Understanding addiction in e-cigarette users – the EVAPE project

Background

Electronic cigarettes (e-cigarettes) are often advertised as a healthier option to combustible cigarettes and as smoking cessation aid. However, e-cigarettes are a growing health concern and their addictive potential remains to be fully understood. Within the EValuation of the Addictive Potential of E-cigarettes (EVAPE) project, we studied subjective and objective measures of addiction in relation to e-cigarette use.

Methods

This cross-sectional analysis was based on 832 participants of the first wave (2016) of England from the ITC Four Country Smoking and Vaping (4CV) Survey, who were using e-cigarettes daily or weekly for at least four months. Perceived addiction to e-cigarettes was categorised as very vs. not/somewhat addicted, and perceived addictiveness of e-cigarettes relative to combustible cigarettes as equally/more addictive vs. less addictive. Objective measures of addiction included urge to vape, time to first vape after waking, frequency of use, and used nicotine strength. We examined associations between these objective and subjective measures of addiction using multivariate logistic regression, adjusted for age, gender, education, and cigarette smoking.

Results

17.8% of participants reported feeling very addicted to e-cigarettes and 42.3% considered e-cigarettes equally/more addictive than combustible cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive (OR 3.43 (95%-CI 2.29-5.19)). All objective measures of addiction were associated with higher perceived addiction, whereas only a shorter time to first vape was associated with perceived product addictiveness.

Conclusions

Subjective measures of addiction to e-cigarettes, in particular perceived addiction, correspond with objective measures. Understanding the addictive potential of e-cigarettes is the cornerstone for developing new strategies for prevention and treatment, and ultimately understanding their role from a public health perspective.

Key messages

The impact of smoking on mortality in the face of population ageing: the example of Germany

Background

Despite weak tobacco control, smoking in Germany has steadily declined over the last 25 years. As policymakers often expect that this trend will also reflect in a declining associated public health burden, I sought to quantify trends in smoking-attributable mortality (SAM) and to explore the impact of population ageing.

Methods

Smoking and mortality statistics from 1992 to 2018 were obtained from the German Statistical Office, from which SAM was calculated separately for each cause of death causally associated with smoking using Levin's formula for population-attributable fractions. The impact of population ageing was explored by comparing crude and age-standardized SAM, respectively. To estimate the impact of population ageing on future SAM, a forward projection until 2040 was modelled assuming continuation of smoking trends and constant mortality rates.

Results

About 126.900 deaths were attributable to smoking in Germany in 2018. Since 1992, total SAM declined only slightly, while stronger decreases were seen in age-adjusted SAM. Differences between crude and age-standardized SAM seem to be particularly striking in men. The forward projection of SAM suggests that recent increases in smoking in the middle aged as well as population ageing dynamics will lead to further steady increases within the next two decades in both sexes to about 138.250.

Conclusions

Results indicate that past decreases in SAM due to declines in smoking were largely compensated by population ageing. In the next two decades, current smoking trends and population ageing will lead to a steady increase in SAM. Only by taking determined immediate policy action could significant inroads into reducing the smoking-associated disease burden be achieved. Also, given still significant smoking rates in middle and old age, there is tremendous potential to curb the associated public health burden by intensifying cessation programs.

Key messages

Contrary to common expectations among policymakers, the smoking-attributable public health burden will strongly increase in the next decades in Germany. Determined immediate policy action is required to halt or attenuate these trends.

Prevalence of second-hand tobacco smoke in relation to smoke-free legislation in the European Union

Background

Second-hand smoke (SHS) is still an important public health problem. With joining the Framework Convention on Tobacco Control (FCTC), all parties acknowledged the health risks of SHS and agreed to implement policies to protect their populations from SHS in public places. The aim of this study was to explore the SHS exposure in restaurants and bars as well as its associations with smoke-free legislation in the European Union.

Methods

Data of Eurobarometer surveys 2014 and 2017 were used to estimate prevalence of SHS exposure. We also extracted data on individual confounders such as smoking status, gender, sex, age and information on social economic status. Additionally, we collected data on country specific data on smoking regulations in restaurants and bars from the Tobacco Control Scale to analyse associations with SHS exposure using multilevel logistic regression. Smoking regulations were categorized into the following three categories: partial ban, comprehensive ban with minor exceptions, and complete ban.

Results

Preliminary results on the prevalence of SHS in restaurants showed a decrease from 11.8% (95% confidence intervals (CI) 11.2-12.5) in 2014 to 8.8% (95% CI 8.3-9.3) in 2017. The crude multilevel model controlling only for smoking prevalence resulted in an odds ratio of 0.39 (95% CI 0.19-0.77) for comprehensive ban with minor exceptions and 0.28 (95% CI 0.16-0.50) for complete ban versus partial ban. Odds ratios remained at significant levels when controlling for all available confounders.

