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Patterns, trends and determinants of e-cigarette use in 28 European Union Member States 2014–2017
Preventive Medicine 116 (2018) 13–18
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Patterns, trends and determinants of e-cigarette use in 28 European Union Member States 2014–2017
T
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Anthony A. Lavertya, , Filippos T. Filippidisa,b, Constantine I. Vardavasc a
Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, United Kingdom Centre for Health Services Research, School of Medicine, National and Kapodistrian University of Athens, Greece c School of Medicine, University of Crete, Greece b
A B S T R A C T
There is a lack of nationally representative data on regular e-cigarette use, as well as on the transition from experimentation to regular use. This study examines changes in these in Europe between 2014 and 2017. Data come from the 2014 (n = 27,801) and 2017 (n = 27,901) adult Special Eurobarometer for Tobacco Survey, providing nationally representative surveys of 28 EU member states. We defined regular use of e-cigarettes as daily or weekly use from a question on frequency of ecigarette use. Among ever users of e-cigarettes we assessed socio-demographic correlates of becoming a regular user. 1.5% of the EU population were regular ecigarette users in 2014, which had risen to 1.8% in 2017. In 2017 63 million Europeans aged 15 or older had ever used e-cigarettes (95% CI, 59.9 million–66.2 million), and 7.6 million (95% CI, 6.5million–8.9 million) were regular e-cigarette users. Among those who had ever used e-cigarettes, participants aged 15–24 years were less likely to be regular user than those aged ≥55 years (16.9% vs. 38.1%), as were never smokers compared with current and former smokers (12.8% vs. 27.0% vs. 41.3%). The proportion of adults who were regular e-cigarette users in 2017 ranged from 4.7% in the UK to 0.2% in Bulgaria. There have been slight rises in the proportion of people regularly using e-cigarettes in the EU, and this varies considerably between member states, indicating the role of the regional environment in supporting or deterring e-cigarette use.
1. Introduction E-cigarettes are now an established product in many high-income countries, although there are still questions around both their population health impacts and their role in smoking cessation (Kennedy et al., 2016). While research from a variety of sources has highlighted large increases in experimentation and use of e-cigarettes in Europe, less is known about precise patterns of use (Filippidis et al., 2017; Beard et al., 2016; Farsalinos et al., 2016). As the use of e-cigarettes becomes more common, there is a need for more detailed assessment of patterns of use, rather than relying on at times ad-hoc data with a range of definitions of use (Amato et al., 2015; Pearson et al., 2017). Patterns of use are important because frequency of use is likely to be linked to differential potential health impacts from inhaling vapour, but also to transitions away from or towards tobacco smoking (Amato et al., 2015; Hitchman et al., 2015). In addition to questions regarding who is using e-cigarettes and their patterns of use, there is also debate over the extent to which experimentation progresses to regular use of e-cigarettes. A recent report from the Royal College of Physicians in the UK has highlighted that while most experimentation does not go on to become regular use, the public health community would benefit from more information on this transition and its socio-demographic correlates (RCP - Royal College of
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Physicians, 2016). As with tobacco, there is wide variation across countries in their policies on e-cigarettes, which are likely to be important in driving use and population health impacts (Yong et al., 2017) and are reflected in different rates of transition from experimentation to regular e-cigarette use (Filippidis et al., 2017). The Tobacco Products Directive (TPD), which European Union (EU) member states (MS) have been mandated to implement since May 2016, is expected to reduce this variation in regulatory policies, although certain provisions are left to the discretion of individual member states (European Parliament and Council, 2014). This study uses two recent Eurobarometer surveys to assess the prevalence of regular e-cigarette use in 2014 and 2017 and changes between these time points, socio-demographic correlates of regular use among those who had ever tried e-cigarettes and geographical variation in these. 2. Methods 2.1. Data source We used data collected in two waves of the Eurobarometer survey. Wave 82.4 was conducted in November–December 2014 (n = 27,801) and wave 87.1 in March 2017 (n = 27,901). Both samples were
Corresponding author. E-mail address: [email protected] (A.A. Laverty).
https://doi.org/10.1016/j.ypmed.2018.08.028 Received 8 February 2018; Received in revised form 9 August 2018; Accepted 21 August 2018 Available online 23 August 2018 0091-7435/ © 2018 Elsevier Inc. All rights reserved.
