Young People and E-Cigarettes in Scotland: A Survey of Secondary School Pupils

Introduction

The purpose of this report is to summarise the results of a survey of secondary school pupils in Scotland about e-cigarettes. The aim of the survey was to gather information about pupils' levels of awareness of e-cigarettes; experimentation and use of e-cigarettes; exposure to the marketing and promotion of e-cigarettes; and their knowledge and attitudes about the products. The results of the survey contribute to a growing evidence base which the Scottish Government will draw on to inform its policies on e-cigarettes.

Background

E-cigarettes or electronic cigarettes are battery-powered handheld devices which heat a liquid to deliver a vapour which is then inhaled by the user, in an act known as "vaping".^[1] They typically consist of a battery, an atomiser and a cartridge containing the liquid.^[2] Earlier models, often referred to as "cigalikes", were designed to closely resemble cigarettes but there is now a wide variety of product types on the market and continued evolution in their design. The liquid is usually flavoured and may or may not contain varying concentrations of nicotine, although in most cases e-cigarettes are used with nicotine.

In the UK e-cigarettes are currently (autumn 2015) subject to general consumer product regulations or manufacturers can apply to the UK Medicines and Healthcare Products Regulatory Agency (MHRA) for a medicines licence.^[3] Other countries have developed alternative approaches to classifying and regulating e-cigarettes (Institute for Global Tobacco Control 2015). The EU Tobacco Products Directive (TPD)^[4] will extend and strengthen existing regulation by creating a consistent regulatory regime for nicotine-containing e-cigarettes and e-liquids across EU Member States. The TPD will be transposed into the domestic law of member states by May 2016. It introduces a number of limitations on e-cigarettes which contain nicotine, including regulations related to their contents and how they are brought to market, and will ban several forms of marketing.

In Scotland, adult smoking rates have been decreasing or have remained fairly stable in recent years (Scottish Government 2015a), while smoking has steadily declined amongst under 18s (ISD 2014). In March 2013, the Scottish Government launched its current tobacco control strategy, Creating a Tobacco-Free Generation, which articulated an ambitious aim of creating a Tobacco Free Generation by 2034 where 5% or fewer of the adult population smoke. The strategy recognised the challenges for tobacco control posed by novel products, including e-cigarettes, and included an action to consider policy responses.^[5] The Programme for Government for 2015-16^[6] indicated that legislative restrictions on e-cigarettes would be introduced and, subsequently, the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill^[7] was introduced to the Scottish Parliament on 5 June 2015. The Bill introduces a number of measures designed to prevent access to e-cigarettes by children and people under the age of eighteen which brings them into line with other age-restricted goods like tobacco and alcohol. The provisions in the Bill were informed by the outcomes of public and stakeholder consultation (including a three-month written consultation: Scottish Government 2015b), ongoing monitoring of the evidence base, policies in other countries, and engagement with the academic and public health communities.

The benefits and risks of e-cigarettes will take time to fully emerge, although there is consensus that they are safer than smoked tobacco (Cancer Research UK 2014; McNeil et al 2015; Nutt et al 2014). Given the relatively short time that they have been in widespread use, there is a shortage of data on the long-term effects of their use for individuals and for public health (Hajek et al 2014; McRobbie 2014; Nutt et al 2014), complicated by the differences in contents and quality of the hundreds of models and liquid brands on the market. There is ongoing debate on the long-term impacts e-cigarettes may have on smoking rates and on global tobacco control efforts.

Sufficient numbers of survey respondents have reported that they have successfully quit smoking tobacco through the use of e-cigarettes for them to be taken seriously as a potentially useful tool to support smoking cessation or for tobacco harm reduction. Surveys with adults repeatedly confirm that most users are either current or former smokers, and that their main motivations for use are to support a cessation attempt or to help the user cut down their tobacco use (ASH 2015a; ASH Scotland 2014a; ONS 2014; West et al 2015).^[8] A proportion will also adopt a pattern of prolonged dual use of tobacco and e-cigarettes so, for example, they can use nicotine in smoke-free environments, or for reasons such as cost.

