As public health debate on the pros and cons of e-cigarettes continues, moves to regulate their promotion and sale are increasingly being proposed and adopted by governments across the world [6]. A key feature of such regulation is preventing child access to e-cigarettes. Thus, understanding the extent of e-cigarette access by young people and the characteristics of those that access them will be crucial in informing prevention and control strategies. Using a sample of over 16,000 14-17 year old school students in North West England, we found that almost one in five had either tried or purchased e-cigarettes. Such rapid penetration into teenage culture of what is essentially a new drug use option is without precedent. As with findings from studies elsewhere [7-9], e-cigarette access was most common in students who smoked conventional cigarettes, particularly those who smoked in greater quantities. Thus, 67.2% of light smokers (<5 per day) and 75.8% of heavier smokers reported having accessed e-cigarettes. These figures are far higher than those for e-cigarette use by adolescent smokers reported in previous studies (e.g. France, 33.4% [8], Korea, 36.6% [9]), and this will in part reflect the different age ranges and broader question asked in our study. However, findings are consistent with other recent studies reporting high levels of e-cigarette access among tobacco smokers (e.g. USA [20]), and this may indicate the rapid expansion in promotion [10] and reducing price [21] of e-cigarettes that means they are widely visible and easily available to teenagers with an interest in smoking.
A key public health concern with e-cigarettes is their potential to recruit children to nicotine dependence. In adults, e-cigarettes are typically used by smokers to help them reduce or quit tobacco use and uptake levels among non-smokers are thought to be very low (typically <1%) [22-25]. Here, however, almost one in twenty (4.9%) teenagers who had never smoked conventional cigarettes reported having accessed e-cigarettes. In fact, although ex-smokers had greater odds of e-cigarette access than never smokers, never smokers accounted for a much larger proportion of the sample (61.2% v 5.1% for ex-smokers) and therefore a larger proportion of those reporting e-cigarette access (15.8%) than ex-smokers (13.6%). Among never-smokers, odds of having accessed e-cigarettes were greater in 14 year olds than in those aged 15 or 16 years. This likely reflects the fact that many young people who are inclined towards smoking will have already tried cigarettes by the age of 15. For individuals who have never used a substance, however, accessing that substance is a first step to initiating use. Further, for conventional tobacco products, perceived ease of accessibility has been found to increase adolescents’ risk of smoking uptake [26].
In the UK, as in many other countries, today’s adolescents have grown up with a strong ‘smoking kills’ message and reducing social acceptance of smoking. Smoking prevention education is delivered in schools from an early age, tobacco advertising is banned, tobacco packaging carries strong visual health warnings and smoke-free legislation prohibits smoking in virtually all enclosed work and public spaces. As tobacco control and smoking prevention activity has increased, smoking prevalence in children has reduced, with 23% of 11-15 year olds in England in 2012 having ever tried smoking compared with 49% in 1996 [27]. However, adolescence is a period of experimentation and while anti-smoking efforts may have deterred many teenagers from trying tobacco, the marketing of e-cigarettes as a healthy alternative may proffer a viable new method for them to experience the nicotine ‘hit’ without the perceived harmful impacts of tobacco. For other products, health claims have been found to produce a ‘halo effect’ that not only encourages purchasing, but also reduces consumers’ information-seeking (e.g. food and nutritional information [28]). Specifically for teenagers, glamorisation of e-cigarettes in advertising, celebrity endorsement and the range of attractive designs and flavourings available are likely to be furthering their appeal [3]. Here, almost a quarter of teenagers that had accessed e-cigarettes had tried smoking conventional cigarettes but not liked them. Although we cannot determine whether this experience occurred before or after accessing e-cigarettes, it is likely that flavourings make e-cigarettes an attractive option to teenagers who would otherwise be put off conventional cigarettes by their taste.
A key finding from our study was the association between alcohol consumption and e-cigarette access. Even after controlling for smoking behaviours, teenagers who drink regularly and binge drink were significantly more likely to have accessed e-cigarettes (Table 1). This association was particularly strong in those that had never smoked. Thus, over one in ten never-smokers who drank regularly and binged had accessed e-cigarettes, with their odds of e-cigarette access more than four times those of never-smokers who did not drink. Among all drinkers, e-cigarette access was associated with binge drinking, drinking to get drunk, involvement in violence after drinking and consumption of spirits; a drink type that has been associated with alcohol-related harm in previous studies [16]. These findings suggest that teenagers that access e-cigarettes are those that are most vulnerable to other forms of substance use and risk-taking behaviours, and that e-cigarettes are rapidly being added to at-risk teenagers’ substance using repertoires.