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independent variables included age; sex; difficulty paying bills; smoking; education; and area of residence. We used the nonparametric Chi-squared test for trend to assess trends in both ever use and ever regular use by age group. We also assessed changes in current regular and ever use of e-cigarettes within each member state between 2014 and 2017 through logistic regression, controlling for smoking and age. Sample sizes at the member state level were relatively small, thus precluding the inclusion of more independent variables. However, age and smoking have been shown to be the two most important factors associated with e-cigarette use and we have included these (Filippidis et al., 2017). Respondents with missing values or ‘don't know’ responses in key variables were excluded from the regression analyses. These corresponded to 3.1% of observations for our analyses on ever use of ecigarettes and 3.6% of observations in our analyses of regular use. We also used population data to estimate the number of regular e-cigarette users across the whole of the EU.
selected through a multi-stage sampling methodology. Primary sampling units were selected within each member state proportional to population size. Starting addresses were selected at random in each primary sampling unit and households were selected systematically following a standard random route starting from the selected addresses. Post-stratification and population size weighting were applied to ensure samples were representative of the population aged ≥15 years in each of the 28 EU member states and across the EU in terms of age, gender and area of residence. These are independent cross-sectional studies with no longitudinal sample. All data were self-reported and collected through face to face interviews in the local language. 2.2. Measures Ever e-cigarette use was assessed with the question ‘Regarding the use of electronic cigarettes or any similar electronic devices (e-shisha, epipe), which of the following statements applies to you?’. Potential responses in 2014 were: ‘You currently use electronic cigarettes or similar electronic devices (e.g., e-shisha, e-pipe)’; ‘You used them in the past, but no longer use them’; ‘You tried them in the past but no longer use them’; ‘You have never used them’; and ‘Don't know’. Potential responses in 2017 were ‘You currently use electronic cigarettes or similar electronic devices (e.g., e-shisha, e-pipe)’; ‘You used to use them, but no longer do so’; ‘You have tried them once or twice’; ‘You have never tried or used them’; and ‘Don't know’. In both surveys, we used the first three responses to indicate ever use. We considered those who gave the response ‘You currently use electronic cigarettes or similar electronic devices (e.g., e-shisha, e-pipe)’ as current e-cigarette users. Those who responded ‘Don't know’ were excluded from the analysis. Ever e-cigarette users were also asked ‘How often do/did you use electronic cigarettes or similar electronic devices (e.g. e-shisha, epipe)?’. Responses included ‘Every day’; ‘Every week’; ‘Every month’; ‘Less than monthly’; and ‘Don't know’. We considered daily or weekly use as ‘regular use’. Thus, we created separate variables for ‘current regular users’ i.e. those who were regular users at the time of the survey and for ‘ever regular users’ i.e. those who were regular users either at the time of the survey or in the past. Tobacco use was assessed using the question “Regarding smoking cigarettes, cigars or a pipe, which of the following applies to you?” Responses were “You currently smoke”; ‘You used to smoke but you have stopped’; ‘You have never smoked’ which we classified as current, former and never smokers respectively. In sensitivity analyses, we also considered potential differences in e-cigarette use between light smokers (using a cut point of 10 or more cigarettes per day). Other data used in these analyses were sex (male; female), age (15–24, 25–39, 40–54, and ≥55 years), age at which they stopped fulltime education (≤15; 16–19 and ≥ 20 years old), and area of residence (rural; and urban). In line with previous work we used a question on difficulty to pay bills (almost never/never; and from time to time/most of the time) as a marker of socio-economic status (Filippidis et al., 2017; Kino et al., 2017; Laverty et al., 2016).
