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. 2013 Aug 3;15(12):2053–2059. doi: 10.1093/ntr/ntt095

A Qualitative Study of How Young Scottish Smokers Living in Disadvantaged Communities Get Their Cigarettes

Edward Donaghy 1, Linda Bauld 2,3, Douglas Eadie 3, Jennifer McKell 3, Brian Pringle 4, Amanda Amos 1,
PMCID: PMC3819977  PMID: 23911845

Abstract

Introduction:

Reducing access to cigarettes is an important element of youth smoking prevention strategies. This is particularly so in disadvantaged communities that have high rates of youth smoking. In 2010, Scotland banned proxy sales of tobacco products to under 18-year-olds who were getting older people to purchase cigarettes on their behalf.

Methods:

A qualitative study using 24 small single-sex friendship groups. Eighty young people, mostly aged 14–16, of whom 57 were smokers, were recruited in 2012 from community youth groups in 3 socially disadvantaged areas of Scotland.

Results:

Participants’ main sources of cigarettes were proxy sales, family, and peers and friends. Younger smokers were more likely to purchase single cigarettes from older smokers at school and to steal cigarettes from family members. Older and regular smokers were more likely to obtain cigarettes through proxy purchases. Proxy purchases were often facilitated by problem drug users who were willing to buy cigarettes for a small monetary reward. Direct purchases in shops were less commonly reported but appeared to involve complicit action by some retailers. Few reported that they bought blackmarket cigarettes, although they were available in these communities.

Conclusions:

Young people in areas of deprivation are still able to circumvent the age-of-sale legislation on selling cigarettes. Even though proxy sales have been banned, they are an important source of cigarettes for disadvantaged young smokers.

INTRODUCTION

There has been considerable success in recent years in countries such as the United Kingdom and United States in reducing smoking uptake in young people. In Scotland, smoking among 15-year-olds has declined from 24% in girls and 25% in boys in 1998 to 14% and 11%, respectively, in 2010 (Black, Eunson, Sewel, & Murray, 2011). The decline in Scotland is associated with the implementation of several national tobacco control policies, including the banning of tobacco advertising and promotion (2003 and 2005), comprehensive legislation on smokefree public places (2006), and increasing the age of sale for tobacco from 16 to 18 years (2007). Further tobacco control action is needed to sustain, and ideally accelerate, the decline in smoking uptake in young people, particularly those from disadvantaged groups. In Scotland, smoking uptake is strongly related to socioeconomic status. Thirteen- and 15-year-old regular smokers are twice as likely as nonsmokers to receive free school meals (available to children from low-income families) and more likely to live in socially deprived areas (Black et al., 2011). A similar pattern is found in countries at the same stage of the tobacco epidemic, including countries in North and Western Europe, Canada, and the United States (Currie et al., 2008; Hiscock, Bauld, Amos, Fidler, & Munafò, 2012; U.S. Department of Health and Human Services, 2012).

One of the key policies aimed at reducing smoking uptake in the United Kingdom was increasing the age of sale of tobacco from 16 to 18 years, which came into force in 2007. This legislation was introduced in response to concerns over the ease with which young people were able to purchase cigarettes from shops. Previous U.K. studies (Croghan, Aveyard, Griffin, & Cheng, 2003; Croghan, Aveyard, & Johnson, 2005; Robinson & Amos, 2010; Turner, Gordon, & Young, 2004) have shown that, as has been found in other countries (DiFranza, Celebucki, & Mowery, 2001; Katzman, Markowitz, & McGeary, 2007; Marsh, Dawson, & McGee, 2013; Wong et al., 2007), young people use a mixture of commercial and social sources to access cigarettes. Commercial sources include direct purchases from shops and proxy sales, that is getting older smokers to buy cigarettes for them. Social sources include borrowing, sharing, and reciprocal arrangements and “commercial” social markets where young people sell cigarettes to their peers. The U.K. legislation increasing the age of sale has clearly impacted on reducing young people’s access to cigarettes through direct purchases in shops. Among 15-year-old smokers, direct purchases declined in Scotland from 82% in 2006 to 57% in 2008 and 54% in 2010 (Black et al., 2009; Black et al., 2011; Maxwell, Kinver, & Phelps, 2007). However, young people still access cigarettes through shops and other sources. U.S. studies have shown that in communities with strongly enforced youth access laws, young smokers found new ways of obtaining cigarettes from shops, including through proxy sales (DiFranza & Coleman, 2001; Forster et al., 1998). It is difficult to assess the impact of the legislation on proxy sales as national surveys prior to 2010 did not ask about these. However, the 2010 survey found that proxy sales were an important source of cigarettes with 54% of 13-year-old smokers and 55% of 15-year-old smokers reporting that they “got someone else to buy them from a shop” (Black et al., 2011). There is also evidence from national English surveys that the impact of increase of age may have been less on disadvantaged young people as reflected in the reported ease of purchasing from shops (Millet, Lee, Gibbons, & Glantz, 2011).

