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News media representations of electronic cigarettes: an analysis of newspaper coverage in the UK and Scotland
  1. Catriona Rooke,
  2. Amanda Amos
  1. UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Medical School, Edinburgh, UK
  1. Correspondence to Dr Catriona Rooke, UK Centre for Tobacco and Alcohol Studies, Centre for Population Health Sciences, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, UK; catriona.rooke{at}ed.ac.uk

Abstract

Objective Electronic Nicotine Delivery Systems (ENDS) have recently been attracting interest for their potential as a less harmful alternative to smoking, their rising popularity and the regulatory issues they raise. The news media can play an important role in shaping public perceptions of new technologies. It is, therefore, important to understand the ways the news media present ENDS. This paper examines how ENDS are represented in the UK and in the Scottish press.

Methods Twelve national UK and Scottish newspapers and the three most popular online news sources were searched between 2007 and 2012. A thematic analysis was conducted to explore how the meanings, uses and users of ENDS are presented, and whether and how this has changed.

Results Newspaper coverage of ENDS increased substantially over this period. Five key themes emerged from the analysis: getting around smokefree legislation; risk and uncertainty; healthier choice; celebrity use; price.

Conclusions Drawing on the diffusion of innovations theory, we suggest that newspaper constructions of ENDS provide readers with important information about what ENDS are for, how they work, and their relative advantages. These themes, and dominance of more positive meanings, raise a number of issues for tobacco control, including concerns around celebrity use and promotion; the impact of increasing ENDS use on social norms around smoking; their potential to undermine smokefree legislation; and their promotion as effective cessation aids.

  • Electronic nicotine delivery devices
  • Media
  • Advertising and Promotion
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Background

Electronic nicotine delivery systems (ENDS), more commonly termed electronic or ‘e’-cigarettes,i have been garnering increasing interest in recent years. This interest is spurred by a range of issues: ENDS’ potential as a less harmful alternative to smoking tobacco, their rising popularity despite uncertainty around safety and efficacy, and the challenge they pose for regulators.1 ,2 Commonly, they are designed to look and feel like conventional cigarettes. Studies investigating ENDS have focussed predominantly on establishing devices’ nicotine delivery characteristics,3–5 their effectiveness for smoking reduction and cessation,6–9 and examining health and safety concerns.10 ,11

The legal status and availability of ENDS varies between jurisdictions. Some countries have prohibited the sale of ENDS (eg, Brazil, Singapore) or regard them as an unapproved product making therapeutic claims (eg, Australia, Canada). In the UK, ENDS are regulated under consumer protection regulations and promotion is not specifically controlled. This has raised concerns over manufacturing and safety standards as well as marketing and advertising practices. The UK medicines regulator (Medicines and Healthcare products Regulatory Agency) announced in June 2013 that ENDS will be regulated as medical products from 2016.12 ENDS have been predominantly sold online, but are now available at newsagents and in supermarkets. Marketing appears to be greatest in countries with relatively high disposable income.13 Studies suggest awareness of ENDS is high in these countries, particularly where they are legally available.14 The popularity of ENDS has risen steeply in the UK. A national online survey of smokers in England found that the percentage of smokers who had never heard of ENDS fell from 38% in 2010 to 21% in 2012, while the proportion of smokers reporting current ENDS use rose from 3% to 7%.15

The diffusion of innovations theory highlights that the mass media (all forms of communication that transmit information to a large audience, such as television, newspapers, radio and websites) are important in making people aware of, and shaping their perceptions of, innovations.16 The theory, which posits that there is a common pattern to the process through which diverse innovations are taken up, outlines five stages to deciding to take up an innovation: knowledge, persuasion, decision, implementation and confirmation. It suggests that key features of an innovation that influence adoption include: relative advantage in comparison to current practice; compatibility with values, previous experience and current needs; the perceived complexity of the innovation; triability or the opportunity to try out the innovation; and observability or how visible the results are to others. Mass media channels are important at the ‘knowledge’ stage in exposing audiences to an innovation and introducing its functions and key characteristics.

Moreover, the news media (forms of mass media that focus on communicating news, including newspapers, online and broadcast news) are a central forum for debates on health and lifestyle. They are a key means by which information is diffused in society, and important sources through which the public become aware of health issues and new products. The news media play an important role in shaping public perceptions of new technologies and public opinion about health issues.17 ,18 Stories in the news do not simply provide information, instead, they can be seen as constructing interpretative frameworks, which shape how a technology or issue is understood.19 ,20 These frameworks, or representations, involve selection and exclusion of material, presenting a particular version of reality.

