might be for people who have never smoked

For fun

They’d have a different taste

They might think it tastes good

Yeah, they might want to try cigarettes but don’t want to (smoke)

Findings

Imagery

Unlike previous work conducted with tobacco packaging/products, little

consistent imagery with e-cigs

Those resembling traditional cigarettes associated with older smokers who

want to quit – reinforced by POS

Some positive imagery from packaging of SKYCIG and VYPE, nightclubs,

fashion, young males, discreet

Pink ‘shisha’ pen associated with positive imagery for some of the girls

“Cos it’s not like

actually smoking, it’s

more attractive”

“The doctor

recommended ones,

the boring ones” (boy, 11-12,)

“Does it come out

pink smoke?”

“cool”

Next steps

Continuing to follow studies with young people

that report on e-cigarette use in any country

Work with others on age of sale introduction

and enforcement (good examples already exist)

Making the case for well designed studies that

will help us understand how these products are

perceived and used by youth

YTPS will report next Spring

Future longitudinal addition to YTPS

Thank you

Linda.Bauld@stir.ac.uk

Linda.Bauld@cancer.org.uk

Acknowledgements:

Kathryn Angus, Maciej Goniewicz,

Deborah Arnott, Allison Ford

& Anne-Marie Mackintosh