Our first contribution comes from Dr Milica Vasiljevic, Research Associate at the Behaviour and Health Research Unit (BHRU), University of Cambridge, UK. Milica describes her recently published experimental study on e-cigarette advertising which was also awarded the 3^rd SPAN Poster Prize at the EUSPR conference in Ljubljana in 2015. She then discusses her own research findings in relation to the new EU Tobacco Products Directive which will come into force in May 2016.

E-cigarettes: potential for benefit or harm?

The availability and use of electronic cigarettes (e-cigarettes) has risen rapidly in the last three years with an estimated 2.6 million people using e-cigarettes in the UK in 2015 and 11.8 million in the USA in 2014^1,2. E-cigarette use is also rising amongst children and adolescents, raising concerns that their use could lead to tobacco smoking^3,4.

E-cigarettes have the potential for benefit and harm, the nature and scale of each currently uncertain in the absence of much evidence. One potential benefit comes from providing a safe delivery mechanism for nicotine and an effective cessation aid. While uncertainty remains regarding their potential for benefit, evidence is accumulating to suggest that e-cigarettes can successfully be used as cessation aids by smokers⁵.

A second potential benefit of e-cigarettes concerns their impact on attitudes towards tobacco cigarettes. For example, they may make attitudes towards tobacco cigarettes more negative through providing an example of nicotine delivery that does not kill many of its users (unlike tobacco cigarettes) or generate unpleasant smells (unlike tobacco cigarettes).

Of concern, however, is their potential to make attitudes towards tobacco smoking more positive (i.e. to re-normalise it) through, for example, marketing that may be appealing to both adult and children non-smokers. Any such impact on children is of particular concern given that any increased appeal of tobacco smoking could increase the chances of tobacco smoking in this group in particular. This is against a background of continued decline in tobacco smoking in children (from 15.8% to 9.2% amongst US high-schoolers in the period from 2011 to 2014⁴, and from 5% in 2010 to 3% in 2014 amongst 11-15 year olds in England; see Figure).

Our study

Internal tobacco industry documents from the 1970’s show that young people find nicotine products with candy-like flavours more appealing than those without⁶. E-cigarettes are currently marketed in over 7,764 different flavours⁷. However, to date there have been no studies examining the impact of e-cigarette adverts, with or without flavours, on the appeal of tobacco smoking in children.

We aimed to fill this gap in a recent study of ours published in Tobacco Control. In this study we assigned 598 English school children (aged 11-16) to one of three groups:

• one group was shown adverts for candy-like flavoured e-cigarettes (e.g., milk chocolate, vanilla ice-cream);
• a second group was shown adverts for non-flavoured e-cigarettes; and
• participants in a third, control group weren’t shown any adverts.

For a sample of the kind of adverts used in the study please refer to the Stanford Research into the Impact of Tobacco Advertising Repository (SRITA) that can be accessed here.

We then asked the children how appealing they thought using e-cigarettes and tobacco smoking is (e.g., did the children think e-cigarettes or tobacco were ‘attractive’, ‘fun’ or ‘cool’?), how much they liked the adverts and how interested they might be in buying and trying e-cigarettes.

What did we find?

The children shown the adverts for candy-flavoured e-cigarettes liked these adverts more and expressed a greater interest in buying and trying e-cigarette products than the children shown the non-flavoured adverts. However, showing the adverts (both flavoured and non-flavoured) made no significant difference to the overall appeal of tobacco smoking or of using e-cigarettes – in other words, how attractive, fun or cool they considered the activities.

Finding that e-cigarette adverts don’t make tobacco smoking more attractive amongst children is reassuring. However, it is concerning that adverts for e-cigarettes with flavours that might appeal to school children could encourage them to buy and try the products.

The new EU Tobacco Products Directive

It is useful to consider the results of the current study in light of the imminent changes in EU regulations surrounding the marketing of e-cigarettes.

Currently, across Europe, marketing and advertising of e-cigarettes is virtually unregulated. From May 2016, however, e-cigarette marketing will fall under the new Tobacco Products Directive (TPD; for more details please see here). The new regulations will limit the exposure of children to TV and newspaper e-cigarette adverts. However, as I understand it the proposed implementation of these regulations in the UK and other EU member states will still allow some form of advertising of e-cigarettes (e.g., posters, leaflets, billboards in shops) so children may still be exposed to e-cigarette adverts. The new EU regulations will also not cover the content of products, with products that appeal to children still available on the market.

When considered in the light of the upcoming regulation and the paucity of research in this area, our study highlights the need for more research examining both the short- and long-term impact of e-cigarette advertising, as well as the link between e-cigarette use and tobacco smoking.

Reference:

Vasiljevic, M, Petrescu, DC, Marteau, TM. Impact of advertisements promoting candy-like flavoured e-cigarettes on appeal of tobacco smoking amongst children: an experimental study. Tobacco Control; doi:10.1136/tobaccocontrol-2015-052593

Access the full text here for free: http://tobaccocontrol.bmj.com/content/early/2016/01/17/tobaccocontrol-2015-052593.full

About the author:

My name is Milica Vasiljevic and I am a Research Associate at the Behaviour and Health Research Unit (BHRU), University of Cambridge, UK. My research focuses on the design and implementation of social-cognitive interventions to change people’s behaviours with the aim of preventing disease. I have also been researching behavioural biases in risk identification and mitigation; automatic processes involved in behaviour change; and mindset priming aimed at changing people’s attitudes, values, and behaviour. At the BHRU, I am involved in primary research exploring the impact of interventions that aim to improve people’s health outcomes, and reduce health inequalities. You can read more about my work by following these links: http://www.bhru.iph.cam.ac.uk/team-members/milica-vasiljevic/ and https://www.researchgate.net/profile/Milica_Vasiljevic

Bibliography:

1. Action on Smoking and Health (ASH). Use of electronic cigarettes (vapourisers) among adults in Great Britain. May, 2015. http://www.ash.org.uk/files/documents/ASH_891.pdf [↩]
2. Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS data brief, no. 217. Hyattsville, MD: National Center for Health Statistics. 2015. [↩]
3. Action on Smoking and Health (ASH). Use of electronic cigarettes among children in Great Britain. June, 2015. http://www.ash.org.uk/files/documents/ASH_959.pdf [↩]
4. Centers for Disease Control and Prevention. Tobacco use among middle and high school students—United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2015;64:381–5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a3.htm?s_cid=mm6414a3_e [↩]
5. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev 2014;12:CD010216. doi: 10.1002/14651858.CD010216.pub2 [↩]
6. Cummings KM, Morley CP, Horan JK, Steger C, Leavell NR. Marketing to America’s youth: evidence from corporate documents. Tob Control 2002;11:i5-i17. [↩]
7. Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control 2014;23:iii3-iii9. doi:10.1136/tobaccocontrol-2014-051670 [↩]

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