ESRC Postdoctoral Fellowship 2020 - Electronic cigarettes: role in smoking cessation and potential risks for children and young people

Lead Research Organisation: London School of Hygiene & Tropical Medicine
Department Name: Public Health and Policy

Abstract

My PhD investigated why e-cigarettes have proved to hold such a broad appeal across society, and whether this could be at the cost of smokers using more effective ways to try to quit tobacco. E-cigarettes are now by far the most common choice of quit route for smokers who do not wish to simply
go 'cold turkey' when trying to end their addiction to conventional tobacco cigarettes. However, in contrast to the huge rise in e-cigarettes' popularity, attendances at local stop smoking services (SSSs, which offer one-to-one support from trained smoking cessation advisors) have declined for seven
consecutive years. Given these services have repeatedly been shown to be considerably more effective than any other routes for quitting smoking, my PhD sought to better understand whether the rise of e-cigarettes could be influencing this drop in service attendance, as well as investigating what kinds of issues influenced smokers when they were weighing up which quit route to use.

I have already published two papers of PhD findings. My systematic review filled an important research gap by collating the worldwide scientific literature on which demographic groups were most likely to use e-cigarettes. Meanwhile, a qualitative paper with the results of my 46 interviews delineated the complex range of factors that play a role in smokers' decision-making about whether to use quit routes such as e-cigarettes or SSSs. It also highlighted the diverse attitudes towards e-cigarettes shown by different SSSs and how this influenced the kinds of support offered to their clients.

This fellowship would allow me the opportunity to publish two further papers of findings, helping to maximise the potential of my PhD research. The first would be a further quantitative paper showing what kinds of knowledge and beliefs amongst the 2000 smokers that I surveyed were related to their use of
SSSs and e-cigarettes. This would therefore provide a natural complement to my already-published interview findings, giving my research more reach to those audiences who are most comfortable with quantitative analyses. The second would be a further piece of analysis from my qualitative dataset. In
light of my finding that SSSs offer very varying levels of support and advice around e-cigarettes, my second paper would drill down further into my interview data to tease out what the key influences are that determine what policy a service arrives at regarding e-cigarettes. This would thus provide important insights for PHE, ASH, NCSCT and other organisations with an interest in ensuring equal provision of support to smokers in different parts of the country.

Finally, the fellowship would also allow me to develop a funding proposal to move my investigations on to crucial, related research questions in the years following. Specifically, this future bid would involve analysing the impact of 'Juul' e-cigarette devices on vaping and smoking habits amongst children and
young people, an age group whose attitudes and behaviours fundamentally determine the health harms caused by smoking within society. Most smokers, after all, take up the habit in adolescence, when they have less understanding about the tenacity of nicotine addiction; in previous research, 90% of smokers had started by age 18 and 95% by age 21. The manufacturer Juul have dominated the vaping market for years in the US but have only arrived on UK shores much more recently. These specific devices have been shown to be driving the far higher rates of teenage vaping seen in the US but, as yet, their impact on UK youngsters' vaping and smoking habits are unknown. This line of enquiry has been sparked both by my PhD's systematic review, which showed the highest rates of vaping were amongst older adolescents and younger adults, and by my qualitative fieldwork, where younger interviewees often relayed experiences of feeling targeted by e-cigarette marketing or spoke of the popularity of vaping amongst their peer groups.

Publications

10 25 50
 
Description Since this work was conceptualised in the months just before the Covid-19 pandemic caused huge societal disruptions globally, it inevitably did not proceed quite as linearly or as rapidly as would have been possible in a Covid-free world. Nonetheless, by placing a slightly greater focus on the element of the fellowship related to children and young people's mental health, I was able to minimise this disruption as far as possible. In particular, by seeking to fully understand how adolescent e-cigarette use was situated in the context of broader mental health challenges faced by teens during the pandemic, I was able to spend a small proportion of my time leading some additional research that built on my PhD and fed directly into future fellowship applications. The slightly broader mental health lens also helped make this research attractive to potential fieldwork sites even a difficult time when the education sector was battling with national school closures and associated disruption to learning. I therefore still managed, despite the pandemic, to undertake some modest but important fieldwork with schools in London and to increase my publication record, all of which directly strengthened the major new NIHR Advanced Fellowship application I submitted in summer 2021, as per the most important objective of my ESRC postdoc. This research led to two publications, one of which set out a research agenda to help schools protect public mental health in the wake of the pandemic, while the other outlined findings from our qualitative research (overall, we highlighted particular dilemmas of the post-lockdown era that our findings indicated for the education sector, and suggested there may be value in reframing the apparent conflict between 'attainment gaps' and personal development, moving towards an educational approach with greater complementarity of these aims).

