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

Summary of Study

Bottom Line: This study is the first to test whether the proliferation of e-cigarettes during a period of limited regulation (2011-2015) led to changes in smoking trajectories as well as smoking attitudes among young people. The results provide little evidence that renormalization of smoking occurred during this period. 

The rate of decline for ever smoking prevalence did not slow between 2011-2015, the period. While decreases for regular smoking did slow, this was specific to groups where the level of decline before 2010 was greatest, possibly reflecting a floor effect in the data. Slowing declines were also found, to a greater magnitude, for cannabis and alcohol use, suggesting change in trend was not unique to tobacco use, but reflected wider changes in youth substance use trajectories. 

Positive perceptions of smoking attitudes declined at a faster rate following the proliferation of e-cigarettes, suggesting that attitudes towards smoking hardened while e-cigarettes were emerging rather than softening, as would be expected were smoking becoming renormalized. These findings are consistent with a previous study in the USA that found little change in smoking trends among adolescents during a period of growth in e-cigarette use.

These findings do not support the hypothesis that e-cigarettes renormalized youth smoking during a period of growing but largely unregulated use.

Perceptions of smoking also changed over time: the percentage of participants who reported that trying a cigarette was ‘OK’ declined from 70% in 1999 to 27% in 2015. The percentage of young people in England reporting that it was ‘OK’ to smoke weekly declined from 36% in 2003 to 14% in 2014. 

Much success in maintaining a continuous downward trajectory in youth smoking in the past 20 years has been achieved through policies that aim to reverse the normalization of smoking. The renormalization hypothesis assumes that growing prevalence and visibility of e-cigarette use will reverse tobacco control successes through increasing the extent to which smoking is once again seen as a ‘normal’ behavior, accepted and accommodated by the non-smoking majority, including young people. 

However, the hypothesis that e-cigarettes will renormalize smoking in young people is premised on an assumption that tobacco use and e-cigarette use are viewed by young people as sufficiently similar for one to renormalize the other. By contrast, some argue that e-cigarettes may denormalize smoking, through social display of an alternative behavior, leading to displacement away from tobacco use for some young people who would otherwise have become smokers.

Read the full study here.

Feature Charticle

Regular smoking Rates Among 15-Year-Olds (Top Series) and 13-Year-Olds (Bottom Series)British Medical Journal

Findings:

  • Decreases for regular smoking did slow slightly between 2011 and 2015 during proliferation of e-cigarette use, but this was specific to groups where the level of decline before 2010 was greatest, possibly reflecting a floor effect in the data. 
  • Slowing declines were also found, to a greater magnitude, for cannabis and alcohol use, suggesting change in trend was not unique to tobacco use, but reflected wider changes in youth substance use trajectories. 
  • Positive perceptions of smoking attitudes declined at a faster rate following the proliferation of e-cigarettes.
  • These findings do not support the hypothesis that e-cigarettes renormalized youth smoking during a period of growing but largely unregulated use.