Conclusions

Between 2014 and 2017, SHS exposure in restaurants decreased significantly. Furthermore, strong associations with smoking regulations were observed suggesting a high compliance. Many tobacco control policies have been introduced during the last years but several countries need to strengthen their smoke-free tobacco control policies to further reduce SHS exposure preventing death, disease and disability.

Key messages

SHS exposure remains a significant public health challenge. The implementation of effective measures could be strengthened through a convergence of tobacco control strategies and policies among European Union member states.

The impact of smoking on deaths and disease in the face of population ageing: the example of Germany

Background

Despite weak tobacco control, smoking in Germany has steadily declined over the last 25 years. As policymakers expect that this trend will reflect in a declining associated public health burden, I sought to quantify trends in smoking-attributable mortality (SAM) and smoking-attributable cancer incidence (SACI) and to explore the impact of population ageing.

Methods

Smoking and mortality statistics from 1992 to 2017 were obtained from the German Statistical Office, from which SAM was calculated separately for each cause of death causally associated with smoking. Cancer incidence data from 1999 to 2016 was obtained from the German Cancer Registry, and SACI was calculated separately for each cancer site causally associated with smoking. The impact of population ageing was explored by comparing crude and age-standardized SAM and SACI, respectively. To estimate the impact of population ageing on future SAM and SACI, a forward projection until 2035 was modelled.

Results

Preliminary results suggest that total SAM and SACI only slightly declined over time, while stronger decreases were seen in age-adjusted SAM and SACI. Differences between crude and age-standardized SAM and SACI seem to be particularly striking in men. The forward projection of SAM and SACI suggests that population ageing will lead to further steady increases within the next two decades in both sexes.

Conclusions

Results indicate that past decreases in SAM and SACI due to declines in smoking were largely compensated by population ageing. In the next two decades, population ageing will lead to a steady increase in SAM and SACI. Only by taking determined immediate action with a comprehensive set of evidence-based tobacco control polices could significant inroads into reducing the smoking-associated disease burden be achieved. Also, given still significant smoking rates in middle and old age, there is tremendous potential to curb the associated public health burden by intensifying cessation programs.

Key messages

Contrary to common expectations among policymakers, the smoking-attributable public health burden will strongly increase in the next decades. Determined immediate policy action is required to halt or attenuate these trends.

Exposure to car smoking among youth in seven countries of the European Union

Background

In the USA and Canada, cars are a major source of secondhand smoke (SHS) exposure among youth. Little is known about the magnitude of this public health problem in European countries. In this report, we study SHS exposure in vehicles among adolescents across 7 member states of the European Union (EU), with a particular focus on socio-economic characteristics and adolescents’ smoking environment.

Methods

Data on self-reported SHS exposure in cars during the past seven days was obtained from the 2016/17 cross-sectional SILNE-R study from 14-17-year old adolescents in EU seven countries (N = 10,481). We applied two multivariate logistic regression models with sociodemographic characteristics and mediating smoking-related factors.

Results

SHS car exposure varied widely across the 7 EU countries: 6% in Finland, 12% in Ireland, 15% in the Netherlands, 19% in Germany, 23% in Portugal, 36% in Belgium and 43% in Italy. Low paternal educational levels were strong correlates of SHS exposure in cars as well as migration background. Other correlates were one’s own smoking status and the relation to the family and peer smoking environment, such as parental smoking, permissive smoking rules at home, and best friends smoking.

Conclusions

In most of these seven countries, a considerable proportion of youth, particularly those from disadvantaged backgrounds, is exposed to SHS in cars. There is a need to ensure adoption and sustained enforcement of smoke-free car legislation. Given the long-term effectiveness of smoke-free car policies, our finding suggests that such policies can contribute towards reducing smoking inequalities.

Key messages

We assessed adolescent secondhand smoke (SHS) exposure in cars in 7 EU countries, which varies widely, ranging from 6% in Finland to 43% in Italy. The findings point to a social gradient, environmental factors in SHS car exposure and call for the rapid implementation of smoke-free car legislation.

Incident depression and mortality among people with different types of dementia: results from a longitudinal cohort study

PURPOSE

The aim of this study was to investigate the independent and combined association of incident depression and dementia with mortality and to explore whether the magnitude of the association varies according to different types of dementia, including Alzheimer's disease and vascular dementia.

METHODS AND DESIGN

The study was based on a population-based longitudinal cohort consisting of 9940 participants at baseline and followed for over 14 years. The sample used for the analyses included 6114 participants with available information on diagnosis of incident dementia and depression. For survival analyses, Cox regression models with incident dementia (n = 293; 5%) and incident depression (n = 746; 12%) as time-dependent variables were used.