The fellowship also allowed me much greater scope to maximise the potential of my PhD datasets. As such, last year, thanks to work undertaken during this fellowship, I was able to publish a further paper with quantitative results from my PhD in a high impact journal in my field, and am also undertaking further analysis of my qualitative interview transcripts to produce a second paper from that dataset too. The quantitative results explored the fact that little is known about whether e-cigarette use influences tobacco smokers' decisions around other smoking cessation options, including the most effective one available: stop smoking service attendance. My cross-sectional survey data therefore assessed associations between use of e-cigarettes and uptake of stop smoking services. Secondary objectives also provided evidence on key factors that influenced smokers' decision-making in this area. In summary, despite speculation that e-cigarette use might deter smokers from accessing SSSs, my study found dual users of tobacco and e-cigarettes were more likely to report uptake of such services, compared to smokers not using e-cigarettes.

Finally, this fellowship has been incredibly valuable for expanding the skills and capabilities I can take forward into my future research career (such as my formal management and supervision skills), thus increasing the potential for me to have a concrete impact over the coming years in the crucial areas of tobacco control and adolescent mental health. It also allowed me scope to significantly expand my network of collaborators, as per one of my other key objectives for this fellowship.
Exploitation Route The JECH paper I have published is already proving of use/relevance to third sector partners (see 'Narrative Impact' section) and the stakeholder workshop held to discuss our findings showed there was significant interest in them from civil service and third sector colleagues, as well as researchers in other universities.
Sectors Communities and Social Services/Policy

Education

Healthcare

 
Description It is still quite early to assess impact, but I did want to highlight one aspect not mentioned elsewhere in my reporting. Following my co-authoring of a 'Research Agenda' piece in the Journal of Epidemiology & Community Health (JECH), MIND - a major third sector organisation in this area - was in touch to discuss the piece and the potential to collaborate on advocacy work in this space, including linking in with relevant Faculty of Public Health Special Interest Groups. Similarly, I helped run a workshop with stakeholders from the civil service and third sector in 2021 who were very interested in findings to date and keen to be involved in future collaboration in this area. So that aspect of my work is already showing promise of having tangible policy interest and relevance beyond academia.
First Year Of Impact 2021
Sector Healthcare
Impact Types Policy & public services

 
Description Direct influence on MSc student teaching
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
 
Description NIHR Three Research Schools' Mental Health Research Fellowship.
Amount £186,885 (GBP)
Funding ID MH052 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 12/2022 
End 03/2024
 
Description Three NIHR Schools Mental Health Research Programme
Amount £47,721 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 03/2022 
End 08/2022
 
Title Qualitative data collection 
Description I have completed 46 semi-structured interviews for the qualitative workstream of my PhD. 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? No  
Impact Findings have been published in a peer-reviewed journal (Addiction), doi: 10.1111/add.14844. An additional analysis of this data is currently being prepared. 
URL https://onlinelibrary.wiley.com/doi/full/10.1111/add.14844
 
Title Smoking Toolkit Study Dataset 
Description I received 8 monthly waves of data commissioned from Ipsos MORI for the quantitative workstream of this PhD. These comprised the data from a series of questions on e-cigarettes and stop smoking services that were added to their existing routine Omnibus survey. 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? No  
Impact Now that data have been analysed, results have been published in Toxics journal - see publications section of this submission. 
 
Description Fellowship mentoring/support - Anna Freud Centre & UCL 
Organisation Anna Freud Centre
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution My NIHR Advanced Fellowship application in summer 2021, although unsuccessful, led me to form a valuable set of collaborations with key stakeholders in the area of children and young people's health, including Jaime Smith, Director of Mental Health and Wellbeing in Schools at the Anna Freud Centre, who was happy to offer her mentoring services for this and future applications. Similar mentoring support was offered by Chris Bonell, Professor of Public Health Sociology at LSHTM, and UCL's Russell Viner, the first Professor of Adolescent Health in the UK and recent President of the Royal College of Paediatrics and Child Health (RCPCH).
Collaborator Contribution These partners supported my NIHR Advanced Fellowship application in summer 2021 (including being formally named as mentors). Jaime Smith at Anna Freud continues to be a valuable collaborator on my current NIHR Three Schools fellowship.
Impact Currently undertaking NIHR Three Schools Fellowship including mentoring/guidance from Jaime Smith at Anna Freud.
Start Year 2021
 
Description Fellowship mentoring/support - Anna Freud Centre & UCL 
Organisation University College London
Country United Kingdom 
Sector Academic/University 
PI Contribution My NIHR Advanced Fellowship application in summer 2021, although unsuccessful, led me to form a valuable set of collaborations with key stakeholders in the area of children and young people's health, including Jaime Smith, Director of Mental Health and Wellbeing in Schools at the Anna Freud Centre, who was happy to offer her mentoring services for this and future applications. Similar mentoring support was offered by Chris Bonell, Professor of Public Health Sociology at LSHTM, and UCL's Russell Viner, the first Professor of Adolescent Health in the UK and recent President of the Royal College of Paediatrics and Child Health (RCPCH).
Collaborator Contribution These partners supported my NIHR Advanced Fellowship application in summer 2021 (including being formally named as mentors). Jaime Smith at Anna Freud continues to be a valuable collaborator on my current NIHR Three Schools fellowship.
Impact Currently undertaking NIHR Three Schools Fellowship including mentoring/guidance from Jaime Smith at Anna Freud.
Start Year 2021
 
