Determinants of ecigarette use and intention to use

Determinants of e-cigarette use and intention to use in Scottish Adolescents Dr Catherine Best Professor Sally Haw School of Health Sciences University of Stirling

DISPLAY project • Determining the Impact of Smoking Point of sale Legislation Among Youth (DISPLAY) • Under Section 1 of the Tobacco and Primary Medical Services (Scotland) Act 2010, it is an offence: Ø To display tobacco products or tobacco related products in places where tobacco products are offered for sale Ø Retailers will be required to conceal cigarettes from general view, either by covering up cigarette gantries/dispensers or by storing cigarettes under the counter. • Scotland ØPOS ban April 2013 supermarkets ØPOS ban April 2015 small shops

Point of sale displays

Study Design Multi-modal before and after study using mixed methods in four purposively selected communities: Ø Data collection at baseline and longitudinal follow-up for 4 years Communities defined as Secondary School Catchment and chosen to reflect 2 levels of rurality (urban vs small town) and 2 levels of deprivation (high vs medium to low) Selected from : Ø Ø Has school roll of 1200+ Located in central belt of Scotland Non denominational Minority ethnic population of < 10%

Study Components 1. Annual mapping study of tobacco retail outlets 2. Annual tobacco advertising and marketing audit 3. Annual crosssectional school survey with embedded cohort of school children 4. Annual focus group interviews with purposive samples of school children

E-cig Point of Sale Displays

E cigarettes • 2014 e-cigarettes added to survey (n=1404, S 2 & S 4) and retail audit (n=96) Ø‘An e-cigarette is a tube that looks like or is similar to a normal cigarette. An e-cigarette may have a glowing tip and puffs a vapour that looks like smoke but unlike normal cigarettes, they don’t burn tobacco’. ØHeard of them Yes 74. 7%, No 17. 9% DK 7. 3% ØTried e-cigs -Yes 17. 3% ØWill try next 6 months - Yes 6. 8%

E-cig Point of Sale Displays

Does exposure to cigarette brands increase the likelihood of adolescent e-cigarette use? Predictors Control for • Current smoking • Never smoking • Frequency of visits to retail outlets • Cig brand recognition • Tobacco retail outlet density • Frequency hanging round street or park • • Family Affluence Scale Age Gender Ethnic group

Analysis Logistic regression Stata version 13 Purposeful selection Nested likelihood ratio testing Robust standard errors to account for clustering by community • α =0. 01 • •

Logistic regression on tried e-cig Variable Model 1 Odds ratio Model 2 Odds ratio (99% CI) (99 % CI) Current smoker 4. 50 (1. 27 to 15. 96) 6. 10 (1. 19 to 31. 22) Not current smoker 1 1 Never smoked 0. 11 (0. 05 to 0. 24) 0. 10 (0. 05 to 0. 20) Ever smoked 1 1 Brand recognition 1. 23 (1. 11 to 1. 37) 1. 21 (1. 06 to 1. 39) Gender male female 1 0. 99 (0. 42 to 2. 31) Family Affluence Scale (1 low) 1 Family Affluence Scale (2 med) 1. 34 (0. 74 to 2. 45) Family Affluence Scale (3 high) 0. 87 (0. 21 to 3. 63) White ethnic group 1 Other ethnic group 1. 83 (0. 63 to 7. 93) Age in years 0. 99 (0. 42 to 2. 31)

Logistic regression on intention to try Variable Model 1 Odds ratio Model 2 Odds ratio (99% CI) Current smoker 3. 22 (1. 07 to 9. 72) 4. 69 (0. 45 to 48. 80) Not current smoker 1 1 Never smoked 0. 06 (0. 02 to 0. 14) 0. 03 (0. 08 to 0. 13) Ever smoked 1 1 Brand recognition 1. 34 (1. 06 to 1. 69) 1. 41 (1. 14 to 1. 73) Tobacco outlet density 1. 13 (1. 04 to 1. 23) 1. 16 (1. 06 to 1. 27) Hanging round in the street ≥ 1/wk 3. 13 (1. 10 to 8. 89) 2. 89 (1. 76 to 4. 73) Hanging round in the street<1/wk 1 1 Gender male female 1 0. 46 (0. 16 to 1. 27) Family Affluence Scale (low) 1 Family Affluence Scale (med) 1. 92 (0. 67 to 5. 47) Family Affluence Scale (high) 1. 72 (0. 81 to 3. 68) White 1 Other ethnic group 0. 60 (0. 05 to 8. 86) Age in years 0. 50 (0. 15 to 1. 69)

Conclusions In our Scottish sample: • Respondents who have never smoked less likely to use e-cigs • More cigarette brands recognised more likely to use ecigarettes • Respondents living in higher tobacco retail outlet density more likely to intend to try e-cig • Respondents hanging round street or park more likely to intend to try e-cig • Current smoking related to having tried e-cigarettes

Regulation • Tobacco point of sale banned in UK • E-cigarette point of sale and advertising unregulated until after EU directive comes into force in 2016. • Current Bill includes restriction on advertising but no intention to ban at POS. • Window of opportunity

E-cigs Debate Positives • Harm reduction in smokers • Cessation aid Negatives • Long-term effects unknown • Re-normalises smoking More evidence needed • Growing use by never smokers

Young people and e-cigs Positives • Tends to be experimentation not regular use • Relatively harmless in comparison to other substances • Potential health impact of occasional/one-off use minimal? Negatives • Young people more easily addicted nicotine • Gateway • Use by never smokers • Advertising spend is growing and so is e-cig use- flavours appealing to young • Re-normalising smoking

Project team • Sally Haw (PI), Martine Stead, Douglas Eadie, Anne Marie Mac. Kintosh, Catherine Best University of Stirling • Andy Mac. Gregor, Clare Sharp, Scot. Cen • Amanda Amos, Jamie Pearce, John Frank, Catherine Tisch, Martine Miller University of Edinburgh • Winfried van der Sluijs, Farhana Haseen University of St Andrews • Funded by NIHR PHR

Thank you • catherine. best 2@stir. ac. uk • @cathbest