E-cigarettes and young E-cigarettes and young people: people:

the evidence so far the evidence so far

BackgroundBackgroundPublic health concerns about children, Public health concerns about children, young people and reduced risk young people and reduced risk products:products:‘‘Gateway’ effect?Gateway’ effect?MarketingMarketing

Channels previously used for traditional Channels previously used for traditional cigarettescigarettes

Plus celebrity endorsements, online promotions Plus celebrity endorsements, online promotions and social mediaand social media

Growing number of e-cigarette product types, Growing number of e-cigarette product types, flavours and product innovationsflavours and product innovations

Investment in e-cigarette point-of-sale displaysInvestment in e-cigarette point-of-sale displays

‘‘Renormalisation’ of smoking?Renormalisation’ of smoking?

Previous reviewPrevious review Review published by Public Review published by Public

Health England in May 2014Health England in May 2014 Identified 9 studies on use in Identified 9 studies on use in

children (up to March 2014). children (up to March 2014). One UK study One UK study In the studies we reviewed, In the studies we reviewed,

with the exception of one with the exception of one Polish survey, ever use was Polish survey, ever use was reported by fewer than one reported by fewer than one in ten children and was in ten children and was concentrated in young concentrated in young people who smokepeople who smoke

Update Update

Since the publication Since the publication of the PHE report we of the PHE report we have been tracking have been tracking all the youth studies, all the youth studies, and applied the same and applied the same search strategy in search strategy in October 2014, March October 2014, March 2015 and May 2015 2015 and May 2015 to identify all to identify all published published studies studies reporting prevalence reporting prevalence of useof use

Following a May 2015 Following a May 2015 update, we identified update, we identified

4141 studies in allstudies in all These are English These are English

language studies onlylanguage studies only There is also a There is also a

significant amount of significant amount of grey literature – grey literature – survey reports survey reports published online etcpublished online etc.

Published peer-reviewed Published peer-reviewed studiesstudies

Data relating to ever use (of e-cigarettes) Data relating to ever use (of e-cigarettes) is available from 12 countries is available from 12 countries

Direct comparisons are difficult with Direct comparisons are difficult with published data because of:published data because of: Differences in age range (aged 10-early 20s)Differences in age range (aged 10-early 20s) Differences in questions askedDifferences in questions asked

‘‘Ever’ use is often combined with regular Ever’ use is often combined with regular or recent use in surveys, although more or recent use in surveys, although more recent ones distinguish between types of recent ones distinguish between types of use. use.

Ever and current use Ever and current use In surveys conducted between 2011 and In surveys conducted between 2011 and

2015, recorded ever use varied very 2015, recorded ever use varied very significantly - from 5% to 62% significantly - from 5% to 62%

Amongst repeat cross sectional surveys Amongst repeat cross sectional surveys there is a consistent pattern of rising use there is a consistent pattern of rising use between yearsbetween years

Except in one Polish study, rates of regular Except in one Polish study, rates of regular use are much lower, commonly less than use are much lower, commonly less than 10%.10%.

Regular use in never smokers also remains Regular use in never smokers also remains low (the highest identified rate is 2%). low (the highest identified rate is 2%).

Example: Canada Example: Canada

Source: Czoli CD, Hammond D, Reid JL, Cole AG, Leatherdale ST (2015). Use of conventional and alternative tobacco and nicotine products among a sample of Canadian youth. Journal of Adolescent Health, doi:10.1016/j.jadohealth.2015.03.006

Example: New Zealand Example: New Zealand

Source: White et al, 2015. Respondents were asked: “Have you ever tried electronic cigarettes?” and those who answered ‘yes’ were classified as “e-cigarette users”.

Repeat cross-sectional survey Repeat cross-sectional survey in Poland in Poland

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

Use in the UKUse in the UK There are a number of representative There are a number of representative

surveys of young people in different parts surveys of young people in different parts of the UK.of the UK.

Leading the way was the work conducted Leading the way was the work conducted by YouGov for ASH in March 2013 and by YouGov for ASH in March 2013 and repeated in March 2014 and again in 2015 repeated in March 2014 and again in 2015 (Great Britain).(Great Britain).

Awareness has risen, as has ever use. Ever Awareness has risen, as has ever use. Ever use was 5% in 2013, 8% in 2014 and has use was 5% in 2013, 8% in 2014 and has risen again slightly in 2015 (2015 results risen again slightly in 2015 (2015 results being analysed).being analysed).

Which ONE of the following is closest to describing your Which ONE of the following is closest to describing your experience of e-cigarettes?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 GB, 2014.