3. Results Characteristics of the sample are displayed in Supplementary Table 1. Across the whole of the EU 1.8% of the adult population (95% CI 1.5 to 2.1) were current regular e-cigarette users in 2017, compared with 1.5% (1.2–1.8) in 2014 (Table 1). The prevalence of ever e-cigarette use was 14.6% (13.9–15.3) in 2017 compared with 11.6% (10.9–12.3) in 2014. This corresponds to 63 million Europeans ever using e-cigarettes (95% CI, 59.9 million–66.2 million), and 7.6 million (95% CI, 6.5 million–8.9 million) current regular e-cigarette users in 2017. In 2014, France (3.6%, 2.4 to 5.2) and the United Kingdom Table 1 Change in daily or weekly (i.e. ‘regular’) use of e-cigarettes in 28 European Union member states (EUMS), from the 2014 and 2017 Special Eurobarometer for Tobacco Survey. 2014
2.3. Analyses Weights provided in the official Eurobarometer dataset were used in all descriptive analyses. Descriptive results are presented as percentage with 95% Confidence Intervals (95% CI) and regression results as adjusted odds ratios (aOR) with 95% CI. We fitted two separate multilevel logistic regression models, which model individuals as nested within member states, to allow for clustering of responses within each member state. The first multi-level logistic regression was fitted in the entire sample of the 2017 survey and assessed the association of having ever used e-cigarettes with age; sex; difficulty paying bills; smoking; education; and area of residence. The second multi-level logistic regression model was fitted only among respondents in 2017 who had ever used e-cigarettes; ever regular use was the dependent variable and 14
2017
EU Member state
n
% (95% CI)
n
% (95% CI)
% change 2014 to 2017
Austria Belgium Bulgaria Croatia Cyprus (Republic) Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Spain Poland Portugal Romania Slovakia Slovenia Sweden United Kingdom EU – all 28 EU MS
1044 1009 1003 1009 500
0.9 0.4 0.6 1.2 1.8
(0.4–2.0) (0.1–1.1) (0.2–1.3) (0.5–2.5) (0.9–3.8)
1001 1023 1044 1048 501
2.6 2.7 0.2 0.3 1.8
199.4% 579.7% −62.5% −75.3% −3.3%
1044
0.6 (0.3–1.4)
1058
1.2 (0.6–2.1)
83.6%
1024 998 1010 1009 1572 1008 1057 1003 1010 1003 1007 504 502 1019 1012 1002 1034 1031 1035 1011 1029 1312
1.8 (1.2–2.9) 0.6 (0.3–1.5) 0.7 (0.3–1.5) 3.6 (2.4–5.2) 1.1 (0.6–2.0) 0.9 (0.5–1.6) 0.3 (0.1–0.9) 2.4 (1.6–3.6) 0.1 (0.0–0.5) 0.8 (0.3–2.1) 0.2 (0.0–1.2) 0.8 (0.3–2.6) 0 (0–0) 1.4 (0.8–2.4) 1.6 (0.9–2.6) 0.9 (0.4–1.9) 0.2 (0.0–1.2) 0.5 (0.2–1.3) 0.1 (0.0–0.8) 0.5 (0.2–1.2) 0.3 (0.1–0.9) 3.6 (2.5–5.2)
1000 1017 1012 1004 1537 1010 1053 1021 1022 1004 1001 510 500 1015 1008 1061 1033 1014 1027 1024 1007 1346
1.7 1.0 0.8 3.7 1.4 2.3 0.6 1.9 0.2 0.8 0.5 1.3 1.9 1.3 1.0 0.9 0.5 0.3 0.4 0.4 0.3 4.7
−5.4% 59.5% 18.0% 5.3% 35.2% 169.0% 107.3% −22.3% 159.3% 4.6% 185.2% 65.0% n/a −5.9% −35.0% 4.2% 175.6% −48.1% 285.6% −24.0% −13.3% 28.5%
27,801
1.5 (1.2–1.8)
27,901
1.8 (1.5–2.1)
(1.7–4.1) (1.8–4.0) (0.1–0.8) (0.1–0.9) (0.8–3.7)
(1.0–2.9) (0.4–2.4) (0.3–1.8) (2.6–5.3) (0.9–2.3) (1.5–3.6) (0.2–1.5) (1.2–3.0) (0.0–0.7) (0.3–2.2) (0.1–2.0) (0.5–3.3) (0.9–4.2) (0.7–2.2) (0.5–2.1) (0.5–1.8) (0.2–1.2) (0.1–0.8) (0.1–1.5) (0.1–1.0) (0.1–1.1) (3.4–6.3)
21.2%
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Regular use
Ever use Country
aOR (95% CI)
Country
aOR (95% CI)
Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom
2.51 [1.88-3.34] 3.45 [2.42-4.93] 0.85 [0.63-1.16] 1.39 [1.02-1.90] 1.56 [1.02-2.38] 1.63 [1.24-2.13] 1.28 [0.94-1.73] 1.92 [1.39-2.64] 1.29 [0.93-1.77] 1.19 [0.91-1.55] 2.00 [1.50-2.66] 1.99 [1.47-2.70] 1.03 [0.72-1.46] 1.20 [0.87-1.65] 1.14 [0.81-1.59] 1.98 [1.49-2.64] 1.55 [1.07-2.23] 1.08 [0.68-1.71] 0.92 [0.54-1.55] 2.06 [1.48-2.86] 0.91 [0.68-1.21] 1.37 [0.93-2.00] 1.10 [0.79-1.53] 1.26 [0.86-1.84] 1.78 [1.21-2.63] 1.56 [1.11-2.20] 1.52 [1.05-2.20] 1.60 [1.23-2.10]
Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom
3.11 [1.37-7.10] 7.13 [2.45-20.71] 0.39 [0.08-1.98] 0.35 [0.09-1.35] 0.90 [0.32-2.55] 1.58 [0.62-4.07] 0.91 [0.47-1.76] 1.04 [0.33-3.28] 0.93 [0.29-2.93] 1.13 [0.69-1.85] 1.58 [0.77-3.22] 2.27 [1.06-4.84] 1.61 [0.38-6.87] 0.79 [0.43-1.46] 1.88 [0.16-22.15] 1.39 [0.43-4.45] 3.22 [0.28-36.53] 1.23 [0.32-4.78] no data 1.21 [0.56-2.63] 0.61 [0.25-1.50] 0.98 [0.37-2.62] 4.67 [0.54-40.68] 0.58 [0.14-2.47] 2.83 [0.29-27.37] 0.78 [0.21-2.92] 0.58 [0.10-3.27] 1.41 [0.93-2.14]
-2
-1
0
1
-2
2
-1
0
1
2
Fig. 1. Changes in regular and ever e-cigarette use between 2014 and 2017 in EU member states. x-axis is shown on log scale. aOR and 95% CI from logistic regression models adjusted for smoking and age.
