1. Young People and the Use of E-cigarettes An overview of the Literature Dr Rosanne Palmer, ASH Wales Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

2. Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco Starting points Confusion And fear – Uncertainty, especially over the long-term implications – Young people What’s our starting point? What do we know so far?

3. Prevalence: who is using them? We know increasing numbers of young people are using electronic cigarettes Predominantly smokers and ex-smokers Association with other risk behaviours Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

4. Some data from Wales Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

5. Some data from Wales Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

6. And why? Most current data focuses on prevalence rates, not on intentions or motivations for use “Have you ever used an e- cigarette?” (Dautzenberg et al, 2013: p22) “Have you ever bought or tried an e-cigarette?” (Hughes et al, 2014: p4) Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

7. Perception and image Pepper et al, 2012: Smokers more willing to try any e- cigarette than non-smokers Participants willing to try e- cigarettes had less negative beliefs about the typical smoker Association between positive beliefs about the devices and likelihood of trying them Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

8. Advertising and marketing CAP/BCAP consultation Market should be current smokers; not appealing to young people Hardcastle et al (2014) suggested young people lack awareness around advertising and marketing Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

9. The nature of the device Before being banned by the FDA flavoured tobacco cigarettes popular among young people Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco Tobacco Free Flor

10. Education and awareness Survey of college students in North Carolina – half of respondents reported that they did not know when asked how harmful e-cigarettes are compared with regular cigarettes Hardcastle et al identified information that young people would like on e-cigarettes Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

11. The million-pound question Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

12. The million-pound question “Use of e-cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents” (Dutra and Glantz, 2014: pE1) “Compared with nonsmokers (never and former smokers), current cigarette smokers were significantly more likely to have used e-cigarettes (P<0.1) and to be current e-cigarette users (P<0.1).” (ibid: pE4) “This is a cross-sectional study, which only allows us to identify associations, not causal relationships. (ibid: pE7) Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

13. Meanwhile, in France… 8.1% of respondents reported having had an experience with e-cigarettes One question; no proof of uptake Main conclusion not directly supported by available data Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

14. Meanwhile, in France… Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

15. Elsewhere Goniewicz and Zielinska-Dach: Survey acknowledged that unable to examine patterns on never smokers e-cigarette use or whether they had later initiated tobacco use Pepper et al (2012) did not ask whether e-cigarette use began prior to initiating smoking regular cigarettes Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

16. The round-up Use among young people is increasing Strongly associated with ever smoking Link to other risky substance behaviours Role of surroundings: partners, parents Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

17. The round-up (2) Intentions of use? Uptake of e-cigarettes? ‘gateway’ effect? Long-term consequences? Exposure to vapour? Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

18. The round-up (3) (Re)normalising smoking? Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

19. Where do we go from here? “One point of consensus, however, is that protections must be put in place to ensure that young people who are at risk for smoking initiation do not use e- cigarettes.” (Pepper, McRae & Gilkey, 2013: p1) Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

20. Where do we go from here? (2) make a list of possible interventions around e- cigarettes and young people discuss your group’s priorities – which intervention/issue is top of your list? justify the intervention chosen in terms of its actual impact on improving public health Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

21. References de Andrade, M; Hastings, G; Angus, K; Dixon, D & Purves, R (2013): The Marketing of Electronic Cigarettes in the UK. A report commissioned by CRUK http://www.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/ @pol/documents/generalcontent/cr_115991.pdf ASH Wales (2014): Young people and electronic cigarettes in Wales http://www.ashwales.org.uk/creo_files/upload/downloads/young_people_an d_e-cigarettes_in_wales_final_march_2014.pdf Bauld, L; Angus, K & de Andrade, M (2014): E-cigarette uptake and marketing. A report commissioned by Public Health England Britton, J & Bogdanovica, I (2014): Electronic Cigarettes. A Report commissioned by Public Health England Cho, JH; Shin, E & Moon, S-S (2011): Electronic-Cigarette Smoking Experience Among Adolescents Journal of Adolescent Health, 49: 542-546 Choi, K & Forster, JL (2014): Beliefs and Experimentation with Electronic Cigarettes: a prospective analysis among young adults American Journal of Preventive Medicine, 46(2): 175-178 Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

22. References Dautzenberg, B; Birkui, P; Noël, M; Dorsett, J; Osman, M & Dautzenberg, M-D (2013): “E-cigarette: A New Tobacco Product for Schoolchildren in Paris” Open Journal of Respiratory Diseases, 3: 21-24 Durmowicz, EL (2014): “The impact of electronic cigarettes on the paediatric population” Tobacco Control, 23: ii41-ii46 Dutra, LM & Glantz, SA (2014): “Electronic Cigarettes and Conventional Cigarette Use among US adolescents. A Cross-sectional Study” JAMA Pediatrics: E1-E8 Goniewicz, ML & Zielinska-Dach, W (2012): “Electronic Cigarette Use among Teenagers and Young Adults in Poland” Pediatrics, 130: e879-e885 Grana, RA (2013): “Electronic Cigarettes: A New Nicotine Gateway “ Journal of Adolescent Health, 52: 135-136 Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

23. References Hardcastle, K; Hughes, K; Worsley, J; Bennett, A; Ireland, R & Sweeney, S (2014):"Most people I know have got one": Young people's perceptions and experiences of electronic cigarettes “ Centre for Public Health, Liverpool John Moores University Hughes, K; Hardcastle, K; Bennett, A; Ireland, R; Sweeney, S & Pike, K (2014):“E-cigarette access among young people in Cheshire and Merseyside. Findings from the 2013 North West Trading Standards Survey “ Centre for Public Health, Liverpool John Moores University Lee, S; Grana, RA & Glantz, SA (2013): “Electronic Cigarette Use among Korean Adolescents: A Cross-Sectional Study of Market Penetration, Dual Use and Relationship to Quit Attempts and Former Smoking“ Journal of Adolescent Health, xxx: 1-7 Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco

24. References Morbidity and Mortality Weekly Report (Sept 6 2013): Notes from the Field: Electronic Cigarette Use among Middle and High School Students - United States, 2011-2012 62(35); 729-730 Pepper, JK; McRee A-L & Gilkey MB (2013): “Healthcare Providers' Beliefs and Attitudes about Electronic Cigarettes and Preventive Counselling for Adolescent Patients” Journal of Adolescent Health, xxx: 1-6 Pepper, JK; Reiterate, PL; McRee. A-L; Cameron, LD; Gilkey, MB & Brewer, NT (2013):“Adolescent Males' Awareness of and Willingness to Try Electronic Cigarettes” Journal of Adolescent Health, 52: 144-150 Sutfin, EL; McCoy, TP; Morrell, HER; Hoeppner, BB & Wolfson, M (2013): “lectronic cigarette use by college students “ Drug and Alcohol Dependence, 131: 214-221 Towards a Tobacco Free Wales Tuag at Gymru Ddi Dybaco