In 2009, the Scottish Government consulted with young people about the Tobacco and Primary (Medical) Services Bill and found general support for the proposal that it should become illegal for adults to buy tobacco for under 18s (ASH Scotland, 2011). A clause banning proxy purchases was subsequently included in the legislation, which was passed in 2010. Under this clause, anyone aged 18 or older who “knowingly buys or attempts to buy a tobacco product or cigarette papers on behalf of a person under the age of 18 commits an offence,” which is subject to a fine of up to £5,000 (Scottish Government, 2010).

This article reports the findings of a qualitative study that explored how adolescents living in disadvantaged communities in Scotland accessed cigarettes 1 year after proxy sales were banned. The study aims to contribute to the international literature on youth access behaviors and considers the implications of the findings for smoking prevention policy in Scotland and elsewhere.

METHODS

Sampling and Recruitment

The study took place in 2012 in three areas in Scotland with high levels of social deprivation. Participant recruitment was facilitated by ASH Scotland, an NGO with extensive experience of partnership activity engaging with young people. ASH Scotland’s Youth Development Officer liaised with youth workers in three different localities to provide access to young people attending community youth groups. The three localities were a large city, another city, and a more rural area that included two small towns and a village. Youth workers invited individuals aged 14–16 to take part in a focus group along with three or four of their friends. The contact person had to be a smoker, an ex-smoker, or had family and friends who smoked. Friends of the initial contact could be of any age and smoking status. Community youth groups were chosen as they provide a more naturalistic setting than more formal settings such as schools and are more likely to encourage the sort of interactions and discussions that are common among friends (Green & Hart, 1999; Hyde, Treacy, Whittaker, Abaunza, & Knox, 2000).

Data Collection

Small, single sex, friendship groups of two to six young people were chosen as a participative method of engaging with young people and exploring their views and experiences around smoking, particularly accessing cigarettes. The average group size was three participants. Small friendship group discussions were chosen in preference to individual interviews or larger focus groups as they provide opportunities for exploring individual experiences and accounts, as well as facilitating interaction and discussion among friends (Bloor, Frankland, Thomas, & Robson, 2001; Lewis, 2009) who may smoke and/or access cigarettes together or from each other. Previous studies have found that research involving young people in deprived areas is particularly suited to using small friendship groups, especially when addressing sensitive issues such as the illegal purchasing of cigarettes (Barbour, 2007; Highet, 2003; Robinson & Amos, 2010). As participants are comfortable and familiar with each other, they can have some control over the interview and this more naturalistic context can facilitate accounts generated from within close friendship bonds such as challenging or confirming accounts (Highet, 2003; Wiltshire, Amos, Haw, & McNeill, 2005). Twenty-four friendship groups were held where the young people usually met. The groups used a semistructured topic guide that allowed for covering certain subjects, but also flexibility within the discussion. This covered participants’ experiences of smoking, how young people accessed tobacco, attitudes to different tobacco products, and views and experiences of legal and illegal forms of tobacco. Participants were able to talk with reference to both their friendship group and other personal experiences outside the group. The discussions lasted on average around 30min with the longest being an hour. The groups were moderated by two experienced qualitative researchers (ED and DE). The group discussions were digitally recorded and transcribed.

Data Analysis

Analysis was iterative and ongoing as the data were gathered and emergent themes were discussed by the research team, allowing for these to be inputted and explored in subsequent friendship groups. An in-depth thematic analysis was conducted by the team. Key categories and subcategories around smoking histories, attitudes toward smoking, and accessing cigarettes in the context of peoples’ biographical and social circumstances were identified through an iterative method involving the reading of all transcripts. These categories were then used to code the transcripts, which was initially carried out independently by four members of the team and was supported by the qualitative data analysis software Nvivo. Regular team meetings were held throughout the analytical process to highlight and resolve differences, ensuring consistency in coding. Quotes included in the Results give the friendship group number and sex (F or M).