Across the whole of the EU in 2014 12.5% of those who had ever used e-cigarettes were current regular users, and this figure was 12.1% in 2017 (Fig. 2). The proportion of ever users who were using regularly in 2017 ranged from 2.0% in Bulgaria to 25.8% in the United Kingdom. Among those who reported ever use of e-cigarettes in 2017, 28.3% were ever regular users (range from 7.6% in Slovenia to 43.9% in Malta) (Supplementary Table 2). Sensitivity analyses categorising current cigarette smokers as light or heavy smokers found that heavy smokers were more likely to have ever used e-cigarettes than light smokers (26.59, 23.12 to 30.59 for heavy smokers, and 19.68, 17.10 to 22.65 among light smokers) (Supplementary Table 3). No differences were detected between these groups for regular use of e-cigarettes.
(3.6%, 2.5 to 5.2) had the highest prevalence of current regular e-cigarette use and Malta had the lowest at 0%. The United Kingdom (4.7%, 3.4 to 6.3) and France (3.7%, 2.6 to 5.3) also had the highest prevalence in 2017, while Italy (0.2%, 0.0 to 0.7) and Bulgaria (0.2%, 0.1 to 0.8) had the lowest. Among those who responded that they ‘currently’ use e-cigarettes in 2017, 86.7% were regular users (daily or weekly) and the rest reported using e-cigarettes every month or less than monthly. After adjusting for age and smoking status both ever use (OR = 1.46, 1.37 to 1.55) and current regular use of e-cigarettes were more common in 2017 than 2014 (OR = 1.32, 1.11 to 1.55). In analyses by individual EU member state there were no cases where ever use of ecigarettes was found to be less common in 2017 than 2014 (Fig. 1). Belgium had the largest increase in ever use of e-cigarettes (OR = 3.45, 2.42 to 4.93) and statistically significant increases were identified in fifteen EU member states. There were no statistically significant changes in regular e-cigarette use in the majority of EU member states, although increases were identified in three EU member states. These were Austria (OR = 3.11, 1.37 to 7.10), Belgium (OR = 7.12, 2.45 to 20.71) and Greece (OR = 2.27, 1.06 to 4.84). Men were more likely than women to have ever tried e-cigarettes (Adjusted Odds Ratio 1.25, 1.15 to 1.60) (Table 2). Younger people were also more likely to have ever tried e-cigarettes (p for trend across age groups < 0.001) as were those with more years in education (1.59, 1.36 to 1.86 for those completing education at age ≥ 20 years compared with ≤15 years). Both former (7.49, 6.51 to 8.61) and current tobacco smokers (22.88, 20.16 to 25.97) were more likely to have ever tried e-cigarettes than never smokers. In analyses among those who had ever tried e-cigarettes, younger people were less likely to have become ever regular users of e-cigarettes (p for trend across age groups < 0.001). We did not detect differences in odds of having been an ever regular e-cigarette user across sex, education, area of residence or difficulty in paying bills. Among those who had tried e-cigarettes, former smokers were more likely to have been ever regular e-cigarette users than never smokers (3.66, 2.47 to 3.12), as were current smokers (2.14, 1.48 to 3.12).
4. Discussion This analysis of two representative surveys of the European population has found that in 2017 1.8% of the total population of the EU were current regular e-cigarette users, corresponding to 7.6 million people. There was wide variation among EU member states in the proportions of ever users of e-cigarettes having transitioned to regular use, and this was most common in the UK. Although younger people were more likely to try e-cigarettes, they were less likely to become ever regular users, and both current and former smokers were more likely to be ever regular users than never smokers. We find that there was a slight rise in current regular e-cigarette users between 2014 and 2017. Much previous research necessarily relied upon examining ever-use (or experimentation with) e-cigarettes, rather than the measure of regular use we employ here (Vardavas et al., 2014). Nonetheless our estimates are similar to those reported in previous work classifying regular use across the EU (Farsalinos et al., 2016). Our findings of an increase in the use of e-cigarettes is in line with reports from a number of locations, including other studies in Europe and the United States (Zhu et al., 2017; Goniewicz et al., 2014; Dockrell et al., 2013; Eastwood et al., 2015). Assessment of levels of regular use is more useful than previous 15
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Table 2 Factors associated with ever e-cigarette use and ever becoming a regular user among those who had ever tried e-cigarettes (n = 3460) among respondents of the 2017 Special Eurobarometer for Tobacco Survey. % of the general population having ever tried e-cigs Total n Sex Female (ref) Male Age (years) ≥55 (ref) 40–54 25–39 15–24 Education (age at completion) ≤15 (ref) 16–19 ≥20 Area of residence Rural Urban Difficulty in paying bills Almost never/Never (ref) From time to time/Most of the time Smoking status Never smoker (ref) Former smoker Current smoker
Ever use aOR (95% CI)
27,801
% among ever users who became regular users
Becoming a regular use aOR (95% CI)
27,901
11.7% 17.7%
1.25 (1.15–1.36)
27.3% 29.6%
1.08 (0.91–1.28)
7.0% 15.3% 20.8% 25.0%
2.10 (1.88–2.36) 3.71 (3.31–4.16) 8.23 (7.10–9.53)
38.1% 38.0% 23.8% 16.9%
1.09 (0.87–1.38) 0.71 (0.56–0.89) 0.61 (0.46–0.82)
8.8% 16.6% 15.0%
1.42 (1.22–1.65) 1.59 (1.36–1.86)
33.1% 31.1% 24.2%
0.94 (0.69–1.27) 0.80 (0.58–1.09)
13.5% 15.1%
1.10 (1.00–1.20)
30.6% 28.0%
0.99 (0.82–1.19)
12.4% 18.9%
1.30 (1.18–1.42)
31.3% 25.1%
0.86 (0.72–1.04)
2.7% 15.7% 37.9%
7.49 (6.51–8.61) 22.88 (20.16–25.97)
12.8% 41.3% 27.0%
3.66 (2.47–5.43) 2.14 (1.48–3.12)
Fig. 2. Proportion of ever e-cigarette users who were current regular users at the time of the 2014 (n = 27,801) and 2017 (n = 27,901) Special Eurobarometer for Tobacco Survey (left) and ever regular users in 2017 (right).
