E-cigarette use and support for banning e-cigarette use in public places in the European Union

Nicotine Dependence in Dual Users of Cigarettes and E-Cigarettes: Common and Distinct Elements

INTRODUCTION

In a sample of dual users of cigarettes and electronic nicotine delivery systems (ENDS; e-cigarettes), we evaluated psychometric properties of ENDS versions of the Nicotine Dependence Syndrome Scale (NDSS), the brief Wisconsin Inventory of Smoking Dependence Motives (WISDM), and the Fagerström Test for Nicotine Dependence (FTND). Using the NDSS, we tested the hypothesis that there would be one common underlying factor of dependence across the cigarette and ENDS scales and other product-specific factors.

AIMS AND METHODS

Adult dual users (N = 404) completed baseline cigarette and ENDS versions of the NDSS, WISDM, and FTND, and biweekly surveys of their smoking and vaping. Analyses included bifactor modeling, which helps to identify both a general and product-specific factor for each item, and exploratory factor analyses of the combined cigarette and ENDS NDSS items and examinations of concurrent and predictive validity.

RESULTS

The bifactor model was not a good fit, suggesting the lack of one common underlying dependence factor. Factor analyses revealed separate, similar factors for both products, with only one factor (priority) showing overlap of cigarette and ENDS items. ENDS scales significantly predicted ENDS use over time, but not cigarette use. Cigarette scales did not predict ENDS use over time.

CONCLUSIONS

Although the cigarette and ENDS NDSS versions showed similar factor structure, there was not a primary common underlying factor reflecting drive or tolerance, but rather product-specific factors. The cigarette scales were not valid for predicting ENDS use. These results highlight the importance of separately assessing dependence for cigarettes and ENDS in dual users.

IMPLICATIONS

Although underlying dimensions of nicotine dependence may be similar for ENDS and cigarettes, separate, product-specific measures may be needed to understand differences in product-specific dependency and predict changes in use of each product over time.

It's Just Steam: a qualitative analysis of New Zealand ENDS users' perceptions of secondhand aerosol

Introduction

Many smokers who begin using electronic nicotine delivery systems (ENDS) report vaping in settings where they would not have smoked and believe secondhand aerosol (SHA) is simply steam. However, current understanding of how ENDS users differentiate between secondhand smoke and SHA, or how vaping norms develop, is limited.

Methods

We conducted in-depth, semi-structured interviews with 39 current ENDS users (dual users and former smokers, now exclusive ENDS users) from New Zealand to explore participants’ perceptions of SHA. We probed how these perceptions arose and examined implications for vaping practices and policy. We managed the data using NVivo V.11 and used a thematic analysis approach to interpret the transcripts.

Results

Participants had limited understanding of SHA, its constituents or its possible effects on others. They drew on the absence of harm information, and their sensory experiences and perceptions of others’ views of vaping, to support the conclusion that SHA posed few, if any, risks to bystanders. Yet despite this perception, some felt they should recognise others’ rights to clean air and most would not vape around children to avoid setting an example.

Conclusions

In the absence of trusted information, participants used sensory heuristics to rationalise their ENDS practices. Policy-makers face the challenge of correcting misperceptions about SHA without deterring full transition from smoking to ENDS use. They could consider including vaping in current smoke-free area policies; this measure would signal that SHA is not harmless, and could protect clean-air settings and reduce potential normalisation of vaping among non-smokers.

Regulation of Electronic Cigarette Use in Public and Private Areas in 48 Countries Within the WHO European Region: A Survey to In-country Informants

Background

The objective of this study is to describe the legislation regulating the use of electronic cigarettes (e-cigarettes) in various places in European countries.

Methods

A survey among experts from all countries of the World Health Organization (WHO) European Region was conducted in 2018. We collected and described data on legislation regulating e-cigarette use indoors and outdoors in public and private places, the level of difficulties in adopting the legislation, and the public support and compliance. Factors associated with the legislation adoption were identified with Poisson and linear regression analyses.

Results

Out of 48 countries, 58.3% had legislation on e-cigarette use at the national level. Education facilities were the most regulated place (58.3% of countries), while private areas (eg, homes, cars) were the least regulated ones (39.6%). A third of countries regulated e-cigarette use indoors. Difficulty and support in adopting the national legislation and its compliance were all at a moderate level. Countries’ smoking prevalence and income levels were linked to legislation adoption.

Conclusions

Although most WHO European Region countries had introduced e-cigarette use legislation at the national level, only a few of the legislation protect bystanders in indoor settings.

