Young adults and e-cigarettes: a qualitative exploration of awareness, experience and attitudes

1 Introduction

1.1 This is a report of a qualitative research study which explored young adults' awareness of and attitudes to e-cigarettes, and their experiences of using these devices. The research was commissioned by the Scottish Government and involved young adults in Scotland aged 16-25. Data collection for this study took place between December 2015 and February 2016.

Policy context

1.2 In recent years, there has been an increase in the sale, promotion and use of e-cigarettes in the UK. Provisional statistics published by the Office for National Statistics in 2015 indicate that, across Great Britain, there are now an estimated 2.2 million current e-cigarette users - equivalent to 4% of the adult population. ^[1] In Scotland, the most recent figures from the Scottish Health Survey (2014) indicate that 5% of over-16s are current e-cigarette users and a further 10% of Scottish adults report having previously used an e-cigarette. ^[2]

1.3 The growth in the sale and use of e-cigarettes comes at a time when the use of conventional tobacco cigarettes among Scottish adults is at its lowest point since 1999 when the Scottish Health Survey started to collect data on smoking, following a gradual decline from 31% in 1999 to 20% in 2014. ^[3] E-cigarette use is strongly associated with smoking, with both current and past use of e-cigarettes much higher among current cigarette smokers than among non-smokers. Only 1% of adults who have never smoked report regular e-cigarette use in Scotland. ^[4]

1.4 Tobacco use has long been identified as a key contributor to poor health in Scotland, and effective tobacco control has been a health improvement priority for successive governments. Legislative action over the past decade has included restricting smoking in public places; raising the legal age for buying tobacco to 18; banning the sale of tobacco from vending machines; and the phased banning of tobacco displays in shops. At the same time, smoking cessation services have been widely available, and ongoing health education campaigns have been targeted at the general population to discourage smoking and encourage quitting.

1.5 The Scottish Government's tobacco control strategy, Creating a Tobacco-free Generation (2013) , sets out a vision for a tobacco-free Scotland (defined as an adult smoking rate of 5% or lower) by 2034. ^[5] This is a challenging target, despite the reductions in prevalence achieved so far. The strategy addresses prevention, protection and cessation, and has an emphasis on tackling health inequalities.

1.6 While the reduction in smoking rates among adults has been encouraging, there has been a particularly dramatic fall among school-aged children. For example, data from SALSUS (the Scottish Schools Adolescent Lifestyle and Substance Use Survey) indicate that, among 15-year-old Scottish schoolchildren, regular smoking has fallen from 29% in 1996 to 9% in 2013. ^[6],[7] This is the lowest rate of regular smoking among this age group since the survey began in 1982. Similarly, among 13-year-olds, regular smoking has fallen from a peak level of 8% in 1998 to 2% in 2013. During this same period, there has been a corresponding increase in the proportion of Scottish teenagers who report never having tried a cigarette. However, the latest findings from the Scottish Household Survey indicate that smoking rates among young adults are still relatively high (19% of males and 17% of females in the 16-24 age group in 2014) which suggests that the transition to becoming a smoker in Scotland is happening at a slightly later age than in the past.

1.7 Evidence is beginning to emerge that the use of e-cigarettes can help adults quit smoking tobacco. However, there are concerns about the potential for use of e-cigarettes by children and young people. Debates tend to focus on two main issues: first, that e-cigarette use could act as a gateway to tobacco use for young people; and second, that their use and promotion could undermine the success of government initiatives and legislation in de-normalising cigarette smoking over the last decade. ^[8]

1.8 Given these concerns, and following a widespread public and stakeholder consultation, the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill was introduced to the Scottish Parliament on 5 June 2015. ^[9] The Bill, which was passed by the Parliament on 3 March 2016, includes several measures intended to prevent access to e-cigarettes by children and young people under the age of 18, bringing them into line with other age-restricted goods like tobacco and alcohol. It also requires that sellers of e-cigarettes be centrally registered and introduces a number of restrictions on the marketing of the products.

E-cigarettes and young people

1.9 A review recently carried out by Professor Linda Bauld and colleagues found that, in four representative surveys carried out among UK teenagers in a 12-month period from 2013 to 2014, a significant proportion had tried e-cigarettes at least once - 8% in one survey across Great Britain, and 12% in a representative UK-wide survey and national surveys in Wales and Scotland. ^[10] However, the proportion who regularly used e-cigarettes (defined as more than once a month) was still very low (ranging from 0.4% in Scotland to 2% in the UK), and regular use was almost entirely confined to young people who also smoked tobacco. The findings of this review are consistent with those of a Scottish Government commissioned survey conducted in late 2014 among secondary school pupils, aged 11-18. ^[11] This survey found that 16% of the sample had used an e-cigarette, but most of these (81%) had tried it only once or twice. Regular use (at least once a month) was reported by 3% of the sample. The 2013 SALSUS survey showed the strong association between e-cigarette use and smoking among teenagers, with 11% of regular smokers and 6% of occasional smokers reporting using e-cigarettes at least once month.

1.10 The Scottish Government's 2014 study found that curiosity was the main reason for first use, sometimes motivated by seeing a friend or family member using an e-cigarette. This differs from the main reason given by adults for using e-cigarettes, which is to reduce or quit smoking. This same survey found high levels of uncertainty about e-cigarettes among Scottish teenagers, due in part to a lack of reliable publicly available information.

1.11 These findings, taken together, suggest that some young people are experimenting with e-cigarettes, and that smokers are most likely to be regular users, but only very small numbers of young non-smokers are currently using these products on a regular basis. However, more research is needed to understand what the influences are that encourage or discourage their use among young people.

Aims of this research

1.12 Much of what we now know about young people's use of e-cigarettes is based on survey findings, and most of these surveys have focused on children and adolescents in school. At the time of this study, in Scotland, there had been little qualitative research carried out among adolescents and no published research with young adults in relation to their views on e-cigarettes. ^[12] This is a significant gap in the evidence particularly since (as noted above) the transition to smoking is generally taking place in the 16-25 year age group. Work in this area is necessary to inform government policy on the regulation of e-cigarettes and public health interventions among young adults.

1.13 The aim of this study was to gather evidence, through primary research, from young adults aged 16-25 in Scotland about their awareness and experiences of using e-cigarettes and their attitudes towards these devices. Given the strong association between smoking and e-cigarette use, the focus of the research was mainly on smokers and vapers in three socio-demographic groups: (i) those who were in further or higher education; (ii) those who were in employment; and (iii) those who were not in employment, education or training ( NEET). Specifically, the research sought to hear from young adults who were no longer in school. Non-smokers were also included in the research, but to a lesser extent.

1.14 The research sought to explore:

• The place of e-cigarettes in the lives of young adults (for example, their own use of, or experimentation with e-cigarettes including the reasons for this, and their interest in trying e-cigarettes in the future)
• What young adults know about these products (for example, in relation to affordability, accessibility, quality, safety, different types of products, and why they are used and by whom)
• Young adults' information and support needs (including where they currently get their information about e-cigarettes, and the levels of trust that they have in relation to these information sources).