Ethical Issues

Information sheets were provided to prospective participants prior to taking part. Following meetings with Local Authority approved youth organizations, consent was agreed through certified young person protected youth workers, who were viewed as acting “in loco parentis.” Parental consent was not required. Before each focus group, study details were described by the researchers, with the opportunity for participants to ask questions. Participant anonymity and confidentiality were emphasized and written consent obtained. Participants were given £10 as a thank you for their time and participation. Ethical approval for the study was obtained from the ethics committee of Stirling University Management School.

RESULTS

Participant Characteristics

Eighty young people took part in the focus groups, 42 females and 38 males. Participants’ ages ranged from 12 to 19 with most between 14 and 16 years (Table 1). Nearly three-quarters (57) were smokers with the remainder comprising similar proportions of ex-smokers and nonsmokers. Most had started smoking around the age of 11 or 12 although some reported trying smoking as young as 8. Most had lived and socialized in the same area all their lives. Nearly all those who had left school were unemployed. Many participants stated that outside of the youth group activities there was little to do other than “hang about the streets with your mates.” Although a few were involved in sports, they tended to be younger and didn’t smoke or had stopped smoking. In one area that had high levels of gang-related knife crime, participants’ socializing was restricted to their immediate geographical area “our patch,” for personal safety.

Table 1.

Participants’ Characteristics

Characteristics Area 1 Area 2 Area 3 Total
Gender
 Female 11 18 13 42
 Male 16 12 10 38
Total 27 30 23 80
Age, y
 12–13 4 2 8 14
 14–15 16 8 3 27
 16–17 7 14 11 32
 18–19 0 6 1 7
Total 27 30 23 80
Smoking status
 Current 19 25 13 57
 Ex-smoker 7 3 1 11
 Nonsmoker 1 2 9 12
Total 27 30 23 80

Most of the older participants (15–16 years) reported that they regularly consumed alcohol and this was influential in them spending time outside their home, in the streets. Participants from all three areas reported high levels of illegal drug use and high numbers of “junkies” (problem drug users) in their community. None of the young people reported using “hard drugs” but smoking cannabis was common in older males. Smoking, either directly or indirectly, was an integral part of these young peoples’ lives. Most had family members who smoked.

Sources of Cigarettes

The vast majority of the smokers were aware of the law increasing the age of sale of cigarettes to 18, but none believed this affected the ability of under 18-year-olds to get cigarettes. Participants described several routes that young people used to access cigarettes. The routes that they used appeared to be related to their age (and how old they looked), their level of smoking consumption, how much money they had, family members’ views about their smoking, and the type of retail outlets in their community. There were no apparent gender differences. The main sources were proxy sales, their family, and buying from peers/sharing with friends. Less commonly reported sources were direct purchases from shops and the blackmarket.

Proxy Sales

The most commonly reported way of getting cigarettes was through proxy sales. The most frequently cited method was to wait outside a shop (usually a small independent retailer) and ask a passerby to go into the shop and buy cigarettes for them. In all areas, this was referred to as a “jump in” where the person would “Get somebody to jump in the shop” (FG7M). Smokers described how they would wait on average 30–45min and up to an hour or more until they were successful.

If you didn’t see anybody you were waiting for - about an hour. About an hour, if you didn’t see anybody … . It depends on if you seen people that you knew. (FG21M)

Smokers told how experienced they had become at identifying who to ask to buy cigarettes for them. These included people they knew to be smokers, such as older friends of brothers and sisters as they assumed or knew that they had also once waited outside shops asking older people to buy cigarettes for them.

You know who to ask after a while you know what type of people to ask … if it was like normal people they would say: ‘no’, or go in and tell the shop keeper, but if it was junkies then they would be like that: ‘yeah’. (FG13M)

It would only ever be junkies that would go in […] I would ask other people but they wouldn’t go in. (FG13F)

All the old grannies and that we don’t ask them because they just … . (wouldn’t do it). (FG2M)

Problem drug users “junkies” were identified as especially successful in providing proxy sales, as to a lesser extent were down-and-outs “jakeys” and problem alcohol users.