The UK currently provides a potentially important case study through which to analyse how ENDS have been represented in the news media and the possible implications for tobacco control. We report on a study that examined how ENDS are presented in UK newspaper coverage. While print newspaper sales are declining in the UK, as elsewhere, around half of British adults read a national newspaper.21 Newspapers are a useful proxy for reporting in other media as they often set the agenda for other formats and are easy to access and search.22 To analyse newspaper coverage, we conducted a thematic analysis.23 Using diffusion of innovations theory as a conceptual lens, our analysis investigates how the meanings, uses and users of ENDS are presented, and whether and how this has changed over time. In particular, we focus on how the characteristics of ENDS are presented to readers, including information on what ENDS are for, how they work and their relative advantages.

Methods

Using the search terms ‘electronic cigarette’, ‘e-cigarette’ and ‘e cigarette’, 12 national UK and Scottish newspapers (and their Sunday editions) were searched using the electronic database Lexis Library. The analysis was carried out for the 5-year period of 1 July 2007 to 30 June 2012. The newspapers selected balanced circulation figures (January–June 2012),24 with a range of readership profiles: serious (Daily Telegraph, Times, Guardian, Independent, Herald, Scotsman), middle-market tabloid (Daily Mail, Express), and tabloid (Sun, Mirror, Daily Star, Daily Record). As online news is an increasingly important source of news reporting, we also searched three of the most popular online news sources: MailOnline, BBC News and guardian.co.uk.25 The website of each source was searched using the search terms above.

All stories mentioning ENDS, whether they were the focus of the article or a passing mention, were included. Articles were excluded if they: were letters, were duplicate articles, appeared both in print and online (ie, in the Guardian and guardian.co.uk—the print edition only was included), were published in Irish editions or, for online sources, the story was in video/audio as opposed to print format (38 articles were excluded). This produced a total of 119 articles (including news articles, editorials and columns).

The thematic analysis was an iterative process involving rereading and coding the articles, generating themes and discussing the coding and themes between the authors. As ENDS are an emergent topic, the initial coding progressed inductively. Articles were read, reread, and then coded focusing on the following questions: What were ENDS presented as being for? What characteristics of ENDS were emphasised? Who were presented as actual/potential users of ENDS? Where was use of ENDS portrayed/imagined? This initial coding was then organised into key ways of presenting ENDS which recurred throughout the coverage. These were refined through further coding and discussion to produce five key themes (box 1). A theme, following Braun and Clarke ‘captures something important about the data in relation to the research question, and represents some level of patterned response or meaning within the data set’.23 All articles were then coded for the presence of the five themes. There could be multiple themes in one article, and a theme did not have to be the central focus of the article to be deemed present. An indication of the prevalence of themes is provided in the Results (table 1) in order to give a sense of how their presence in articles varied over time. Thirteen articles did not contain any of the five key themes. These articles fell into two main categories: brief reports on surveys sponsored by an ENDS retailer or stories whose main focus was not ENDS.

Box 1

Five main themes

  • Getting around smokefree legislation: Presents e-cigarettes as being intended for getting around smokefree legislation and/or discusses e-cigarettes as allowing users to smoke in places covered by the smokefree legislation.

  • Risk and uncertainty: Suggests that concerns are being raised about e-cigarettes, and/or that e-cigarettes may be harmful or contain harmful substances, and/or are not adequately tested or regulated.

  • Healthier choice: Presents e-cigarettes as a healthier alternative to smoking tobacco cigarettes, and/or says e-cigarettes do not contain any of the harmful substances found in tobacco, or suggests that they are less harmful than tobacco products, and/or suggests that e-cigarettes can help with stopping smoking.

  • Celebrity use: Mentions in an interview with a ‘celebrity’ that the interviewee uses an e-cigarette, and/or mentions a ‘celebrity’ being spotted using an e-cigarette or are known to use e-cigarettes, and/or mentions that a ‘celebrity’ is promoting an e-cigarette brand.

  • Price: Notes the cost of buying e-cigarette/s or a starter pack; suggests that e-cigarettes are expensive; suggests that using an e-cigarette will help save money (compared with smoking).

