Impacts of EU Tobacco Products Directive regulations on use of e-cigarettes in adolescents in Great Britain: a natural experiment evaluation
Authors: Moore Graham , Hallingberg Britt , Brown Rachel , McKell Jennifer , Van Godwin Jordan , Bauld Linda , Gray Linsay , Maynard Olivia , Mackintosh Anne-Marie , Munafò Marcus , Blackwell Anna , Lowthian Emily , Page Nicholas 
Published: July 2023

Background
E-cigarettes are a popular smoking-cessation tool. Although less harmful than tobacco, use of e-cigarettes by non-smokers should be prevented. There is concern about the use of e-cigarettes by young people and that e-cigarettes may renormalise smoking. In May 2016, Tobacco Products Directive regulations aimed to reduce e-cigarettes’ appeal to young people.

Aims
To examine the effects of the Tobacco Products Directive regulations on young people’s use of e-cigarettes, and the role of e-cigarettes in renormalising smoking.

Design
A mixed-method natural experimental evaluation combining secondary analyses of survey data, with process evaluation, including interviews with young people, policy stakeholders, retailers and trading standards observers, and observations of retail settings.

Settings
Wales, Scotland and England.

Participants
Survey participants were aged 13–15 years, living in England, Scotland or Wales and participated in routinely conducted surveys from 1998 to 2019. Process evaluation participants included 14- to 15-year-olds in England, Scotland and Wales, policy stakeholders, trading standards offices and retailers.

Intervention
Regulation of e-cigarettes, including bans on cross-border advertising, health warnings and restrictions on product strength.

Comparison group
Interrupted time series design, with baseline trends as the comparator.

Main outcome measures
The primary outcome was ever e-cigarette use. Secondary outcomes included regular use, ever and regular smoking, smoking attitudes, alcohol and cannabis use.

Data capture and analysis
Our primary statistical analysis used data from Wales, including 91,687 young people from the 2013–19 Health Behaviour in School-aged Children and School Health Research Network surveys. In Scotland, we used the Scottish Schools Adolescent Lifestyle and Substance Use Survey and in England we used the Smoking Drinking and Drug Use surveys. The process evaluation included interviews with 73 young people in 2017 and 148 young people in 2018, 12 policy stakeholders, 13 trading standards officers and 27 retailers. We observed 30 retail premises before and after implementation. Data were integrated using the Medical Research Council’s process evaluation framework.

Results
Ever smoking continued to decline alongside the emergence of e-cigarettes, with a slight slowing in decline for regular use. Tobacco Products Directive regulations were described by stakeholders as well implemented, and observations indicated good compliance. Young people described e-cigarettes as a fad and indicated limited interaction with the components of the Tobacco Products Directive regulations. In primary statistical analyses in Wales [i.e. short (to 2017) and long term (to 2019)], growth in ever use of e-cigarettes prior to Tobacco Products Directive regulations did not continue after implementation. Change in trend was significant in long-term analysis, although of similar magnitude at both time points (odds ratio 0.96). Data from England and Scotland exhibited a similar pattern. Smoking followed the opposite pattern, declining prior to the Tobacco Products Directive regulations, but plateauing as growth in e-cigarette use stalled.

Limitations
Alternative causal explanations for changes cannot be ruled out because of the observational design.

Conclusions
Young people’s ever and regular use of e-cigarettes appears to have peaked around the time of the Tobacco Products Directive regulations and may be declining. Although caution is needed in causal attributions, findings are consistent with an effect of regulations. Our analysis provides little evidence that e-cigarettes renormalise smoking. More recent data indicate that declines in smoking are plateauing.

Future work
International comparative work to understand differences in use of e-cigarettes, and tobacco, within varying regulatory frameworks is a priority.

Study registration
This study is registered as ResearchRegistry4336.

Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.