RESULTS

Cox models adjusted for relevant confounders indicated that comorbidity of incident vascular dementia and incident depression was associated with a much higher mortality risk (HR 6.99; 95% CI 3.84-12.75) than vascular dementia in the absence of depression (HR 2.80; 95% CI 1.92-4.08). In contrast, estimates for comorbidity of Alzheimer's disease and depression were slightly lower than those for Alzheimer in absence of depression (HR 3.56; 95% CI 1.83-6.92 and HR 4.19; 95% CI 2.97-5.90, respectively). Incident depression in the absence of incident dementia was only weakly associated with mortality.

CONCLUSIONS

These findings indicate that depression and vascular dementia might have synergistic effects on mortality. The results have relevant public health implications for prevention, routine screening for and early treatment of depression among older people, especially those at risk of vascular dementia.

[E-Cigarettes: Assessment of Health Effects and Potential Benefits for Smokers]

E-cigarettes are electronic devices used to vaporize a flavored liquid resulting in aerosols to be inhaled by the user. The high variety of e-cigarettes and liquids makes it difficult to assess the health effects of e-cigarette use. The ingredients of the liquids - apart from nicotine - are generally recognized as safe for oral and dermal use, however, toxicological data on health effects upon chronic inhalation are missing. Studies have detected several harmful substances in e-cigarette aerosol, including carcinogens, but in lower concentrations than tobacco smoke. Evidence suggests that e-cigarette use entails acute health effects such as inflammatory responses in the lung. In animal and in vitro studies e-cigarette aerosol showed adverse effects like cytotoxicity, increased infiltration of inflammatory cells and pro-inflammatory cytokines, increased oxidative stress and moderate inflammation. Compared to tobacco smoking e-cigarettes are very likely to be less harmful, however, due to scarce data the extent of harm reduction cannot be quantified. Although smokers often use e-cigarettes to quit smoking, currently they are not approved as smoking cessation aids. As e-cigarette aerosol is a new source of air pollution, it is reasonable to assume that it poses an increased health risk to bystanders, in particular to vulnerable persons such as children and people with health conditions. E-cigarettes can have a positive effect on public health, if many smokers completely switch from smoking tobacco to e-cigarettes and, finally, also stop e-cigarette use, and if at the same time adverse consequences (such as increased initiation among youths) remain limited.

Educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions: findings from the International Tobacco Control Europe Surveys

This study examined educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions among adult smokers. Longitudinal data (N = 7571) from two waves of six countries of the International Tobacco Control (ITC) Europe Surveys were included. Generalized estimating equation analyses and multiple linear and logistic regression analyses were conducted. Higher educated smokers noticed anti-tobacco information slightly more often than lower educated smokers (F(2) = 25.78, P < 0.001). Noticing anti-tobacco information was associated with more negative smoking-related attitudes (β = 0.05, P < 0.001) and more quit intentions (OR = 1.08, P < 0.001). Among smokers without a quit intention at baseline, a positive association was found for noticing anti-tobacco information at baseline with follow-up quit intention (OR = 1.14, P = 0.003). No other longitudinal associations were found. No educational differences were found in the association of noticing anti-tobacco information with smoking-related attitudes but associations with quit intentions were found only among low (OR = 1.12, P = 0.001) and high educated respondents (OR = 1.11, P < 0.001) and not among moderate educated respondents (OR = 1.02, P = 0.43). Noticing anti-tobacco information may positively influence quit intentions and possibly smoking-related attitudes. Lower educated smokers were as likely to be influenced by anti-tobacco information as higher educated smokers but noticed anti-tobacco information less often; increasing reach of anti-tobacco information may increase impact in this group.

Trends in cigarette smoking initiation and cessation among birth cohorts of 1926-1970 in Germany

This study examines temporal differences in cigarette smoking initiation and cessation among male and female birth cohorts of 1926-1970 born in Germany. Based on the German Federal Health Survey 1998 the sample is divided into a series of 5-year sex-birth cohorts, beginning with those born between 1926 and 1930 and extending to those born between 1966 and 1970. The final data file consists of a sample of 5110 people. Ever-smoking prevalence among men varies from 60 to 70% between the birth cohorts, while in women born 1926-1930 ever-smoking increases from 20 to about 50% in those born 1966-1970. A reduction of the median age at starting smoking also takes place between the cohorts. With 8.5 years this decrease is more incisive among women, compared with a drop of 2 years among men. Regarding cessation patterns the analysis shows a shift towards a shorter duration of smoking with succeeding birth cohorts, again this shift is more incisive in women. But even in the youngest cohort still more than 50% of ever-smokers smoke regularly for more than 25 years. In Germany tobacco-control activities are required in order to take antismoking actions that especially prevent youth from starting to smoke and that support smokers in quitting.