Table 1

Prevalence of themes—as a proportion of the total number of stories each year (2007–2012)

CR led the analysis, regularly discussing the development and refining of themes with AA. Articles were then coded for presence of themes by CR. To check coding reliability, 19% (23) of the articles selected using a random number generator, were also coded by AA using the definitions in the box. Cohen's kappa for the five themes ranged from 0.86 to 1 indicating a good level of agreement for all themes. Illustrative quotes from articles are given in the Results with the source, date and page number for newspapers.

Results

Of the 119 articles analysed, 27 were from broadsheet newspapers, 26 middle-market tabloid, 29 tabloid and 37 from online sources (6 BBC News, 5 guardian.co.uk, 26 MailOnline). The earliest reportage of e-cigarettes in our sample occurred in July 2007 coinciding with the implementation of legislation prohibiting smoking in enclosed public places (1 July 2007) in England (legislation was introduced in Scotland a year earlier). E-cigarettes did not initially receive much coverage with eight stories appearing in the first year (July 2007–June 2008) and 21 in the second (July 2008–June 2009). Coverage rose over the 5 year period with most occurring in the last 2 years (75 stories between July 2010 and June 2012 compared to 44 between July 2007 and June 2010).

Overall, the most commonly mentioned theme was healthier choice followed by getting around smokefree (table 1). All stories in the first year used the getting around smokefree theme and mentioned the price of an e-cigarette. The healthier choice theme appeared in around half or more of the stories each year. We now go on to discuss how these themes were presented in stories.

‘Getting around’ the smokefree legislation

The first stories to appear presented e-cigarettes primarily as a way to ‘get around’ the smokefree legislation. For example, the first article to mention e-cigarettes appeared in the Mail on Sunday and was entitled ‘Electriciggy: the battery-powered nicotine fix that its investors insist will allow smokers to beat the ban’, informing readers that the ‘Electronik cigarette’ …stays strictly inside the law banning lighting up in public buildings which, after just a week in force, is already testing smokers’ willpower to the limit. (08/07/07: 43)

In this theme, e-cigarettes are introduced as a way to ‘beat’, ‘get around’ or ‘dodge’ the ‘smoking ban’, and descriptions highlighted that e-cigarettes may be used inside, often emphasising the legality of this using phrases such as ‘inside the law’. Most commonly it was pubs and clubs where e-cigarettes were envisaged being used.

Stories emphasising this theme often had a defiant or rebellious tone, with some underlining giving smokers a ‘choice’ or ‘freedom to smoke where you want’. A column in the Guardian by Alexander Chancellor demonstrates this tone: I have recently tried a rechargeable “electronic cigarette” […] I am particularly looking forward to ‘smoking’ it in restaurants and cinemas, where I will be able to say boo to anyone who tries to stop me. (Guardian, 25/07/08, Features: 5)

The characteristics of e-cigarettes most commonly brought to the fore in this theme were: the ‘hit’ of nicotine it provides, the light at the tip and, particularly, the ‘realistic puffs of smoke’; descriptions reinforced that e-cigarettes are like smoking a cigarette in several key ways (satisfying nicotine cravings, sensation of inhaling smoke) but differed in one significant way—they can be used indoors.

Often, these stories included personal experience with, or public opinions about, this strange new product. For example, the Mail on Sunday (08/07/07: 43) story highlighted above appeared with an insert in which the reporter tried out an e-cigarette in a pub and reported the reactions of others. Particularly in the earlier stories there were concerns over feeling silly ‘smoking’ an e-cigarette, problems with getting them to work, and surprised or confused reactions from the public.

Price

Another theme that appeared in the early coverage was price. The cost of purchasing an e-cigarette or ‘starter kit’ was frequently mentioned in descriptions, for example, ‘It costs £35 pounds to buy a starter park and £4 for refills after that.’ (BBC News, 08/10/08). The majority of articles mentioned the cost neutrally. A minority of earlier stories noted that they were expensive, while some later coverage portrayed e-cigarettes as a way to save money: The value of the e-cigarette is apparent enough. For a start it is far cheaper. The calculation is that one recharged “e” is the equivalent of 15 cigarettes - and mine comes at £2 a time: a saving of more than £3 a packet. (Independent, 31/12/11)

Whilst commonly occurring, this theme was rarely the main focus of stories.