of tobacco use (World Health Organization, 2013). The assessment of weekly and daily use of e-cigarettes was recommended by a panel of experts on the assessment of e-cigarette use in the population in order to improve our understanding of the potential population health
studies which have relied on experimentation with e-cigarettes, and thus produced higher levels of use. Many people who experiment with e-cigarettes are infrequent users (Amato et al., 2015), and studying current regular use is in line with recommendations for the monitoring 16
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4.1. Strengths and limitations
impacts of e-cigarettes (Delnevo and Bauer, 2009; Pearson et al., 2017). Frequency of e-cigarette use is important because both any potential negative impacts from e-cigarette use and positive impacts such as quitting tobacco use are more common among those using e-cigarettes regularly (Amato et al., 2015; Hitchman et al., 2015; Biener and Hargraves, 2015; Pulvers et al., 2015). Our data also highlights that younger people are more likely to be ever users, but not regular users of e-cigarettes, which is in accordance with other data on prevalence of use (Filippidis et al., 2017; Vardavas et al., 2015; Bauld et al., 2017). These findings also support the idea that younger people may be experimenting with e-cigarettes, in common with experimentation with other products in early life. We were also able to assess the extent to which people experimenting with e-cigarettes transition to regular use of these products. We find that the proportion of current regular users among those who reported having ever tried e-cigarettes was around 1 in 8 in both 2014 and 2017. However, when considering ever regular use -i.e. at any point in time- we estimated that among those who have tried e-cigarettes, about 3 in 10 were daily or weekly users at least at some point in time. These findings suggest that for the majority of e-cigarette users, regular use is relatively short-lived. While these percentages may be low, it is important to note that even these low percentages correspond to a large number of people in the EU regularly using e-cigarettes. Unfortunately although we did however find that current and former smoking is an important predictor, the nature of our data did not allow us to investigate whether this is because people only use e-cigarettes regularly while trying to quit tobacco smoking (successfully or not), or because it is a gateway to smoking or for any other reason. This is crucial for the evaluation of their role in public health; therefore more research is required in this area. We detected large differences across EU member states in both the prevalence of ever and regular use as well as the proportion of those experimenting with e-cigarettes who go on to become regular users. A large number of factors are likely to influence these relationships, including the local characteristics of the e-cigarette and tobacco markets, relative costs of nicotine products, tobacco control policies and, regulation and promotion of e-cigarettes (Yong et al., 2017; Laverty et al., 2016; Cobb et al., 2015). Our data shows that the UK is a clear outlier with high levels of regular use and transition from experimentation to regular use and the UK has been noted to have a regime very favourable to e-cigarettes. The rate of transition from ever to regular use in the UK is ten times higher than in member states like Bulgaria, Croatia, Italy, Romania and Sweden. Although some differences in the products that are popular in these member states may exist, these large differences in conversion rates suggest the importance of environmental factors in sustaining regular e-cigarette use. Associations between tobacco policies, and prices and e-cigarette use have been noted in previous research in the US and Europe (El-Shahawy et al., 2018; Stoklosa et al., 2016; Huang et al., 2014). For example, the UK has the highest prevalence of regular e-cigarette use of any member state in our sample and Public Health England have been notably positive about e-cigarettes (McNeil et al., 2018). While we have been unable to examine specifically which factors are linked to more e-cigarette use, this would be a useful focus of further work. Although we have defined regular use here as people using e-cigarettes daily or weekly this does not fully reflect potential differences in frequency of use. There may be large variations in patterns of use even among people using e-cigarettes daily, for example in their puffing behaviours (Cooper et al., 2016). This variation may be crucial, as there may be a dose-response relationship between e-cigarette use and outcomes related to it, such as adverse health effects and success/failure of smoking cessation attempts. More attention is needed in this area, even though it can be difficult to ascertain this given different types and forms of e-cigarettes and rapid changes in this area (Zhu et al., 2014).
