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BACKGROUND: The electronic cigarette (e-cigarette) use to subsequent smoking relationship in adolescents has received much attention. Whether an intervention to reduce smoking initiation attenuated this relationship was assessed. METHOD: Data were from 3994 adolescent never smokers (aged 13-14 years at baseline) as part of a cluster randomised controlled trial. Self-report measures of smoking, e-cigarette use and covariates were assessed and used to predict ever smoked cigarettes, any recent tobacco smoking and regularly smoked cigarettes at 24-month follow-up. RESULTS: Baseline ever use of e-cigarettes was associated with ever smoked cigarettes (OR=4.03, 95% CI 3.33 to 4.88; controlling for covariates, OR=2.78, 95% CI 2.20 to 3.51), any recent tobacco smoking (OR=3.38, 95% CI 2.72 to 4.21; controlling for covariates, OR=2.17, 95% CI 1.76 to 2.69) and regularly smoked cigarettes (OR=3.60, 95% CI 2.35 to 5.51; controlling for covariates, OR=1.27, 95% CI 1.17 to 1.39) at follow-up. For ever smoked cigarettes only, the impact of e-cigarette use was attenuated in the intervention (OR=1.83) compared with control (OR=4.53) condition. For ever smoked cigarettes and any recent tobacco smoking, the impact of e-cigarette use was attenuated among those with friends who smoked (OR=2.05 (ever smoked); 1·53 (any tobacco use)) compared with those without friends who smoked (OR=3.32 (ever smoked); 2·17 (any tobacco use)). CONCLUSIONS: This is one of the first studies to show that e-cigarette use was robustly associated with measures of smoking over 24 months and the first to show an intervention to attenuate the relationship. Further research with a broader age range of adolescents is required.

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BACKGROUND: In cross-sectional surveys, increasing numbers of adolescents report using both electronic cigarettes (e-cigarettes) and cigarettes. This study assessed whether adolescent e-cigarette use was associated prospectively with initiation or escalation of cigarette use. METHODS: Data were from 2836 adolescents (aged 13-14 years at baseline) in 20 schools in England. At baseline, breath carbon monoxide levels, self-reported e-cigarette and cigarette use, sex, age, friends and family smoking, beliefs about cigarette use and percentage receiving free school meals (measure of socioeconomic status) were assessed. At 12-month follow-up, self-reported cigarette use was assessed and validated by breath carbon monoxide levels. RESULTS: At baseline, 34.2% of adolescents reported ever using e-cigarettes (16.0% used only e-cigarettes). Baseline ever use of e-cigarettes was strongly associated with subsequent initiation (n=1726; OR 5.38, 95% CI 4.02 to 7.22; controlling for covariates, OR 4.06, 95% CI 2.94 to 5.60) and escalation (n=318; OR 1.91, 95% CI 1.14 to 3.21; controlling for covariates, this effect became non-significant, OR 1.39, 95% CI 0.97 to 1.82) of cigarette use. CONCLUSIONS: This is the first study to report prospective relationships between ever use of e-cigarettes and initiation and escalation of cigarette use among UK adolescents. Ever use of e-cigarettes was robustly associated with initiation but more modestly related to escalation of cigarette use. Further research with longer follow-up in a broader age range of adolescents is required.

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This study investigated 30 male smokers' experiences of an appearance-focused, facial-ageing intervention. Individual interviews ( n = 21) and three focus groups ( n = 9) were conducted. Transcripts were analysed using thematic analysis. Male smokers explained that viewing the impacts of smoking on their own faces was the most effective part of the intervention and 22 men (73%) said that they intended quitting smoking or reducing number of cigarettes smoked post-intervention. It is recommended that designers of appearance-focused interventions target men in the future as the current findings demonstrated that the majority of men engaged well with the intervention.

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BACKGROUND: The current literature suggests that forming implementation intentions (simple 'if-then' plans) about how to refuse the offer of a cigarette may be an effective intervention to reduce smoking initiation in adolescents. This study is a pragmatic trial to test the effectiveness and cost-effectiveness of such an intervention in reducing smoking initiation in a sample of UK adolescents. METHODS/DESIGN: A cluster randomised controlled trial with at least 36 schools randomised to receive an implementation intention intervention targeting reducing smoking initiation (intervention group) or increasing homework (control group). Interventions will be conducted at the classroom level and be repeated every six months for four years (eight interventions). Objectively assessed (carbon monoxide monitor) and self-reported smoking plus smoking related cognitions (e.g., smoking intentions, attitudes, norms and self-efficacy) will be assessed at baseline and 12, 24, 36 and 48 months post baseline. Objectively assessed smoking at 48 months post baseline will be the primary outcome variable. Health economic analyses will assess life years gained. DISCUSSION: The results of the trial will provide information on the impact of a repeated implementation intention for refusing offers of cigarettes on rates of smoking initiation in adolescents. TRIAL REGISTRATION: ISRCTN27596806.

