Are ads for candy-flavoured e-cigs tempting teens to...

"Advertisements for … flavoured e-cigarettes could encourage children to try vaping," ITV News reports after a study found children shown these ads were more likely to express an interest in trying flavoured e-cigs.

The study included about 500 UK schoolchildren aged 11 to 16. It aimed to see whether different e-cigarette adverts influenced their views and attitudes towards smoking tobacco or using e-cigarettes.

The researchers were particularly interested in flavoured e-cigarettes. They speculated flavours such as milk chocolate could make these brands more appealing to children.

They found adverts for flavoured e-cigarettes were more appealing compared with those for non-flavoured e-cigarettes – and children said they'd be more interested in going out and buying them. But whether they would actually do this is another matter. This research has only examined attitudes, not behaviour.

The good news is the research found adverts for flavoured or non-flavoured e-cigarettes made no difference to the children's opinion of whether or not they'd be more likely to try smoking real cigarettes, regardless of whether or not the researchers showed them adverts.

However, one important limitation of this research is it excluded children who had tried smoking or used e-cigarettes before. In so doing, the researchers may have excluded a group who could have had different attitudes towards smoking or e-cigarettes.

Overall, the results suggest advertising flavoured e-cigarettes may heighten their appeal to young people, and possibly introduce them to an addictive nicotine-containing product. More research is needed to further examine this important potential risk.

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, with funding provided by the Department of Health Policy Research Programme.

It was published in the peer-reviewed medical journal, Tobacco Control, and the article is available on an open-access basis to read online or download as a PDF.

The UK media's reporting was generally accurate, with many papers including useful quotes from independent experts.

What kind of research was this?

This randomised controlled trial (RCT) aimed to investigate how English schoolchildren aged 11 to 16 responded to different e-cigarette adverts.

Research continues to look at whether the potential benefits of e-cigarettes – essentially, helping smokers quit – outweigh the potential harms. One potential harm is their appeal to children, particularly when they come in chocolate and candy-like flavours.

This may then influence the likelihood of these children taking up tobacco smoking. E-cigarettes are reportedly now the most frequently used nicotine products among children in countries with strong tobacco control policies.

Research done by the World Health Organization (WHO) reported e-cigarettes may provide a gateway into smoking by initiating nicotine use that would not have occurred without e-cigarettes, and those who become addicted to nicotine may than sway towards tobacco. Another criticism is e-cigarettes may also "re-normalise" smoking and make it seem attractive.

This study aimed to address this gap by estimating the impact of adverts for candy-like flavoured e-cigarettes versus non-flavoured types in terms of how appealing they made tobacco smoking and using e-cigarettes.

Randomising the children to which advertisement they viewed should have ruled out differences in their characteristics that could influence the results.

What did the research involve?

The study recruited 598 schoolchildren aged 11 to 16 from two English schools. They were randomised into three groups and provided with booklets that contained:

12 adverts for candy-like flavoured e-cigarettes
12 adverts for non-flavoured e-cigarettes
no adverts (control condition)

The main outcome the researchers examined was the appeal of tobacco smoking, which was assessed by asking, "Please cross the circles that best describe how you feel about smoking tobacco cigarettes", with a scale of one to five ranging from "unattractive" to "attractive", "not cool" to "cool", and "boring" to "fun".

The appeal of smoking e-cigarettes was assessed similarly as a secondary outcome. Other secondary outcomes included assessing:

the perceived harms of smoking – asking "Smoking can harm your health", "How dangerous do you think it is to smoke more than 10 cigarettes a day?", and "How dangerous do you think it is to smoke one or two cigarettes occasionally?"
susceptibility to smoking – asking "If one of your friends offered you a cigarette, would you smoke it?", "Do you think you will smoke a cigarette at any time during the next year?", and "Do you think you will be smoking cigarettes at 18 years old?"
the appeal of the e-cigarette advert, how much they liked it, and whether they'd then be interested in going to buy them
awareness of e-cigarettes before this study

The researchers also asked whether the children had ever smoked cigarettes or used e-cigarettes before.