This study presents recent data from March 2017 with more granular data on patterns of e-cigarette use than previous studies. The Eurobarometer surveys are large and representative both at national levels and for the whole EU, and the sampling strategy is designed to allow comparison between EU Member States. The questions ascertaining e-cigarette use were essentially the same in both waves, allowing good comparisons over time as well as being noted to be required for cross-national comparisons (Amato et al., 2015). Nonetheless, the data presented here is self-reported, in common with the majority of e-cigarette studies. The questions on e-cigarette use also did not differentiate types of e-cigarettes, such as cigalikes or modifiable tank types. Additionally, the Eurobarometer surveys are not longitudinal, and so any conclusions regarding causality should be treated with caution. While we were able to conduct analyses at the level of the member state, we have not explicitly included potential factors which may be related to use, such as Gross Domestic Product or tobacco control policies. Finally, the 2017 Eurobarometer did not ask participants specifically whether they were using e-cigarettes which contained nicotine or not, so we were unable to provide this breakdown. Nonetheless, the 2014 Eurobarometer survey did ask about nicotine in e-cigarettes and found that the vast majority do contain nicotine (Farsalinos et al., 2016; Dawkins et al., 2013). 5. Conclusion There have been slight rises in the proportion of people regularly using e-cigarettes in the EU, and this varies considerably by EU Member States indicating the potential influence of the regional legislative and social environment on regular e-cigarette use at a population level. Competing interests The authors declare no competing interests. Acknowledgements AAL is funded by the National Institute of Health Research (NIHR RP 2014-04-032). The Public Health Policy Evaluation Unit at Imperial College is grateful for the support of the National Institute of Health Research School of Public Health Research. This work is partially supported through a grant from the European Commission (Horizon2020 HCO-6-2015; EUREST-PLUS: 681109; Vardavas). Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ypmed.2018.08.028. References Amato, M.S., Boyle, R.G., Levy, D., 2015. How to define e-cigarette prevalence? Finding clues in the use frequency distribution. Tob. Control. 25 (e1), e24–e29. https://doi. org/10.1136/tobaccocontrol-2015-052236. Anon, 2014. Directive of the European Union on the Approximation of the Laws, Regulations and Administrative Provisions of the Member States Concerning the Manufacture, Presentation and Sale of Tobacco and Related Products and Repealing Directive 2001/37/EC. http://e. Bauld, L., MacKintosh, M.A., Eastwood, B., et al., 2017. Young people's use of e-cigarettes across the United Kingdom: findings from five surveys 2015–2017. Int. J. Environ. Res. Public Health 14 (9). https://doi.org/10.3390/ijerph14090973. Beard, E., West, R., Michie, S., Brown, J., 2016. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ 354. http://www.bmj.com/content/354/bmj.i4645. abstract. Biener, L., Hargraves, J.L., 2015. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine Tob. Res. 17 (2), 127–133. https://doi.org/10.1093/ntr/
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Patterns, trends and determinants of e-cigarette use in 28 European Union Member States 2014–2017
T
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Anthony A. Lavertya, , Filippos T. Filippidisa,b, Constantine I. Vardavasc a
Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, United Kingdom Centre for Health Services Research, School of Medicine, National and Kapodistrian University of Athens, Greece c School of Medicine, University of Crete, Greece b
A B S T R A C T
There is a lack of nationally representative data on regular e-cigarette use, as well as on the transition from experimentation to regular use. This study examines changes in these in Europe between 2014 and 2017. Data come from the 2014 (n = 27,801) and 2017 (n = 27,901) adult Special Eurobarometer for Tobacco Survey, providing nationally representative surveys of 28 EU member states. We defined regular use of e-cigarettes as daily or weekly use from a question on frequency of ecigarette use. Among ever users of e-cigarettes we assessed socio-demographic correlates of becoming a regular user. 1.5% of the EU population were regular ecigarette users in 2014, which had risen to 1.8% in 2017. In 2017 63 million Europeans aged 15 or older had ever used e-cigarettes (95% CI, 59.9 million–66.2 million), and 7.6 million (95% CI, 6.5million–8.9 million) were regular e-cigarette users. Among those who had ever used e-cigarettes, participants aged 15–24 years were less likely to be regular user than those aged ≥55 years (16.9% vs. 38.1%), as were never smokers compared with current and former smokers (12.8% vs. 27.0% vs. 41.3%). The proportion of adults who were regular e-cigarette users in 2017 ranged from 4.7% in the UK to 0.2% in Bulgaria. There have been slight rises in the proportion of people regularly using e-cigarettes in the EU, and this varies considerably between member states, indicating the role of the regional environment in supporting or deterring e-cigarette use.
