Impacts of e-cigarette regulation via the EU Tobacco Products Directive on young people’s use of e-cigarettes: a natural experiment

e-cigerette device sourrounded by smoke, 1400px

E-cigarettes are a polarising issue in contemporary public health, with some arguing that they should be embraced as a safer alternative to smoking, while others are concerned that they may 'renormalise' smoking. These different views on e-cigarettes, which are to date informed by limited evidence on both sides, have led to growing public confusion in relation to the harms of e-cigarettes, and divergence in policy responses.

Until recently, young people's use of e-cigarettes remained low and almost exclusively confined to smokers. However, there is some evidence that regular use of e-cigarettes is now beginning to increase among non-smokers. To date, there is no evidence that this has led to increased smoking uptake among young people. However, even if this does not lead to increased smoking, the percentage of young people using some form of nicotine regularly appears to have increased for the first time since the turn of the century. While nicotine in itself carries few potential risks for adults, there is evidence that it can have harmful effects on emotional and cognitive functions in adult life if used regularly during adolescence, when the young person's brain is still developing. Hence, were young people who would not otherwise have smoked to become regular users of nicotine via e-cigarettes, this carries some risks to public health. Debates regarding how to limit young people's use of e-cigarettes have largely ignored these issues and focused predominantly on perceived links to smoking uptake.

The recent EU Tobacco Products Directive (TPD) has introduced a number of new restrictions on e-cigarettes in the UK. Much advertising is now banned. Since May 2017, all products containing nicotine now carry health warnings on 30% of the surface of the packet. Any product with a nicotine concentration above 20mg/ml needs to be licensed as a medicine.

This project investigates the role of e-cigarette regulation via the TPD in influencing trajectories in young people’s use of e-cigarettes. We examine if the legislation interrupts or reverses current upward trends in young people's use of e-cigarettes. As the TPD will be implemented alongside legislation regulating tobacco even further (for example, plain packaging), we will examine changes in smoking trajectories, but will not be able to disentangle impacts of e-cigarette regulation from other components. We will test the renormalisation hypothesis which provides the theoretical basis stated within the TPD documentation, by analysing whether the decline in young people's smoking rates since 1998 has been interrupted by the growing presence of e-cigarettes.

We will combine secondary quantitative datasets to compare youth e-cigarette and smoking trajectories (the Health Behaviour in School Aged Children/School Health Research Network survey in Wales, SALSUS in Scotland and the Smoking, Drinking and Drug Use survey in England), to address the above aims. In addition, we will explore the implementation and context of TPD regulation via observations and stakeholder interviews, and will use qualitative interviews, before and after full implementation of TPD, to understand the processes through which legislation impacts on young people's perceptions of e-cigarettes.

This project is funded by the National Institute for Health Research.


Cardiff University

Graham Moore

Simon Murphy

Britt Hallingberg

Rachel Brown

University of Stirling

Anne Marie MacKintosh

Jennifer McKell 

University of Edinburgh

Linda Bauld   

University of Bristol

Marcus Munafo

Olivia Maynard

Anna Blackwell

MRC/CSO Social and Public Health Sciences Unit logo 800 wide