Description Ipsos MORI & UCL 
Organisation Ipsos MORI
Country United Kingdom 
Sector Private 
PI Contribution Ipsos MORI were commissioned, as part of this fellowship, to add a series of questions relating to e-cigarettes and NHS stop smoking services into their routine Omnibus survey that already provides data for UCL's Smoking Toolkit Study. A sub-contract was therefore established with Ipsos MORI, as well as a collaborator agreement with UCL. I led on the development of these agreements, guided by my university's Research Operations Office.
Collaborator Contribution Ipsos MORI conducted the fieldwork for this PhD's new questions on e-cigarettes and NHS stop smoking services which were added into their existing Omnibus survey over the course of 8 months in 2017. Both Ipsos and UCL provided valuable input on the wording of these new questions.
Impact We received 8 datasets from Ipsos MORI. These have been analysed and the results published in Toxics journal - see publications section of this submission.
Start Year 2017
 
Description Ipsos MORI & UCL 
Organisation University College London
Department MRC Laboratory for Molecular Cell Biology
Country United Kingdom 
Sector Academic/University 
PI Contribution Ipsos MORI were commissioned, as part of this fellowship, to add a series of questions relating to e-cigarettes and NHS stop smoking services into their routine Omnibus survey that already provides data for UCL's Smoking Toolkit Study. A sub-contract was therefore established with Ipsos MORI, as well as a collaborator agreement with UCL. I led on the development of these agreements, guided by my university's Research Operations Office.
Collaborator Contribution Ipsos MORI conducted the fieldwork for this PhD's new questions on e-cigarettes and NHS stop smoking services which were added into their existing Omnibus survey over the course of 8 months in 2017. Both Ipsos and UCL provided valuable input on the wording of these new questions.
Impact We received 8 datasets from Ipsos MORI. These have been analysed and the results published in Toxics journal - see publications section of this submission.
Start Year 2017
 
Description PHE / OHID / UKHSA 
Organisation Public Health England
Country United Kingdom 
Sector Public 
PI Contribution As a clinical academic in public health, I am required to hold an honorary (unpaid) contract with Public Health England - as was - now the Office for Health Improvement and Disparities (OHID) and/or the UK Health Security Agency (UKHSA). This has involved previously providing some ad hoc support to the London Coronavirus Response Cell to undertake some informal mixed methods analysis of data relating to schools in London. This small project has been unpaid and complements the broader children and young people research focus of my postdoctoral plans, so will help strengthen the fellowship applications I will be re-submitting shortly.
Collaborator Contribution Voluntary advice/guidance on my research from consultants in public health and data scientists at PHE/UKHSA.
Impact Co-authored an abstract that was accepted for presentation at the 2021 PHE R&D conference. Oral presentation on findings to audience including Chief Medical Officer and Faculty of Public Health President at UKHSA annual conference 2022.
Start Year 2021
 
Description School for Public Health Research 
Organisation National Institute for Health Research
Department NIHR School for Public Health Research
Country United Kingdom 
Sector Academic/University 
PI Contribution During 2021, I spent a small proportion of my time recruiting and line managing a Research Fellow to understake a small research project responding to the pandemic by investigating the impact Covid-19 had had on mental health among adolescents - including in relation to e-cigs, tobacco and other substances - and the support that schools offer in this area. I therefore offered line management and guidance throughout the course of the research study.
Collaborator Contribution Although I was not directly responsible for this study, it formed part of a Public Mental Health (PMH) research programme supported by funding from NIHR's School for Public Health Research (SPHR). It also benefited hugely from the wide collaboration and PPI opportunities afforded by being part of this PMH programme of SPHR.
Impact Results paper published in British Educational Research Journal (BERJ) - see publications section of this submission. 'Research Agenda' paper published in Journal of Epidemiology and Community Health (JECH) - see publications section of this submission. Blog published on SPHR website: https://sphr.nihr.ac.uk/news-and-events/recruitment-challenges-of-school-based-research/
Start Year 2020
 
Description Blog on recruitment 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Co-authored blog on NIHR School for Public Health Research website exploring recruitment challenges of school-based research in the wake of Covid-19
Year(s) Of Engagement Activity 2021
URL https://sphr.nihr.ac.uk/research/qualitative-case-study-of-how-schools-can-be-better-equipped-to-tac...
 
Description Blog on research findings 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Co-authored blog on NIHR School for Public Health Research website exploring findings from small piece of research undertaken during ESRC fellowship period.
Year(s) Of Engagement Activity 2023
URL https://sphr.nihr.ac.uk/news-and-events/blog/the-importance-of-school-culture-in-supporting-student-...
 
Description Clinical Research Network - support for promotion 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Schools
Results and Impact I represented LSHTM at an inaugural meeting of the North-West London schools research network, presenting on my research plans, and later participated in an interview for a promotional video showcasing the network to attract more schools to be part of it.
Year(s) Of Engagement Activity 2021
URL https://www.youtube.com/watch?v=Pn-KM5gw5Is
 
Description Stakeholder workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Online stakeholder workshop held with third sector, civil service and academia stakeholders to explore and contextualise findings from small School for Public Health Research schools study.
Year(s) Of Engagement Activity 2021