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Have e-cigarettes renormalised or displaced youth smoking? Results of a segmented regression analysis of repeated cross sectional survey data in England, Scotland and Wales
  1. Britt Hallingberg1,
  2. Olivia M Maynard2,
  3. Linda Bauld3,
  4. Rachel Brown1,
  5. Linsay Gray4,
  6. Emily Lowthian1,
  7. Anne-Marie MacKintosh5,
  8. Laurence Moore4,
  9. Marcus R Munafo2,
  10. Graham Moore1
  1. 1 Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement, School of Social Sciences, Cardiff University, Cardiff, UK
  2. 2 School of Experimental Psychology, University of Bristol, Bristol, UK
  3. 3 Usher Institute and UK Centre for Tobacco and Alcohol Studies, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
  4. 4 MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Glasgow, UK
  5. 5 Centre for Tobacco Control Research, Institute for Social Marketing, University of Stirling, Stirling, UK
  1. Correspondence to Dr Britt Hallingberg, School of Social Sciences, Cardiff University, Cardiff CF10 3AT, UK; Hallingbergbe{at}


Objectives To examine whether during a period of limited e-cigarette regulation and rapid growth in their use, smoking began to become renormalised among young people.

Design Interrupted time-series analysis of repeated cross-sectional time-series data.

Setting Great Britain

Participants 248 324 young people aged approximately 13 and 15 years, from three national surveys during the years 1998–2015.

Intervention Unregulated growth of e-cigarette use (following the year 2010, until 2015).

Outcome measures Primary outcomes were prevalence of self-reported ever smoking and regular smoking. Secondary outcomes were attitudes towards smoking. Tertiary outcomes were ever use of cannabis and alcohol.

Results In final models, no significant change was detected in the pre-existing trend for ever smoking (OR 1.01, CI 0.99 to 1.03). There was a marginally significant slowing in the rate of decline for regular smoking (OR 1.04, CI 1.00 to 1.08), accompanied by a larger slowing in the rate of decline of cannabis use (OR 1.21, CI 1.18 to 1.25) and alcohol use (OR 1.17, CI 1.14 to 1.19). In all models and subgroup analyses for smoking attitudes, an increased rate of decline was observed after 2010 (OR 0.88, CI 0.86 to 0.90). Models were robust to sensitivity analyses.

Conclusions There was a marginal slowing in the decline in regular smoking during the period following 2010, when e-cigarettes were emerging but relatively unregulated. However, these patterns were not unique to tobacco use and the decline in the acceptability of smoking behaviour among youth accelerated during this time. These analyses provide little evidence that renormalisation of youth smoking was occurring during a period of rapid growth and limited regulation of e-cigarettes from 2011 to 2015.

Trial registration number Research registry number: researchregistry4336

  • electronic nicotine delivery devices
  • harm reduction
  • public policy
  • denormalization

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  • Contributors GM conceived the study. EL, BH, and GM compiled the dataset. BH and GM analysed the data with senior statistical guidance and oversight from LG. BH wrote the first draft of the manuscript with OM and GM. BH revised the drafts. All authors contributed to data interpretation, critical revisions, and final approval of the manuscript. BH is the guarantor.

  • Funding This work presents independent research funded by the National Institute for Health Research (NIHR) in England under its Public Health Research Board (grant number 16/57/01). The views expressed in this article are those of the authors and do not necessarily reflect those of the National Health Service (NHS), the NIHR or the Department of Health for England. The work was also undertaken with the support of The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence. Joint funding (MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. LM and LG acknowledge support from the Medical Research Council and the Chief Scientist Office (MC_UU_12017/13 and MC_UU_12017/14) of the Scottish Government Health Care Directorates (SPHSU13 and SPHSU14). The School Health Research Network is a partnership between DECIPHer at Cardiff University, Welsh Government, Public Health Wales and Cancer Research UK, funded by Health and Care Research Wales via the National Centre for Health and Wellbeing Research.

  • Competing interests LB declares a secondment post with Cancer Research UK and all other authors report no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethics approval Ethical approval was provided by the School of Social Sciences Research Ethics Committee at Cardiff University (SREC/2188).

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

  • Data sharing statement Detailed information and access to data for the Smoking Drinking and Drug Use Among Young People in England Survey and the Scottish Adolescent Lifestyle and Substance Use Survey, are available from the UK data archive:

  • Patient consent for publication Not required.

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