Professor Linda Bauld presentation from E-Cigarette Summit 2014

1. Prof Linda Bauld
Professor of Health Policy
University of Stirling
UKCTAS and Cancer Research UK

2. Are children using e-cigarettes?

3. 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?

4. 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

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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%).

11. 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

12. E-cigarette/smoking by children: USA
Source: US CDC data from National Youth Tobacco Survey 2011 and 2012. Graph from Bates & Rodu

13. 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

14. 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.

15. 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.

16. 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).

17. 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”

18. 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)

19. 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)

20. 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

21. 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)

22. 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)

23. 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”

24. 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

25. Thank you
Linda.Bauld@stir.ac.uk
Linda.Bauld@cancer.org.uk
Acknowledgements:
Kathryn Angus, Maciej Goniewicz,
Deborah Arnott, Allison Ford
& Anne-Marie Mackintosh