Stakeholders' Views on E-cigarette Legislation: A Qualitative Study in Taiwan

Objectives: Little is known about stakeholders' opinions on e-cigarette legislation in Taiwan. Our aim is to understand the perspectives of stakeholders regarding the current legal system and measures that could be included in future e-cigarette legislation in Taiwan.

Materials and Methods: We conducted in-depth interviews with 14 Taiwanese stakeholders, using semi-structured questionnaires, either face-to-face or via telephone, in 2016–2017. All interviews were transcribed.

Results: The current legal system is applied to e-cigarettes even though it does not mention them specifically, this system carries risks and faces challenges from anti-tobacco and vaper groups. Some weaknesses in the current legislative framework were noted, including the facts that e-cigarettes are sold without government approval, that there are no manufacturing standards, no inspections or monitoring, and no regulations for usage or advertising. There was wide acceptance among stakeholders that e-cigarettes should be better regulated, particularly e-cigarettes containing nicotine. Most interviewees agreed that there is a need to restrict e-cigarette use by teenagers and in public places where tobacco smoking is prohibited. Most interviewees also would like to restrict marketing, ban sales in vending machines, via mail order, and over the internet; label content and nicotine levels; and introduce health warnings and taxation.

Conclusions: Almost all interviewees agreed that there is a need for a specific legal framework for e-cigarettes in Taiwan, and that e-cigarettes should be regulated in the same way as combustible cigarettes.

Positive perceptions of electronic cigarettes relative to combustible cigarettes are associated with weaker support for endgame policies on combustible cigarettes: A population-based cross-sectional study in Hong Kong

INTRODUCTION

Positive perceptions of electronic cigarettes (e-cigarettes) relative to combustible cigarettes (CCs) may erode support for endgame policies on CCs through smoking renormalization (increasing public acceptance of smoking). We investigated the associations between perceptions of e-cigarettes relative to CCs and support for endgame policies on CCs in Hong Kong.

METHODS

Adult respondents (N=2004) were surveyed using landline random digit dialing in 2015. Perceived relative harm and relative addictiveness of e-cigarettes were combined as an overall perception of e-cigarettes relative to CCs with 5 levels and we analyzed individually 'neutral/positive/mixed/unknown' perceptions against the 'negative' perception. Five individual items with dichotomous responses assessed the support for endgame policies on CCs. Support for banning the sale/use of CCs (yes/no) was also assessed. Multivariable regressions yielded adjusted odds ratios (AORs) of supporting endgame policies (individual policy items, all 5 policy items, at least 1 policy item, banning the sale/use of CCs) in relation to perceptions of e-cigarettes relative to CCs, adjusting for age, education attainment, marital status, CC smoking status and ever e-cigarette use.

RESULTS

Support for individual endgame policy items (from 51.8% to 80.0%), banning the sale (63.8%) and use (67.5%) of CCs were generally high. Few respondents perceived e-cigarettes as more harmful (16.6%) or more addictive (9.3%) than CCs. Positive perceptions of e-cigarettes (24.0%) were associated with less support for 'ban CC sales in 10 years if there is a product providing nicotine not made from tobacco' (AOR=0.62, 95% CI: 0.40-0.97), 'ban CC use when it's prevalence falls below 5%' (AOR=0.66, 95% CI: 0.44-0.98) and 'banning the sale of CCs' (AOR=0.63, 95% CI: 0.42-0.94).

CONCLUSIONS

Positive perceptions of e-cigarettes relative to CCs were associated with less support for endgame policies on CCs in Hong Kong. Public health actions are needed to disseminate evidence-based knowledge of e-cigarettes.

The Prevalence of Cigarette and E-cigarette Smoking Among Students in Central and Eastern Europe-Results of the YUPESS Study

Electronic cigarettes (e-cigarettes) are an alternative to traditional tobacco cigarette smoking. The aim of this study was to assess the prevalence of cigarette smoking and e-cigarette use among university students from Central and Eastern Europe and to investigate personal characteristics associated with cigarette and e-cigarette smoking. A questionnaire-based cross-sectional survey was performed between 2017–2018 among university students in five European countries: Belarus, Lithuania, Poland, Russia, and Slovakia. The questionnaire included 46 questions related to the frequency and habits of traditional cigarettes and e-cigarettes use. Completed questionnaires were obtained from 14,352 students (8800 medical; aged 20.9 ± 2.4 years) with an overall response rate of 72.2%. Two-thirds of the respondents had smoked a traditional tobacco cigarette and 43.7% had used an e-cigarette. Overall current smoking status included 12.3% traditional cigarette smokers, 1.1% e-cigarette users, and 1.8% were dual users with the remainder being non-smokers. Smoking status differed between the research centres (p < 0.001). Females were less likely to try either cigarettes (OR = 0.83) or e-cigarettes (OR = 0.62) and were less likely to be current cigarette (OR = 0.64), e-cigarette (OR = 0.34), or dual users (OR = 0.33) than males. Perception of e-cigarettes significantly differed between smokers and non-smokers (p < 0.001). Among university students, cigarettes are more popular than e-cigarettes.

