Our primary aim was to understand the effects of TPD regulations on young people’s use of e-cigarettes. To achieve this, we explored the context of young people’s smoking and e-cigarette use prior to TPD regulations, the implementation of the regulations, and the mechanisms and outcomes that followed from implementation. Table 18 provides an overview of the key conclusions mapped against each of the original study aims.
| Aim | Conclusion |
|---|---|
| Did increased regulation of e-cigarettes interrupt prior growth of young people’s e-cigarette use? | E-cigarette use, both ever and regular use, peaked around the time of implementation of TPD regulations. Although alternative causal explanations cannot be ruled out, this is consistent with an effect of the TPD on young people’s use of e-cigarettes |
| How did young people perceive risks and social norms surrounding e-cigarettes (and how did perceptions change over time as products become TPD compliant)? | Young people typically differentiated between e-cigarette and tobacco products and viewed both as risky, but in different ways, with e-cigarettes associated with unknown harms and potential electrical accidents. Between 2017 and 2019, perceived harms changed and young people increasingly saw e-cigarettes as being at least as harmful as tobacco |
| How did young people interpret and respond to the presence or absence of health warnings on e-cigarette packets? | Perhaps owing to informal supply chains, many young people did not report having ever seen e-cigarettes in their packets and exposure to warning labels was low. The message was seen as unlikely to influence young people when compared when more powerful health messaging on tobacco cigarettes |
| To what extent, and in what ways, did young people continue to interact with e-cigarette marketing after the prohibition of cross-border advertising? | Young people reported little exposure to marketing and little brand awareness in qualitative interviews, although much exposure centred around video-sharing websites. Quantitative data indicated that many young people could recall exposure to at least one form of marketing in the past month after cross-border advertising had been removed |
| Have trajectories in young people’s ever and current smoking been significantly interrupted (positively or negatively) by growing prevalence of e-cigarettes? | There was little evidence of change, positive or negative, in the decline in young people’s smoking during the period when e-cigarettes were gaining substantial popularity among adult smokers, but the products were largely unregulated |
| Did the rate of decline in young people’s smoking change after additional regulation of tobacco and e-cigarettes in May 2016 (including TPD and plain packaging)? | In more recent data sets, following the regulation of e-cigarettes alongside a broader suite of tobacco regulation, there was some tentative evidence that declines in young people’s use of tobacco were beginning to stall, and this was particularly evident in Scotland and Wales |
| To what extent was compliance with TPD in product sales achieved, and what are the barriers to and facilitators and unintended consequences of implementation? | Although stakeholders described challenges stemming from a lack of communication from official bodies, compliance with the legislation was perceived by stakeholders as high, which concurred with our observations. Trade bodies were seen as playing a major role in facilitating implementation by providing information on what was required to achieve compliance. A number of legal loopholes for enabling the use of high-strength e-cigarettes were identified, and some concerns remain among some stakeholders that some of the less evidence-based aspects of the regulations might deter smokers from using e-cigarettes |
| To what extent, and in what ways, did variations between UK countries in e-cigarette policy emerge during the study period? | There were no major divergences between nations identified during the study period. However, policy stakeholders cited more informal differences between UK nations in the extent to which e-cigarettes were endorsed as a smoking-cessation aid |
| What other changes to the regulatory context of tobacco and e-cigarettes occur during the study period in the UK and across individual UK countries? | There were few changes to the regulatory context, other than those anticipated at the beginning of the study. However, major events, such as the EVALI outbreak, had far reaching spill-over effects in other nations, likely acting as a key explanation for young people’s increased perception of e-cigarettes as ‘as bad as tobacco’ |
Our data provided limited support for the notion that e-cigarettes were renormalising smoking prior to their regulation via the TPD. Qualitative findings suggested that some forms of e-cigarette use itself, predominantly casual use in social contexts, such as parties, were becoming normalised. However, throughout the time series, regular use of e-cigarettes remained low, particularly among never smokers and, hence, concerns that e-cigarettes are acting as a gateway to addiction for a new generation of never smokers are not currently reflected in the data. TPD regulations were, to some extent, contested by stakeholders in terms of the extent to which the restrictions represented a move to treat e-cigarettes like tobacco, or proportionate restrictions aimed at achieving goals of limiting the appeal of e-cigarettes to non-smokers. Aspects such as marketing restrictions were generally viewed positively, although some elements relating to device characteristics were described as needing some ongoing refinement. Nevertheless, regulations were, for the most part, well implemented. Our study provides evidence that young people’s experimental use of e-cigarettes appears to have stopped growing in the nations of Great Britain around about the time of TPD regulations being implemented. A conclusion that this trend was caused by the TPD regulations is challenged by young people’s reports of limited interactions with elements of the regulations, such as device labelling, and reports that e-cigarettes were seen as a fad that had begun to run its course. However, the fact that this plateauing in e-cigarette use has occurred in the UK just as e-cigarette use was undergoing a substantial period of growth in less-regulated contexts, such as North America, perhaps strengthens a potential conclusion that regulations, such as marketing restrictions and mandatory declaration of new products, might have inhibited the ability of manufacturers to reignite young people’s interest in e-cigarettes as this began to wane. Our study took place in a context of rapidly evolving support for a role for e-cigarettes in cessation from smoking. The findings of our study are reassuring in that, during this time, young people’s interest in e-cigarettes appears to have stopped increasing. Nevertheless, continued collection of robust national data to monitor whether or not this trend continues remains important. The suite of tobacco regulation implemented in 2016, including the TPD regulations and plain packaging for tobacco cigarettes, appears, however, not to have been sufficient to maintain or increase the downwards trajectory in young people’s use of tobacco, which, particularly in Scotland and Wales, appears to have plateaued in very recent years. If UK nations are to achieve goals of becoming smoke free by 2030, then further action will likely be needed to prevent smoking uptake among the minority of young people who are likely to continue to take up smoking in contemporary society.