The high prevalence of e-cigarette access amongst teenagers in our study, and particularly their use among those that have never smoked conventional cigarettes, highlights the urgent need for age restrictions on the promotion and sale of e-cigarettes. With such restrictions increasingly being introduced, understanding how teenagers that access e-cigarettes are able to access other age-restricted products (i.e. cigarettes and alcohol) will support enforcement work. Among smokers, obtaining cigarettes from friends or family over the age of 18 was independently associated with e-cigarette access. Friends and family are also key sources of e-cigarettes for teenagers [29]. Among drinkers, teenagers who bought alcohol themselves from off-licensed premises and those who asked adults outside shops to purchase alcohol for them (known as proxy purchasing) also had increased odds of e-cigarette access. Both these methods represent mechanisms by which minors access alcohol illicitly without the knowledge or supervision of parents or guardians, and both have been associated with risky alcohol consumption and alcohol-related harms in previous studies [15,16]. Their association with e-cigarettes suggests that teenagers who access e-cigarettes are already familiar with strategies to bypass age legislation on restricted products.
Across all analyses conducted in our study, having a parent or guardian who smokes was one of the strongest predictors of e-cigarette access. Associations between parental and child smoking are widely reported [30], and are thought to operate through both genetic and environmental influences. Similar relationships may exist for propensity to experiment with e-cigarettes. The Trading Standards survey did not ask students whether or not their parents used e-cigarettes, yet the availability of e-cigarettes in the home may be an important consideration for future interventions. Although the content of e-cigarettes varies [31], single cartridges typically contain several hundred ‘puffs’ and unguarded, could easily be ‘shared’ by children without the adult users’ knowledge. The involvement of parents along with schools in work to address e-cigarette use in children is likely to be particularly important as their lack of smoke and odour means that, unlike conventional cigarettes, they can easily be used in bedrooms or on school property without detection.
Like all cross-sectional surveys, this study had a number of limitations. Firstly the question on e-cigarettes included in the Trading Standards survey was specific to access, asking whether students had tried or bought e-cigarettes. However, preventing child access to e-cigarettes is the focus of current regulatory responses to e-cigarettes. While it is not possible to determine how many of those teenagers who accessed e-cigarettes had either bought or used them, it seems reasonable to assume that many teenagers who are motivated to purchase an e-cigarette would also be interested in trying it. The survey did not record any measure of e-cigarette access frequency nor of when e-cigarette access had occurred, and thus it was not possible to identify whether teenagers that reported both e-cigarette access and smoking had accessed e-cigarettes before or after conventional cigarettes. While school surveys can be limited by time availability in the classroom, results from this survey justify a greater focus on e-cigarettes in the next iteration of the survey, including questions on frequency of e-cigarette use and age of initiation. School participation was voluntary and compliance data were not recorded, thus selection bias cannot be ruled out. In the absence of residential postcode data, students were assigned to a quintile of deprivation on an ecological basis and while this may have meant some students were misallocated, the deprivation profile of the sample was generally consistent with that for the 14-17 year old population in the North West region (sample, quintile 1, 12.5%; 2, 15.1%; 3, 15.8%; 4, 18.7%; 5, 37.9%; North West, quintile 1, 15.6%; 2, 16.3%; 3, 15.6%; 4, 18.0%; 5 34.5%). Students that could not be assigned to a deprivation quintile were excluded from analysis and therefore represent additional potential bias in the final sample. As with all surveys of self-reported social behaviours, students’ may have under or over reported e-cigarette access, smoking and drinking behaviours due to factors including social desirability, poor recall or lack of knowledge. Finally, while little data are available on the regional distribution of e-cigarette use among either children or adults in England, prevalence of tobacco smoking tends to be higher in the North than in the South [32]. Thus findings should not be considered representative of all 14-17 year olds in England or the North West region.