Because we know like if we asked somebody who was walking past the shop in the street that is dead posh and ask them ‘excuse me would you go in the shop for me please?’ they would be like: ‘no, we are not encouraging you to smoke’ and that. But see if it’s junkies. (FG12M)

If a junkie walks along then you are sorted. (FG19F)

In all three areas, smokers stated that for the price of a cigarette or some “change” (small amount of cash left over from the cigarette purchase), proxy sales were the easiest when problem drug users would approach a small retail shop.

It’s mostly junkies that go in for you because they just don’t care. (FG6F)

Do you know what I mean? Junkies go in no sweat. We done it today, it took about ten minutes … Aye, see if a junkie wants twenty pence, he’ll go in for you, as long as he gets a twenty pence … See if he only gets one pence, chance he will still do it for you. (FG19F)

Certain areas and locations were perceived to be easier than others to achieve proxy sales. One young smoker reported that there was only one shop in the vicinity they spent time in and this area was generally quieter than other retail sites that had frequent shoppers.

Sometimes it can be hard, sometimes you can be waiting for an hour. It depends like where you are like (Area X) or (Area Y). Area Y is quite hard, no one jumps in. There’s just one shop. It’s just a wee village. (FG2M)

Several stated that they would often move to different areas if unsuccessful. Areas with high levels of drug addicts would frequently be chosen. Newsagents close to pharmacies (chemist shops) were popular as, in Scotland, these are licensed to dispense methadone to heroin addicts as part of NHS community treatment plans.

You’d normally go down before school started or at lunchtime, waiting at the chemist for all the junkies to come down and send them to the shop (for cigarettes). (FG15M)

A less common form of proxy sales involved getting cigarettes from family members. Most participants reported that their families refused to purchase cigarettes for them although some of the older smokers said that they sometimes did.

My sister when she took us to the game (football) she jumped in for fags for me. (FG2M)

Many older smokers who acquired cigarettes through proxy sales would use these cigarettes as a revenue source for future proxy purchases. They did this by selling single cigarettes at school or to their peers and friends, thereby maintaining the cycle of supply and demand.

I was making fifty pence a fag, so I must have made good, […] you are always making a profit. (FG4M)

People sell them in school for like 50p for one. Of a tenner (a packet of ten), a ten of fags you get a fiver (five pounds) back. So if I keep some and I go to school tomorrow and sell them- I make myself money. (FG7M)

When asked if they would proxy purchase cigarettes if asked when older, most replied that they would as they had benefited from such help.

If somebody came up to me and asked me if I would go in and get them fags I’d say: ‘aye’. Because I do it like at this age, so I am not going to be like a hypocrite and no do it. (FG19F)

Families as Sources of Cigarettes

Most participants said that their families were opposed to them smoking and actively discouraged it. However, for many smokers, access to cigarettes was strongly associated with family members being smokers. There were two ways of getting cigarettes from this source. Stealing one or two cigarettes from packets left around the home was more commonly reported among younger smokers. However, when families had larger quantities in the house, higher numbers could be stolen.

When my dad has a sleeve (multi-pack of 20 packets) I’ll help myself to a few as he won’t miss them. (FG14F)

The second way was being given a cigarette or money to buy cigarettes, with this being more common among older participants, with 16 often seen as a transitional age when smoking was more widely accepted. Among some family members there seemed to be a tacit acceptance that there wasn’t much they could do to stop a young person smoking if they wanted to.

My family can’t really stop me because I’m just going to do it. So they just let me do it. (FG8M)

My mum gives me money to buy fags. Because she can’t get me stopped so she’s kind of join them, (if can’t) beat them. (FG9F)

Peers and Friends as Sources of Cigarettes

The third major source of cigarettes described by participants was sharing with friends and/or buying from older smokers at school. This involved all ages but was more common among younger smokers. The older smokers reported that they usually only shared cigarettes when they had no money. The older smokers were a source of cigarettes for younger smokers, selling single cigarettes to younger pupils who could not afford to buy whole packets.