After their initial analyses revealed differences in responses between children with previous use and those without, those who had used tobacco or e-cigarettes before were removed from the sample. This left a final population of 471 children for analysis.

What were the basic results?

The main outcome – the appeal of tobacco smoking – was rated low across all three experimental groups, with no significant differences between the groups.

Looking at the secondary outcomes, there was also no significant difference between the three groups for:

the appeal of e-cigarettes – overall rated low
perceived harms of tobacco smoking – overall rated high
susceptibility to tobacco smoking

There were, however, differences in the appeal of the e-cigarette adverts and interest in buying the product.

Children exposed to the flavoured adverts rated them as significantly more appealing and had more interest in buying the product than children who saw the non-flavoured adverts.

How did the researchers interpret the results?

The researchers concluded that: "Exposure to adverts for e-cigarettes does not seem to increase the appeal of tobacco smoking in children. Flavoured, compared with non-flavoured, e-cigarette adverts did, however, elicit greater appeal and interest in buying and trying e-cigarettes."

They suggested other studies are needed to further examine the impact of adverts for flavoured and non-flavoured e-cigarette.

Conclusion

This study primarily aimed to see whether exposing children to different types of e-cigarette advert influenced the appeal of tobacco smoking. The researchers found no evidence of an effect for this.

They found showing schoolchildren adverts for flavoured or non-flavoured e-cigarettes, or no adverts at all, had no effect on what the children thought about smoking tobacco, its potential harms, or how likely they were to try smoking tobacco.

In the sense of the lack of appeal tobacco has for this group, the findings seem like quite good news. But how appealing each group found the e-cigarette advert was different.

Though there were no differences between the groups in terms of how attractive or "cool" they rated smoking e-cigarettes, the adverts for the flavoured cigarettes were rated as being significantly more appealing than the non-flavoured adverts.

And, crucially, the children shown these adverts stated they had more interest in going out and buying the product.

This suggests more children with prior experience of smoking tobacco or using e-cigarettes could be lured into trying them by adverts for flavoured e-cigarettes, and hence be exposed to addictive nicotine for the first time.

Importantly, whether children would actually do this or not is another matter. The study only asked the children to rate how much they liked the advert and whether they'd be interested in buying e-cigarettes – it didn't look at whether they went on to do this.

The findings definitely seem suggestive, but other things besides adverts could influence a child's actions, including socioeconomic factors, personal characteristics, lifestyle, and peer pressure.

The study's other limitations should also be noted:

The children were randomised into three groups, which should balance out any differences in characteristics. But the researchers found prior use of tobacco or e-cigarettes was having an effect, so these children were excluded from the sample for analysis. This may have impacted the generalisability of the results to the overall population.
This is quite a good sample size of around 500 schoolchildren, although they are only from two English schools. Their results may be representative of children across the UK, but we don't know this for sure.
The sample size was thought to be large enough to determine the impact of e-cig adverts on the appeal of smoking real cigarettes, the main outcome of this research. This means although the study did find differences between the groups in terms of the appeal of the adverts, there is less confidence in the reliability of this result because it wasn't the main outcome.
There is the possibility for bias in the children's answers. That is, knowing the stigma attached to smoking, the children may be more likely to have given what they thought were the "correct" answers – smoking is harmful, I wouldn't be influenced to try it – rather than the most truthful ones.
This study used still images of adverts. We don't know what appeal televised adverts have, for example, or the impact of children seeing these products for sale in shops.

Overall, this research highlights the important need to further examine the effect of e-cigarette advertising and its appeal to children and young people.

Current recommendations on advertising e-cigarettes state any advert should "not feature characters that are likely to resonate with youth culture or appeal to under-18s".

Determining what and what doesn't appeal to this age group is arguably a very difficult task. There have been calls from some quarters for a blanket ban on all e-cigarette advertising in the UK. Whether this will be implemented by the government is currently uncertain.