Secondhand exposure to e-cigarette aerosols among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Electronic cigarette (e-cigarette) use has grown significantly in some European Union (EU) Member States (MS). A better understanding of the exposure to secondhand e-cigarette aerosols (SHA) is necessary to develop and implement comprehensive regulations on e-cigarette use in public places. This study aims to assess the observation of e-cigarette use in public places, the self-reported exposure to SHA, and the level of users' comfort using e-cigarettes in the presence of others.

METHODS

This is a cross-sectional study of the Wave 1 International Tobacco Control 6 European Countries Survey recruiting adult smokers (n=6011) across six EU MS: Germany, Greece, Hungary, Poland, Romania, and Spain, within the EURESTPLUS Project. A descriptive analysis was conducted to estimate the prevalence (%) of observed e-cigarette use in different places, frequency of self-reported exposure to SHA, and level of comfort using e-cigarettes in the presence of others.

RESULTS

In all, 31.0% of smokers observed others using e-cigarette in public places, 19.7% in indoor places where smoking is banned, and 14.5% indoors at work. Almost 37% of smokers reported to be ever exposed to SHA, ranging from 17.7% in Spain to 63.3% in Greece. The higher prevalence of observed e-cigarette use and passive exposure to SHA was reported by smokers of younger age, of higher educational level and those being current or former e-cigarette users. Part (8.8%) of the smokers who were also e-cigarette users reported feeling uncomfortable using e-cigarettes in the presence of others.

CONCLUSIONS

A third of smokers from six EU MS reported being exposed to SHA. Prevalence differences were observed among the countries. In the context of scarce evidence on long-term health effects of exposure to SHA, precautionary regulations protecting bystanders from involuntary exposure should be developed.

Study Protocol of European Regulatory Science on Tobacco (EUREST-PLUS): Policy implementation to reduce lung disease

Efforts to mitigate the devastation of tobacco-attributable morbidity and mortality in the European Union (EU) are founded on its newly adopted Tobacco Products Directive (TPD) along with the first-ever health treaty, the WHO Framework Convention on Tobacco Control (FCTC). The aim of this Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EURESTPLUS) is to monitor and evaluate the impact of the implementation of the TPD across the EU, within the context of WHO FCTC ratification. To address this aim, EUREST-PLUS consists of four objectives: 1) To create a cohort study of 6000 adult smokers in six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) within a pre-TID vs post-TPD implementation study design; 2) To conduct secondary dataset analyses of the Special Eurobarometer on Tobacco Survey (SETS); 3) To document changes in e-cigarette product parameters (technical design, labelling/packaging and chemical composition) pre-TID vs post-TPD; and 4) To enhance innovative joint research collaborations on chronic non-communicable diseases. Through this methodological approach, EUREST-PLUS is designed to generate strong inferences about the effectiveness of tobacco control policies, as well as to elucidate the mechanisms and factors by which policy implementation translates to population impact. Findings from EUREST-PLUS have potential global implications for the implementation of innovative tobacco control policies and its impact on the prevention of lung diseases.

E-Cigarettes: Implications for Health Promotion in the Asian Pacific Region

Since their introduction to the United States in 2007, electronic cigarettes (e-cigarettes) use has grown exponentially. This rapid growth in e-cigarette use has been heralded by some as a potential important public health measure that could ultimately replace tobacco cigarettes, while others recommend a cautionary approach until there is clear evidence they will not become “new tobacco” bringing a possible myriad of other problems. E-cigarettes may have real benefits, however they do expose users and those nearby to organic compounds, solvents and particulate matter, with there being limited data relating to their health impact. It is unclear as to whether this relatively new device has the potential to exacerbate nicotine addictions, or play a part in reducing harm and smoking cessation. The fundamental requirement of public health practice is to do no harm and from the inconclusive evidence we have to date on e-cigarettes, it appears a cautious approach is warranted. This commentary reviews evidence that supports a cautious approach to e-cigarette availability in Australia and the Asian Pacific region.