Risk and uncertainty

Towards the end of 2008, another theme began to appear: e-cigarettes as potentially risky. In October, four articles in different newspapers highlighted ‘fears’ over e-cigarettes and linked concerns to rising sales caused by e-cigarettes not being covered by smokefree legislation. The key concerns raised were over the lack of knowledge about, and regulation of, the product. These stories drew on the views of ‘experts’—representatives of Action on Smoking and Health and WHO are quoted as raising concerns—and retailers of e-cigarettes.

The key feature of e-cigarettes in this theme is that they are potentially harmful to health, unsafe, or that not enough is known about them. Some stories presented nicotine itself as a dangerous poison, particularly in relation to children: …trading standards officers say they contain up to 18 mg of liquid nicotine in refill cartridges which could prove fatal to young children if swallowed. (MailOnline, 13/03/09)

Others reported ‘scientific’ studies that had found e-cigarettes to contain risky substances: …carcinogens and toxic chemicals such as diethylene glycol, which is found in anti-freeze. (Independent on Sunday, 26/07/09: 16).

This theme was also present in reports of instances where e-cigarettes had been banned, or where efforts were being made to implement a ban, due to health/safety concerns (eg, Australia, Canada). Controversy and uncertainty were highlighted, with concerns raised that e-cigarettes are not appropriately regulated or that not enough is known about them: There is a worrying lack of safety data on electronic cigarettes, despite their growing popularity with the public, two leading Greek researchers have warned (BBC News, 20/01/10)

In some stories, e-cigarettes were compared unfavourably with ‘tried and tested’ nicotine replacement therapies (NRT).

Celebrity use: the ‘latest must-have accessory’

A theme emerging from 2009 onwards was the use and promotion of e-cigarettes by celebrities. Some stories depicted e-cigarettes as a fashionable new product, and these articles were often accompanied by pictures of celebrities using e-cigarettes. One example is a story that appeared in the Sun, Express and Mail on Sunday about Lady Victoria Hervey promoting a brand that she ‘helped design’: Sarah Harding has been spotted puffing away on one and Kate Moss is said to be on the waiting list for the most unlikely must-have accessory of London Fashion Week: an electronic cigarette. Perhaps even more surprising is the woman who is touting these little white sticks around town: Lady Victoria Hervey. (Mail on Sunday, 27/09/09)

Celebrity stories often noted other advantages, for example, highlighting that e-cigarettes can be used inside, that one can ‘enjoy the social side of smoking without the nasty smoke’ (as suggested in the above story), or that they were being used to help the person in the story quit smoking. During 2011, several stories appeared in the MailOnline (almost 40% of stories in the MailOnline were celebrity stories) describing spotting Katherine Heigl, an American actress who the stories suggested was trying to quit smoking, using an e-cigarette. These stories, whose focus ranged from her use of e-cigarettes, her outfit and her figure, described her ‘struggle’ to quit smoking: “I’ve tried everything. I’ve tried the patch, I’ve tried the gum, I’ve done Chantix, twice, which made me bananas...” (MailOnline, 15/03/11), emphasising the difficulty of quitting and the potential of e-cigarettes as a new approach.

A healthier choice: tobacco substitute; quitting aid

The ‘healthier choice’ theme presented e-cigarettes primarily as allowing users to make a positive choice for their health. Initially, this theme appeared in the form of a brief aside in stories focussing on e-cigarettes as a way to get around smokefree legislation; later it was introduced alongside the ‘risky’ theme as a defence of e-cigarettes, for example: Michael Ryan of E-Lites insisted that e-cigarettes provide ‘a much healthier alternative to tobacco cigarettes’ and are only ‘marketed to existing smokers over 18 years’. (MailOnline, 12/08/09)

This presentation suggests disagreement over the riskiness of e-cigarettes, reframes the risk in comparison with smoking cigarettes, and presents those selling e-cigarettes as responsible. This theme contained two subthemes: e-cigarettes as a ‘healthier alternative’ to tobacco cigarettes and as a tool for quitting smoking.