Aye, there is people selling them at school as well aren’t they for 50p? It’s usually first years (who buy them) when they start smoking. (FG8M)

Everyone does it …. Really common, if somebody doesn’t have enough to buy their own packet of fags they will just be like: ‘oh I’ve got a pound, can I buy two fags off you?’. It’s mostly at school you sell the most. (FG14F)

If we buy like our own packets for £3.00–£4.00 and we smoke what we need in a day then the ones that we have (leftover) we could sell them for 50p. But if you say it’s your last one and you are not wanting to give you it up, they will be like ‘fine I’ll give you £1.00, I’ll give you £2.00, I’ll give you anything it’s just I need that fag!’ and it’s like: ‘ok’ and then you get loaded. (FG9F)

Direct Purchases From Shops

A less commonly reported source was buying cigarettes directly from shops. Such attempts were restricted to small independent, often family owned, shops rather than supermarkets that were perceived to more strictly enforce the law. Young smokers felt this was because supermarkets had a greater “chance of getting done for it” (FG22F) if caught breaking the law. Attempts often involved subterfuge by the young smoker and/or complicity with the shop assistant, such as only trying to buy cigarettes when there were no other customers, exchanging cigarettes and money out of sight of surveillance cameras or when a certain person was serving who was known to be more lax.

Aye, you just wait until nae-body else is in the shop and make sure you’re no on the CCTV … sometimes go outside or round back to buy them. (FG10M)

When the wee old guy is in we’ll try go in and get them because the wee old guy is more likely[…] He just like kind of hides it behind the desk. (FG1F)

Some participants were aware of ways of obtaining fake identification stating they were 18 years or older. For example, purchasing over the Internet or from local people who provided it for a price, or amending personal identification themselves. However, few had done so. Some participants also reported that cigarettes, usually singles, could be purchased from ice cream vans.

Blackmarket and Illicit Sources

In all three areas, young smokers were aware of where illicit or blackmarket cigarettes could be purchased. However, very few said that they had used this source. Some had experience of older family members buying them, but direct experience was limited. Younger participants were less likely to know about such sources, and among those that were aware there was sometimes a perception that they were now less common. Illicit supply routes appeared to be more established in one urban community where some participants knew where they could buy such products.

You get them anywhere; you’ve just got to know the right places. (FG12M)

The overwhelming majority of participants spoke in derogatory terms about illicit cigarettes. They were very rarely bought by young smokers, and then, only as a “last resort.” This reflected negative perceptions about their taste, effect on young peoples’ lungs, and what they were likely to be made of. Many participants conflated blackmarket or “dodgy” cigarettes with being fake and therefore of poor quality.

They are pure disgusting, I’d rather eat horse shit. (FG15M)

DISCUSSION

While it is not possible to determine from this qualitative study whether proxy sales have declined following the 2010 legislation, the findings indicate that for many young smokers in deprived communities proxy sales are an important way in which they circumvent the age of sale legislation. In many respects these participants’ accounts echo those of young smokers who participated in a qualitative study carried out in deprived areas of Birmingham (England) in 2009, 2 years after the age of sale was increased in England (Robinson & Amos, 2010). However, while in England, proxy sales are not illegal, in Scotland they are. There was no indication in our current study that disadvantaged Scottish young people had encountered difficulties in obtaining proxy sales other than finding people willing to undertake these for them. While such purchases entailed a greater investment of time than attempting direct purchases, this was deemed acceptable by participants as they were more likely to be successful and fitted in with their social activities that mostly involved hanging out with friends. There were no reports of shops refusing proxy purchases or of other formal action against these. Indeed, there have been no prosecutions in Scotland for proxy sales.

One novel finding, where accounts of young people in this study differed from the Birmingham study (Robinson & Amos, 2010) and most previous studies in the United Kingdom and elsewhere, was in the importance of problem drug users as proxy purchasers. This may reflect the local contexts in which the study was undertaken, but is also likely to relate to the high levels of social disadvantage in these communities. A previous study in Massachusetts found that young people would target “shabbily dressed” young men and, in some communities, homeless people who would make a purchase for them in exchange for a few cigarettes (DiFranza & Coleman, 2001). A recent New Zealand study found that young people might ask people who “were drunk” but this was not common (Marsh et al., 2013). Another novel finding from our study was that proxy sales weren’t just a source of cigarettes for young people per se, but helped increase general access to cigarettes by older smokers selling some of their proxy purchases as single cigarettes, at inflated prices, to younger smokers.