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OBJECTIVE: A systematic review was conducted in order to identify physical appearance interventions related to smoking cessation and to evaluate their effectiveness in order to inform smoking cessation practice. METHODS: Articles were only included if they focused on an appearance intervention related to changing smoking attitudes, intentions or behaviour. A total of 17 online databases were searched using date restrictions (1980 to 2011), yielding 4356 articles. After screening, 11 articles were identified that met the review criteria. Seven articles investigated the impacts of facial age-progression software on smoking cessation. Three articles focused on reducing weight concerns in order to improve smoking abstinence rates. One oral health article was identified which focused on physical appearance in order to prevent or reduce smoking. RESULTS: Few studies have focused on physical appearance interventions in smoking cessation however the identified studies report positive impacts on smoking-related cognitions and cessation behaviours. Two different methods of quality analysis were conducted for quantitative and qualitative papers. The consensus was that the quality of the articles was generally weak. Of the 10 quantitative articles, 9 were rated weak and 1 was rated moderate. The one qualitative study provided clear, in-depth information. CONCLUSIONS: Questions still remain as to whether physical appearance interventions have an impact on smoking attitudes, intentions or behaviours, particularly in British samples. To inform practice, additional, well-designed, studies are needed. They should include control groups, use robust randomised allocation to conditions, measures with established reliability and validity and take measures pre and post intervention.

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OBJECTIVES: To investigate whether exposure to a smoking-related facial age-progression technique impacts on quit smoking cognitions, nicotine dependence, and self-reported and objectively assessed smoking in young women in a randomized controlled trial. METHODS: eighteen- to 34-year-old women smokers (n = 70) were allocated at random to either an appearance-related intervention (plus usual care) or control (usual care) group. Women completed questionnaires assessing attitudes, subjective norms, perceived behavioral control and intention to quit smoking immediately before, immediately after, and four weeks after receiving the intervention or usual care. At the first and last time points they also completed measures of nicotine dependence and self-reported and objectively assessed smoking (breath carbon monoxide levels). RESULTS: The two groups were well matched at baseline. Using intention to treat analyses and baseline as a covariate, women in the appearance-related intervention group compared to the control group had significantly more positive attitudes, subjective norms, perceived behavioral control, and intentions to quit smoking immediately after exposure. Only the effects on quit smoking attitudes remained significant at four weeks postintervention. Nicotine dependence and self-reported smoking (total cigarettes in last seven days), but not objective smoking, were significantly lower in the intervention compared with control group at four weeks. CONCLUSIONS: This study suggests that an appearance-related smoking intervention may be a useful adjunct to traditional cessation programs with young women smokers.

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OBJECTIVES: This study was designed to investigate women's experiences of engaging in an age-appearance anti-smoking intervention. METHODS: Ten 18- to 34-year-old women gave accounts of their experiences after engaging in an age-appearance facial morphing anti-smoking intervention in interviews (n= 7) and a focus group (n= 3), and 37 women gave their accounts while they were engaged in the intervention. Transcripts were analysed using a thematic analysis broadly informed by the procedures of Grounded Theory. RESULTS: Women were very concerned about the impact of ageing on their faces in general, and in particular the additional impact of smoking on their skin. Women were concerned about other people's reactions to them as older smokers with wrinkled skin, and many experienced a physical shock reaction (including reports of nausea) to seeing how they would age if they continued to smoke. They reported that seeing their own face aged on the computer screen increased their perceived risk of skin wrinkling. Women reported being highly motivated to quit smoking as a result of the intervention, and many reported that they would take active steps to quit having seen how they would look if they continued to smoke. This was linked with increased perceived personal responsibility for quitting. CONCLUSIONS: Results are discussed in relation to suggestions for anti-smoking interventions aimed at women in the 18- to 34-year-old age group. It is concluded that interventions incorporating age-appearance morphing techniques are likely to be effective in helping women to take active steps to quit smoking.

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