Although evidence suggest e-cigarettes have a potentially important role in reducing smoking rates, there are a number of important questions which cannot be answered by the existing evidence base. A Cochrane Review^[9] (McRobbie et al 2014) assessed the evidence for their use in cessation and confirmed that there was a shortage of conclusive trials. At this stage, there is a shortage of longitudinal data and clinical trial results to fully assess their effectiveness for smoking cessation. It is not certain how effective e-cigarettes are compared to well-established and proven cessation methods; it is unknown what proportion of people who have stopped smoking with an e-cigarette will remain abstinent over the long term; and there are insufficient data to pinpoint the characteristics of smokers which might make individuals more or less likely to benefit from using e-cigarettes.

While some smokers could benefit from using e-cigarettes, the Scottish Government does not think these products are suitable for under-18s and the Bill currently before the Scottish Parliament includes a number of provisions to enforce an age restriction on sales.

Two themes often dominate debates about e-cigarettes and children and young people: the risk that their use could act as a gateway into the use of smoked tobacco; and the risk that widespread use and promotion could re-normalise tobacco use by undermining or undoing hard-won successes by governments to de-normalise smoking. It is still too early to establish the extent to which these risks pose a genuine threat to tobacco control efforts.

There are also concerns about the effects of e-cigarette marketing on young people. Analyses^[10] of the content of websites, adverts and promotional materials have shown that some marketing appears to have been aimed at a younger adult demographic; could appeal to adolescents and children, who look to elders as role models; and could lead to confusion and to associations being made with tobacco. Until this survey was undertaken, there were no representative data on the extent to which adolescents in Scotland are exposed to e-cigarette marketing. During the fieldwork period the UK Committee of Advertising Practice and the Broadcast Committee of Advertising Practice (2014) launched a new code to ensure that e-cigarettes are promoted responsibly. The rules are enforced by the Advertising Standards Authority. The CAP/BCAP rules require that adverts should not target children.

There is a well-established evidence base for the association between smoking and an individual's exposure and receptivity to tobacco marketing which has underpinned legislative measures to protect young people and adult non-smokers from exposure to tobacco advertising.^[11] Experience with tobacco and other products (e.g. alcohol and junk food) shows that it is not possible to create a regime which guarantees that children will not be exposed to advertising aimed at adults.

Methods

The Scottish Government's Health Analytical Services Division and Public Health Division commissioned a module of questions on e-cigarettes in the Young People in Scotland schools omnibus survey. The survey is managed by Ipsos-MORI who undertook the field-work and collaborated with the Scottish Government on the development of the research questions. The questionnaire is included as an Appendix.

The fieldwork was undertaken between 23 September and 14 November 2014 with a representative sample of 2,016 pupils, aged 11-18 years, in 50 state secondary schools across Scotland. Schools were selected from the national schools database using a sampling frame stratified by local authority, school size, and urban-rural classification. Two school years from each school were selected through randomised allocation. Respondents participated in the survey during mixed ability class time (e.g. Personal and Social Education) using a confidential self-completion, paper-based questionnaire. Teachers were provided with written instructions on questionnaire administration and each respondent was provided with a sealable envelope for their completed questionnaire to ensure confidentiality. Information leaflets and opt-out forms were provided to respondents' parents and/or guardians. Pupils were provided with information leaflets explaining the purpose of the survey, how confidentiality was maintained, that they were free to accept or decline participation, and if they chose to participate to what extent they did so. The survey was conducted in accordance with the Market Research Society's Code of Conduct for good practice.

This report has been prepared by the Scottish Government's Health Analytical Services Division. Analysis was undertaken by an Abertay University PhD student as part of an internship with the Scottish Government through the Scottish Graduate School of Social Sciences. The results in this report are primarily descriptive statistics. Percentages reported may not always equal 100% due to rounding. For brevity, the Young People in Scotland module on e-cigarettes is referred to as the "YPIS" in this report. Data are compared to a number of other surveys, particularly the Scottish Government's Scottish Adolescent Lifestyle and Substance Use Survey (SALSUS), which is the most authoritative source of information on tobacco, alcohol and drug use amongst adolescents in Scotland.^[12]