As a ‘healthier alternative’ e-cigarettes were presented as a replacement for smoking, and key features emphasised were the effects of nicotine and the action of smoking without the harmful substances in tobacco: The electronic cigarette looks very similar to a normal cigarette and acts as an alternative to smoked tobacco products. The battery-operated device provides small doses of nicotine when the smoker inhales but without the tar, tobacco or carbon monoxide of a traditional cigarette. (BBC News, 01/11/10)

Some stories discussed e-cigarettes in the context of the development of ‘safer cigarettes’ or innovation/investment by tobacco companies. These stories drew on ideas about tobacco harm reduction that have become increasingly prominent in academic and policy debates (particularly in England).2 ,26 These stories picked up on the view that a new approach is needed for smokers who can't/won't quit and that ‘safer substitutes’ are a solution. A few articles in 2011 reported on the annual report of the UK Cabinet Office Behavioural Insights Team,27 which suggested the use of e-cigarettes for harm reduction: Smokeless electronic cigarettes are to be promoted by health chiefs in a bid to cut the number of people dying from smoking diseases. (Daily Star, 16/09/11: 21).

This coverage suggested official backing for e-cigarettes and highlighted their ‘potential to save lives’. It also noted the riskiness of e-cigarettes and the need for appropriate regulation. The healthier alternative subtheme was rarely a key focus of stories; rather it offered an additional reason that e-cigarettes might be used.

The first article to talk about e-cigarettes in the context of quitting smoking was in April 2009 and appeared in coverage of a gadget show: …he ended up buying a strange new gizmo for himself - menthol-flavoured electronic cigarettes. […] He had tried everything to ditch the habit, including acupuncture, patches and gum. He reckoned the electronic fags might just work. (Guardian, 18/04/09, Home: 8)

This quote highlights a common discourse—having tried everything to quit smoking and then finding e-cigarettes. Some articles referred to e-cigarettes as a type of NRT. Others included personal accounts (both positive and negative) or (as highlighted above) descriptions of celebrities using e-cigarettes to quit smoking. Often addiction and difficulty quitting were emphasised, and e-cigarettes were presented as a tool to help ‘break’ the ‘addiction’ or ‘habit’, with the importance both of nicotine and the act of smoking highlighted.

As noted in relation to celebrity use, many articles incorporated more than one theme, for example: Advocates believe e-cigarettes provide a stepping-stone to quitting, but opponents say their health impact is unknown. Now New York is considering a state-wide ban… (MailOnline, 26/01/11)

The inclusion of several of the key themes in one story was more common from 2011 onwards.

Discussion

As interest in ENDS has risen, and ENDS marketing becomes increasingly widespread in the UK, UK newspaper coverage of this product has also increased. This is the first study, to our knowledge, to analyse newspaper representations of ENDS in the UK. In the corpus we analysed, five key themes relating to smokefree legislation, health, risk, price and celebrity were used in presenting ENDS to readers. Coverage often appeared to take a somewhat ‘balanced’ approach: many articles included more than one theme and presented the reader with positives and negatives of ENDS use. However, overall, coverage tended (in terms of prevalence and attention given to themes) towards positive themes, with more focus on reasons for using ENDS rather than on potential risks. There was a shift over time in the coverage from uncertainty over a strange new product and a focus on getting around smokefree legislation towards greater familiarity with ENDS and drawing on multiple themes.

Our analysis highlights that newspaper coverage of ENDS in the UK provides readers with important, and selective, information about what ENDS are for and their key features. Drawing on ideas about how innovations are taken up,16 these representations communicate various characteristics of ENDS that are associated with uptake: particularly their relative advantages compared with smoking or NRTs, and their compatibility with values, previous experience and current needs. Several relative advantages over smoking were highlighted—healthier, cheaper, not covered by smokefree legislation, used by celebrities—and most articles mentioned at least one of these. Advantages over current NRTs also emerged: ENDS similarities to cigarettes and ability to replicate the act of smoking, and the possibility of them working where NRTs have failed. Similarly, ENDS’ ability to meet a range of needs that smokers may have was highlighted: restrictions on their smoking, concerns about health, desire to quit smoking, the expense of smoking. Furthermore, the themes often drew on broader discourses about smoking, emphasising that people smoke because they are addicted to nicotine and that quitting smoking is very difficult. Coverage often mapped ENDS onto more familiar products, and drew parallels with both cigarettes and NRTs, linking use of ENDS to previous experience. Significantly, the most recent marketing slogan of one popular brand E-Lites is ‘Smoking, reinvented’. Indeed, many of the themes reported in this analysis reflect key messages from the marketing of ENDS.28 This dominance of more positive representations and communication of key characteristics of ENDS suggests that the news media coverage has not only paralleled increased interest in, and use of ENDS, but may have contributed to it.

