1. Recall of e-cigarette point of sale displays by 12-17 year olds and e-cigarette use Dr Catherine Best School of Health Sciences University of Stirling

2. 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:  To display tobacco products or tobacco related products in places where tobacco products are offered for sale  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  POS ban April 2013 supermarkets  POS ban April 2015 small shops

3. Point of sale displays

4. Study Design Multi-modal before and after study using mixed methods in four purposively selected communities:  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 :  Has school roll of 1200+  Located in central belt of Scotland  Non denominational  Minority ethnic population of < 10%

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

6. E-cig Point of Sale Displays

7. E-cig POS We know tobacco POS influences susceptibility and uptake of smoking in young people=Reason for legislation No research to date on e-cig POS Not necessarily same – tobacco brands more established- e-cig recent and variable presence

8. E cigarettes 2014 retail audit -77% tobacco retailers sold e- cigs and 49% had e-cig POS display Data presented here from 2015 school survey Response rate 87% n=3808  ‘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’.  Tried e-cigs -Yes 22.2%  Will try next 6 months - Yes 9.8%

9. Does exposure to e-cigarette POS increase the likelihood of adolescent e-cigarette use? Predictors Recall e-cig POS small shops Recall e-cig POS supermarkets Control for Family Affluence Scale Age Gender Ethnic group Recall other sources of e-cig ad Recall e-cigs on internet Ever smoking

10. Analysis Logistic regression Stata version 14 Variance estimated using sandwich estimator to account for clustering by community α =0.01

11. Logistic regression on tried e-cig Odds ratio (99% CI) Unadjusted model Odds ratio (99% CI) Adjusted model Recall e-cig POS supermarket 2.56 (1.89 to 3.47)1.70 (0.99 to 2.94) Recall e-cig POS small shop 2.89 (2.36 to 3.54)1.90 (1.45 to 2.48) Recall internet e-cig ads2.02 (1.73 to 2.35)1.70 (1.16 to 2.50) Recall other e-cig ads1.57 (1.33 to 1.85)0.98 (0.83 to 1.17) Never smoked tobacco 0.08 (0.05 to 0.13) Gender- female 0.82 (0.64 to 1.05) Ethnic group-non-white 1.83 (0.80 to 4.20) Age 1.16 (1.08 to 1.24) FAS low 1 FAS medium 1.03 (0.76 to 1.40) FAS high 1.14 (0.63 to 2.04)

12. Logistic regression on intention to try Unadjusted model OR 99% CI Adjusted model OR 99% CI Recall e-cig POS supermarket 3.60 (3.03 to 4.27)1.60 (1.15 to 2.23) Recall e-cig POS small shop 3.93 (2.76 to 5.60)1.91 (1.08 to 3.37) Recall internet e-cig ads2.38 (1.51 to 3.76)1.43 (0.82 to 2.52) Recall other e-cig ads2.01 (1.87 to 2.17)1.27 (0.76 to 2.12) Never smoked tobacco 0.33 (0.26 to 0.42) Tried e-cigarette 16.71 (13.04 to 21.42) Gender- female 0.64 (0.27 to 1.50) Ethnic group-non-white 1.35 (0.90 to 2.02) Age 1.17 (1.03 to 1.33) FAS low 1 FAS medium 1.13 (0.79 to 1.62) FAS high 1.57 (1.07 to 2.30)

13. Conclusions In our Scottish sample: Respondents who recalled seeing e-cigarettes in small shops more likely to have tried e-cigs Respondents who recalled seeing e-cigs in small shops and supermarkets more likely to intend to try e-cigs in next 6 months

14. 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 ban on ban on sales to children but no intention to ban at POS. Window of opportunity

15. Young people and e-cigs Is it a problem? NO Tends to be experimentation not regular use- ‘curiosity’ Relatively harmless in comparison to other substances Potential health impact of occasional/one-off use minimal? YES 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 Use in young never-smokers undesirable

16. E-cigs Debate is Polarised Pro Harm reduction in smokers Cessation aid Anti Long-term effects unknown Re-normalises smoking Involvement of Big tobacco

17. A Balancing Act Positive AND negative Challenge is to find balance How to : Promote to adult smokers Minimise appeal to young never smokers The kind of problem behavioural medicine can address

18. Project team Sally Haw (PI), Catherine Best, Susan Murray University of Stirling Martine Stead, Douglas Eadie, Anne Marie MacKintosh, University of Stirling Andy MacGregor, Susan McConville, Amanda Amos, Jamie Pearce, John Frank University of Edinburgh Jamie Pearce, Gozde Ozakinci, Dorothy Currie, Farhana Haseen University of St Andrews Funded by NIHR PHR

19. Thank you catherine.best2@stir.ac.uk @cathbest