1. Introduction E-cigarettes are now an established product in many high-income countries, although there are still questions around both their population health impacts and their role in smoking cessation (Kennedy et al., 2016). While research from a variety of sources has highlighted large increases in experimentation and use of e-cigarettes in Europe, less is known about precise patterns of use (Filippidis et al., 2017; Beard et al., 2016; Farsalinos et al., 2016). As the use of e-cigarettes becomes more common, there is a need for more detailed assessment of patterns of use, rather than relying on at times ad-hoc data with a range of definitions of use (Amato et al., 2015; Pearson et al., 2017). Patterns of use are important because frequency of use is likely to be linked to differential potential health impacts from inhaling vapour, but also to transitions away from or towards tobacco smoking (Amato et al., 2015; Hitchman et al., 2015). In addition to questions regarding who is using e-cigarettes and their patterns of use, there is also debate over the extent to which experimentation progresses to regular use of e-cigarettes. A recent report from the Royal College of Physicians in the UK has highlighted that while most experimentation does not go on to become regular use, the public health community would benefit from more information on this transition and its socio-demographic correlates (RCP - Royal College of
⁎
Physicians, 2016). As with tobacco, there is wide variation across countries in their policies on e-cigarettes, which are likely to be important in driving use and population health impacts (Yong et al., 2017) and are reflected in different rates of transition from experimentation to regular e-cigarette use (Filippidis et al., 2017). The Tobacco Products Directive (TPD), which European Union (EU) member states (MS) have been mandated to implement since May 2016, is expected to reduce this variation in regulatory policies, although certain provisions are left to the discretion of individual member states (European Parliament and Council, 2014). This study uses two recent Eurobarometer surveys to assess the prevalence of regular e-cigarette use in 2014 and 2017 and changes between these time points, socio-demographic correlates of regular use among those who had ever tried e-cigarettes and geographical variation in these. 2. Methods 2.1. Data source We used data collected in two waves of the Eurobarometer survey. Wave 82.4 was conducted in November–December 2014 (n = 27,801) and wave 87.1 in March 2017 (n = 27,901). Both samples were
Corresponding author. E-mail address: [email protected] (A.A. Laverty).
https://doi.org/10.1016/j.ypmed.2018.08.028 Received 8 February 2018; Received in revised form 9 August 2018; Accepted 21 August 2018 Available online 23 August 2018 0091-7435/ © 2018 Elsevier Inc. All rights reserved.
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independent variables included age; sex; difficulty paying bills; smoking; education; and area of residence. We used the nonparametric Chi-squared test for trend to assess trends in both ever use and ever regular use by age group. We also assessed changes in current regular and ever use of e-cigarettes within each member state between 2014 and 2017 through logistic regression, controlling for smoking and age. Sample sizes at the member state level were relatively small, thus precluding the inclusion of more independent variables. However, age and smoking have been shown to be the two most important factors associated with e-cigarette use and we have included these (Filippidis et al., 2017). Respondents with missing values or ‘don't know’ responses in key variables were excluded from the regression analyses. These corresponded to 3.1% of observations for our analyses on ever use of ecigarettes and 3.6% of observations in our analyses of regular use. We also used population data to estimate the number of regular e-cigarette users across the whole of the EU.
selected through a multi-stage sampling methodology. Primary sampling units were selected within each member state proportional to population size. Starting addresses were selected at random in each primary sampling unit and households were selected systematically following a standard random route starting from the selected addresses. Post-stratification and population size weighting were applied to ensure samples were representative of the population aged ≥15 years in each of the 28 EU member states and across the EU in terms of age, gender and area of residence. These are independent cross-sectional studies with no longitudinal sample. All data were self-reported and collected through face to face interviews in the local language. 2.2. Measures Ever e-cigarette use was assessed with the question ‘Regarding the use of electronic cigarettes or any similar electronic devices (e-shisha, epipe), which of the following statements applies to you?’. Potential responses in 2014 were: ‘You currently use electronic cigarettes or similar electronic devices (e.g., e-shisha, e-pipe)’; ‘You used them in the past, but no longer use them’; ‘You tried them in the past but no longer use them’; ‘You have never used them’; and ‘Don't know’. Potential responses in 2017 were ‘You currently use electronic cigarettes or similar electronic devices (e.g., e-shisha, e-pipe)’; ‘You used to use them, but no longer do so’; ‘You have tried them once or twice’; ‘You have never tried or used them’; and ‘Don't know’. In both surveys, we used the first three responses to indicate ever use. We considered those who gave the response ‘You currently use electronic cigarettes or similar electronic devices (e.g., e-shisha, e-pipe)’ as current e-cigarette users. Those who responded ‘Don't know’ were excluded from the analysis. Ever e-cigarette users were also asked ‘How often do/did you use electronic cigarettes or similar electronic devices (e.g. e-shisha, epipe)?’. Responses included ‘Every day’; ‘Every week’; ‘Every month’; ‘Less than monthly’; and ‘Don't know’. We considered daily or weekly use as ‘regular use’. Thus, we created separate variables for ‘current regular users’ i.e. those who were regular users at the time of the survey and for ‘ever regular users’ i.e. those who were regular users either at the time of the survey or in the past. Tobacco use was assessed using the question “Regarding smoking cigarettes, cigars or a pipe, which of the following applies to you?” Responses were “You currently smoke”; ‘You used to smoke but you have stopped’; ‘You have never smoked’ which we classified as current, former and never smokers respectively. In sensitivity analyses, we also considered potential differences in e-cigarette use between light smokers (using a cut point of 10 or more cigarettes per day). Other data used in these analyses were sex (male; female), age (15–24, 25–39, 40–54, and ≥55 years), age at which they stopped fulltime education (≤15; 16–19 and ≥ 20 years old), and area of residence (rural; and urban). In line with previous work we used a question on difficulty to pay bills (almost never/never; and from time to time/most of the time) as a marker of socio-economic status (Filippidis et al., 2017; Kino et al., 2017; Laverty et al., 2016).