It should be noted that this study does not provide the full picture of all news media coverage on ENDS. However, newspaper coverage is strongly related to coverage in electronic news media.19 Furthermore, we report on a sample of UK and Scottish national newspapers, but these include newspapers with high circulation figures and a range of readership profiles and are therefore likely to provide a good reflection of overall coverage. Furthermore, while we have analysed key themes appearing in newspaper stories, we do not know how these themes were received and interpreted by different audiences. Further research is needed on how mass media and marketing constructions of ENDS impact on smokers’ views and behaviours.

The themes described here raise several issues for tobacco control. The interest in celebrity use and promotion provokes unease around the glamourising of a product containing an addictive substance. This links to more general concerns about marketing and promotion of ENDS.26 ,28 The focus on the act of smoking in stories and the inclusion of images which highlight the visual similarity between ENDS and cigarettes raises concerns about the impact of increasing ENDS use on social norms. Social denormalisation strategies, which seek to change social norms around smoking,29 are an important approach in tobacco control, and an increase in visibility of ENDS in smokefree spaces might undermine these efforts.26 An issue that has been raised concerning alternative nicotine-delivery devices is the potential for them to be promoted in ways that undermine smokefree legislation, and encourage dual use of cigarettes and alternatives rather than quitting. The key themes identified in this study indicate that this is a real concern.

Moreover, that the ‘healthier choice’ theme occurred most frequently in stories, and often referred to ENDS as a quitting aid or NRT, raises concerns about making of health claims based on limited scientific evidence. Research highlights that brands claiming to deliver nicotine do so with varying efficacy.3–5 While internet surveys suggest that users consider ENDS a satisfactory replacement for cigarettes,6 ,9 and a recent 12-month randomized controlled trial concluded they hold promise for smoking reduction and abstinence,7 evidence on their efficacy for smoking cessation is still limited.

The role of harm reduction and ENDS are areas of significant divergence within the tobacco control community. The implications of this study may, therefore, be assessed differently by those with different positions on these debates. While some may see raising awareness among smokers about a less harmful alternative to smoking as a positive development, others will be concerned by many of the representations described. Nevertheless, it seems likely that there are elements of this coverage that most tobacco control advocates would agree require action. While the concerns raised above may not outweigh the benefits that ENDS could provide to individual smokers, they underscore the need to subject the claims being made about ENDS to appropriate scrutiny. This analysis further highlights the pressing need for prompt implementation of appropriate controls over the marketing and promotion of these products.26 The increase in, and glamourising elements of, ENDS coverage underscore the need to place age restrictions on the availability of ENDS. Furthermore, with increasing coverage of and use of ENDS in the UK, and widespread positive messages about them, it may become increasingly challenging to implement appropriate controls.

What this paper adds

  • Electronic Nicotine Delivery Systems (ENDS) have been attracting interest for their potential as a less harmful alternative to smoking, their rising popularity and the regulatory issues they raise. The news media play an important role in shaping public perceptions of new technologies but we know little about how they cover ENDS. Newspaper coverage of ENDS in the UK increased substantially between 2007 and 2012. This coverage may have paralleled increased interest in, and use of, ENDS, and may have contributed to it. Newspaper representations of ENDS can provide readers with important, and selective, information about what ENDS are for, how they work, and their relative advantages. Five key themes were found to dominate the presentation of ENDS: getting around smokefree legislation, a healthier choice, risk and uncertainty, price and celebrity use. These themes, and dominance of more positive representations, raise several issues for tobacco control including concerns around celebrity use and promotion; the impact of increasing ENDS use on social norms around smoking; and their promotion as effective cessation aids.

References

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Footnotes

  • Contributors CR and AA designed the study and undertook the analysis. CR wrote the first draft of the paper.

  • Funding This study was funded by the UK Centre for Tobacco Control Studies, a UKCRC Public Health Research Centre of Excellence. Funding to UKCTCS from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council and the National Institute of Health Research, under the auspices of the UK Clinical Research Collaboration is gratefully acknowledged.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i ‘ENDS’ is used throughout this paper, except in the Results where we use ‘e-cigarette’, as this was the term used in the coverage.

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