Not aware of e-cigarettes

Youth Tobacco Policy Youth Tobacco Policy SurveySurvey

Youth Tobacco Policy Youth Tobacco Policy Survey Survey funded by funded by CRUKCRUK

Only Only UK wide UK wide survey survey on tobacco and e-cig on tobacco and e-cig use in youth (11-16 use in youth (11-16 years)years)

E-cigs added in 2014, E-cigs added in 2014, 77thth Wave of the Wave of the surveysurvey

Sample was 1,204Sample was 1,204

Main focus is on Main focus is on tobacco and e-tobacco and e-cigarette cigarette marketingmarketing

Papers being Papers being prepared on prepared on promotion and promotion and flavours, flavours, marketing and marketing and perceptions of perceptions of harmharm

New YTPS results: New YTPS results: prevalenceprevalence

Amongst the representative sample of Amongst the representative sample of UK 11-16 year olds:UK 11-16 year olds: 12% had ever tried an e-cigarette12% had ever tried an e-cigarette 2% used one more than monthly and 1% 2% used one more than monthly and 1%

more than weeklymore than weekly Amongst never smokers: Amongst never smokers:

3% had ever tried an e-cigarette 3% had ever tried an e-cigarette No never smoking young people were No never smoking young people were

regularly (defined as ‘at least monthly’) regularly (defined as ‘at least monthly’) using an e-cigarette using an e-cigarette

Comparing UK youth Comparing UK youth surveyssurveys

Surveys in 2014 are very similar at UK and devolved nation level. Regular use (defined as ‘atleast monthly’) in never smokers was 0% in 3 surveys and 0.7% (n=54) in one survey in Wales.

Meanwhile, smoking Meanwhile, smoking prevalence continues to prevalence continues to

decline decline

What about the future? What about the future?

Will more young people take up vaping?Will more young people take up vaping? How do young people perceive the How do young people perceive the

relative harms of cigarettes and e-relative harms of cigarettes and e-cigarettes/vapouriserscigarettes/vapourisers

If more young people start using them, If more young people start using them, will these be young people who already will these be young people who already smoke, those who might have smoked, or smoke, those who might have smoked, or those who might otherwise never have those who might otherwise never have used a manufactured nicotine product?used a manufactured nicotine product?

Perceptions of e-cig harm by Perceptions of e-cig harm by smoking statussmoking status

Source: ASH Smokefree Youth

20132013

20142014

Do we have a crystal Do we have a crystal ball?ball?

No, but we do have No, but we do have NorwayNorway. . Here, snus is used and provides Here, snus is used and provides

some parallels.some parallels. This is a less harmful (although by This is a less harmful (although by

no means risk free) oral tobacco no means risk free) oral tobacco product where clear health gains product where clear health gains have resulted from smoking have resulted from smoking cessation, reduction and smoking cessation, reduction and smoking substitution. substitution.

Use of cigarettes and snusUse of cigarettes and snusNorwegians aged 16-30 years Norwegians aged 16-30 years

1985-20131985-2013

Males Females

r = - 0.900, p<0.001 r = - 0.811, p<0.001

Source: Lund I, Lund KE. How has the availability of snus influenced cigarette smoking in Norway? Int J Environ Research and Public Health 2014; 11. Larsen E, Rise J, Lund KE. Risk characteristics of adolescent snus users compared to non-users of tobacco, smokers and dual users of snus and cigarettes. Addiction Research and Theory 2013; 38 (7): 2288-2294.

Smoking status, ever Smoking status, ever snus userssnus users

Sample aged 16-79 years, n=2240. Source: Lund, 2015Lund I, Lund KE. How has the availability of snus influenced cigarette smoking in Norway? Int J Environ Research and Public Health 2014; 11. Larsen E, Rise J, Lund KE. Risk characteristics of adolescent snus users compared to non-users of tobacco, smokers and dual users of snus and cigarettes. Addiction Research and Theory 2013; 38 (7): 2288-2294.

 

YTPS and ‘susceptibility’YTPS and ‘susceptibility’

YTPS findings suggest that ever smokers currently not using e-cigarettes are far morelikely (73%) than never smokers (31%) to try these products in the future.

What about the ‘gateway’What about the ‘gateway’ Until we have longitudinal data on young Until we have longitudinal data on young

people and e-cigarettes, concerns about the people and e-cigarettes, concerns about the relationship between these products & relationship between these products & tobacco use can’t be fully explored, except to tobacco use can’t be fully explored, except to show the obvious (that current smokers use show the obvious (that current smokers use them). Indeed we may never have the data to them). Indeed we may never have the data to fully explore ‘the gateway’. fully explore ‘the gateway’.

However, we should recognise that a However, we should recognise that a significant number of young people in a range significant number of young people in a range of countries, including the UK, are now being of countries, including the UK, are now being exposed to nicotine for the first time by using exposed to nicotine for the first time by using an e-cigarette. an e-cigarette.

ConclusionsConclusions There are now more than 40 published studies There are now more than 40 published studies

reporting the prevalence of e-cigarette use in reporting the prevalence of e-cigarette use in children. children.

Direct comparisons between studies are Direct comparisons between studies are difficult, however it is clear that children as difficult, however it is clear that children as young as 10 are experimenting with e-young as 10 are experimenting with e-cigarettes and repeat cross -sectional surveys cigarettes and repeat cross -sectional surveys show increasesshow increases

However regular use is concentrated in tobacco However regular use is concentrated in tobacco smokers. Regular use by never smoking smokers. Regular use by never smoking children remains very rare. children remains very rare.

Ongoing research and surveillance is essential Ongoing research and surveillance is essential to see what happens next. to see what happens next.

Thank youThank you

Linda.Bauld@stir.ac.ukLinda.Bauld@cancer.org.uk

Acknowledgements: Kathryn Angus, Ann McNeill,Allison Ford, Anne-Marie Mackintosh, Deborah Arnott,Martin Dockrell, Hazel Cheeseman, Graham Moore, Maciej Gonewicz , Brian Eastwood, Nicola Smith, Karl Lund.