Direct purchases of cigarettes were less commonly reported. These findings reflect national survey data that show that while direct purchases have declined these are still an important source. While there appears to have been considerable success in reducing underage sales in supermarkets in Scotland and England (Black et al., 2011; Fuller, 2012; Robinson & Amos, 2010), some small independent shops and/or shop assistants are still not fully enforcing the legislation. Indeed, as found in the previous English study (Robinson & Amos, 2010), it would appear that some are complicit in enabling under 18-year-olds to buy cigarettes. Similar findings of some retailers’ complicity in illegal sales have been found in U.S. studies (DiFranza et al., 2001). This is particularly worrying as, at the time of this study, the age of sale legislation had been in force for more than 4 years. In addition, significant resources have been invested by the Scottish Government, via local authorities and trading standards officers, in the Enhanced Tobacco Sales Enforcement Initiative (ETSEP). Previous studies in other countries have found that the combination of strategies used in ETSEP, that is, retailer education, sustained enforcement, and graduated penalty schemes, increase retailer compliance with age of sales laws (DiFranza, 2012; Richardson et al., 2009; Stead & Lancaster, 2005). However, in 2009/2010, 15.6% of retailers in Scotland subject to test purchases failed (SCOTTS, 2011). This may underestimate the true level of such sales as the young people used in test purchases have to be 16 or under, not look older than their age, and answer truthfully about their age if asked (SCOTTS, 2011).

Blackmarket and illicit sources of cigarettes were reportedly rarely used. This contrasts with findings from the North of England where young people reported these were a significant source (Crossfield, Hodgson, & Rutter, 2010; Lewis & Russell, 2012), but is similar to young smokers’ reports in the Birmingham study (Robinson & Amos 2010). These studies were all carried out in areas of deprivation where blackmarket sources of cigarettes are more common (Department of Health, 2008). The findings from this study suggest that young smokers’ engagement with the blackmarket in areas of deprivation may be influenced by not only their awareness and access but their perceptions of the quality of the tobacco products on sale and the widespread negative image of “fake” cigarettes that are perceived to be blackmarket products. Thus, as has been found elsewhere (Katzman et al., 2007), price was important in determining what they bought, in these communities young smokers did not want illicit cigarettes, which may reflect concerns about image and presentation of self (Haines, Poland, & Johnson, 2009; Michell & Amos,1997; Nichter, 2003).

As with all qualitative research, caution is needed in generalizing from these findings to disadvantaged young smokers more generally. Certain behaviors might not have been discussed or may have been presented in ways that did not reflect the actual situation. For example, nonsmokers may have been more reticent in expressing views, which differed from smokers. It is also possible that some participants might have felt intimidated in sharing their views and experiences in the groups (Barbour, 2007; Finch & Lewis, 2009). While the friendship groups appeared to create a safe atmosphere in which participants felt able to divulge and discuss illegal or subversive behavior, there is a risk that shared assumptions, views and behaviors were not discussed in some groups as they were “taken for granted” among these friends (Bloor et al., 2001; Finch & Lewis, 2009).

However, these findings raise considerable challenges to further reducing underage cigarette sales, not only in Scotland but in other countries. While raising the age of sale appears to have had positive effects, and may have contributed to a decline in youth smoking prevalence (Millett, Lee, Gibbons, & Glantz, 2011), young smokers are still able to circumvent this legislation through the apparent support of some local people and retailers, as has been found in other countries (Richardson et al., 2009; Stead & Lancaster, 2005). These findings suggest that retailer education, while essential, will not be sufficient to address this problem, particularly in disadvantaged communities where smoking is still the norm. Proxy sales, although illegal, were an important source of cigarettes although this may be different in communities with stronger social norms against youth smoking where adults are less willing to engage in such sales. We are not aware of any action that has been taken on this in Scotland. This is consistent with a recent review of the effectiveness of tobacco sales laws in a number of countries, which concluded that there was “little evidence that merely enacting a law without sufficient enforcement had any impact on youth tobacco use” (DiFranza, 2012). In addition, sustained policy action at the national and community level is needed to continue to de-normalize smoking and reduce the attractiveness of smoking and cigarettes for young people.

FUNDING

This study was funded by the Scottish School of Public Health Research, with additional support from the UK Centre for Tobacco Control Studies, a UKCRC Public Health Research Centre of Excellence. Funding to UK Centre for Tobacco Control Studies from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council, and the National Institute of Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. The views expressed in this article are those of the authors and not necessarily the funders.

DECLARATION OF INTERESTS

None declared.

ACKNOWLEDGEMENTS

We would like to thank ASH Scotland for facilitating access to local community groups and all those youth workers who helped recruit the young people. We would also like to thank the young people who shared their views with us.

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