Title: Does a ban on vaping in public places prevent the “renormalisation” of smoking? A natural experiment
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Ecigarettes are a polarising issue in contemporary public health, with some arguing that the public health community should embrace them as a safer alternative to smoking, while others are concerned that they may "renormalise" smoking. These divergent views on e-cigarettes, which are to date informed by limited evidence on both sides, have led to growing public confusion in relation to the harms of e-cigarettes, and divergence in policy responses. In Wales, the Welsh Government have committed to banning vaping in public places, citing concerns that if left unchecked, the growing visibility of vaping would "renormalise smoking". Other UK countries have opposed this position and do not plan to legislate. Reasons for not legislating include the limited evidence for the renormalisation hypothesis, though some also cite potential harms of legislation; for example, if e-cigarettes lose a key advantage over tobacco (that they can be used in public), smokers may continue to use tobacco in these contexts, and may be less likely to view e-cigarettes as a viable alternative to tobacco. This emerging disjuncture provides a time limited opportunity for a mixed-method natural experiment to understand how smoking trajectories are impacted by this legislation in Wales, by comparison to Scotland where no legislation will be implemented. We will combine a range of secondary quantitative datasets to compare youth smoking trajectories (the Health Behaviour in School Aged Children/School Health Research Network survey in Wales, and SALSUS in Scotland), and adult smoking trajectories (the Integrated Household Survey, the Adult Tobacco Policy Surveys and Omnibus Surveys) for a period of up to 18 years prior to legislation and then following legislation. Smoking rates have in recent years converged between these two countries. If the hypotheses that e-cigarettes renormalise smoking, and that legislating to limit their use in public places will prevent this, hold, we will expect to see a reemergence of differences between countries in youth experimentation with smoking, and adult smoking rates. The latter may arise from lowered motivation to quit where smoking becomes more normalised and less stigmatised. We will also conduct an indepth longitudinal qualitative process evaluation in order to understand perceptions of e-cigarettes, their roles in renormalising or denormalising smoking, perceived impacts and unintended harms of legislation and issues of implementation and compliance. We will interview 30 young people and 30 adults in Wales and Scotland before and after legislation to investigate renormalisation processes. Potential unintended harms of legislation will be explored through qualitative interview research with vapers and smokers into patterns of e-cigarette and tobacco use, and perceived impact of legislation on these. This will focus on for example, the perceived impact of the ban on nicotine usage while in public places (i.e. smoking vs vaping outside of bars) and changes in perceptions of e-cigarettes as a viable alternative to tobacco among smokers. We will investigate issues relating to compliance to legislation through qualitative interviews with staff in hositality establishments as well as environmental health and policy stakeholders.

Lay abstract: Ecigarettes have divided many within the public health community, with some arguing that they represent a less harmful potential replacement for tobacco, while others argue that they may promote smoking through renormalisation. There is some evidence that they can be effective in helping people to stop smoking, but also some evidence that they are mostly being used alongside tobacco rather than as a replacement ("dual use"), while young people are increasingly experimenting with e-cigarettes. These differences in perspective have given rise to different policy response. In Wales, the government has committed to banning use of e-cigarettes in public places, citing concerns that they renormalize smoking. Other UK governments have said that they will not do this, citing the lack of evidence that e-cigarettes renormalise tobacco, as well as potential harms. For example, there are some concerns that if e-cigarettes lose a key advantage over smoking (that they can be used in public), smokers may simply continue to use tobacco instead of switching. We will conduct a mixed-method "natural experiment" comparing trends in adult and youth smoking before and after legislation in Wales, against Scotland where no legislation will be implemented. While historically, Scotland has had higher rates of smoking than Wales, rates have become very similar in the 2 countries in recent years. If the renormalisation hypothesis is correct, we would expect to see a re-emergence of differences between countries in smoking rates, with smoking once again becoming more prevalent in Scotland. We will combine a number of routinely collected survey datasets among youth and adults in Scotland and Wales for a period of up to 18 years prior to legislation, and a year after. In addition, we will collect qualitative interview data from adults and young people before and after the introduction of legislation, to understand perceptions of e-cigarettes and tobacco use and how these are impacted by legislation. These will investigate perceptions of smoking norms and stigma. Interviews with smokers will examine perceptions of e-cigarettes as an alternative to smoking. Interviews with vapers will examine perceived impacts of legislation on patterns of e-cigarette and tobacco use. We will also conduct interviews with premises staff and policy and practice stakeholders to understand barriers and facilitators to compliance.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;RESPIRATORY;STROKE