3. Results Characteristics of the sample are displayed in Supplementary Table 1. Across the whole of the EU 1.8% of the adult population (95% CI 1.5 to 2.1) were current regular e-cigarette users in 2017, compared with 1.5% (1.2–1.8) in 2014 (Table 1). The prevalence of ever e-cigarette use was 14.6% (13.9–15.3) in 2017 compared with 11.6% (10.9–12.3) in 2014. This corresponds to 63 million Europeans ever using e-cigarettes (95% CI, 59.9 million–66.2 million), and 7.6 million (95% CI, 6.5 million–8.9 million) current regular e-cigarette users in 2017. In 2014, France (3.6%, 2.4 to 5.2) and the United Kingdom Table 1 Change in daily or weekly (i.e. ‘regular’) use of e-cigarettes in 28 European Union member states (EUMS), from the 2014 and 2017 Special Eurobarometer for Tobacco Survey. 2014
2.3. Analyses Weights provided in the official Eurobarometer dataset were used in all descriptive analyses. Descriptive results are presented as percentage with 95% Confidence Intervals (95% CI) and regression results as adjusted odds ratios (aOR) with 95% CI. We fitted two separate multilevel logistic regression models, which model individuals as nested within member states, to allow for clustering of responses within each member state. The first multi-level logistic regression was fitted in the entire sample of the 2017 survey and assessed the association of having ever used e-cigarettes with age; sex; difficulty paying bills; smoking; education; and area of residence. The second multi-level logistic regression model was fitted only among respondents in 2017 who had ever used e-cigarettes; ever regular use was the dependent variable and 14
2017
EU Member state
n
% (95% CI)
n
% (95% CI)
% change 2014 to 2017
Austria Belgium Bulgaria Croatia Cyprus (Republic) Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Spain Poland Portugal Romania Slovakia Slovenia Sweden United Kingdom EU – all 28 EU MS
1044 1009 1003 1009 500
0.9 0.4 0.6 1.2 1.8
(0.4–2.0) (0.1–1.1) (0.2–1.3) (0.5–2.5) (0.9–3.8)
1001 1023 1044 1048 501
2.6 2.7 0.2 0.3 1.8
199.4% 579.7% −62.5% −75.3% −3.3%
1044
0.6 (0.3–1.4)
1058
1.2 (0.6–2.1)
83.6%
1024 998 1010 1009 1572 1008 1057 1003 1010 1003 1007 504 502 1019 1012 1002 1034 1031 1035 1011 1029 1312
1.8 (1.2–2.9) 0.6 (0.3–1.5) 0.7 (0.3–1.5) 3.6 (2.4–5.2) 1.1 (0.6–2.0) 0.9 (0.5–1.6) 0.3 (0.1–0.9) 2.4 (1.6–3.6) 0.1 (0.0–0.5) 0.8 (0.3–2.1) 0.2 (0.0–1.2) 0.8 (0.3–2.6) 0 (0–0) 1.4 (0.8–2.4) 1.6 (0.9–2.6) 0.9 (0.4–1.9) 0.2 (0.0–1.2) 0.5 (0.2–1.3) 0.1 (0.0–0.8) 0.5 (0.2–1.2) 0.3 (0.1–0.9) 3.6 (2.5–5.2)
1000 1017 1012 1004 1537 1010 1053 1021 1022 1004 1001 510 500 1015 1008 1061 1033 1014 1027 1024 1007 1346
1.7 1.0 0.8 3.7 1.4 2.3 0.6 1.9 0.2 0.8 0.5 1.3 1.9 1.3 1.0 0.9 0.5 0.3 0.4 0.4 0.3 4.7
−5.4% 59.5% 18.0% 5.3% 35.2% 169.0% 107.3% −22.3% 159.3% 4.6% 185.2% 65.0% n/a −5.9% −35.0% 4.2% 175.6% −48.1% 285.6% −24.0% −13.3% 28.5%
27,801
1.5 (1.2–1.8)
27,901
1.8 (1.5–2.1)
(1.7–4.1) (1.8–4.0) (0.1–0.8) (0.1–0.9) (0.8–3.7)
(1.0–2.9) (0.4–2.4) (0.3–1.8) (2.6–5.3) (0.9–2.3) (1.5–3.6) (0.2–1.5) (1.2–3.0) (0.0–0.7) (0.3–2.2) (0.1–2.0) (0.5–3.3) (0.9–4.2) (0.7–2.2) (0.5–2.1) (0.5–1.8) (0.2–1.2) (0.1–0.8) (0.1–1.5) (0.1–1.0) (0.1–1.1) (3.4–6.3)
21.2%
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Regular use
Ever use Country
aOR (95% CI)
Country
aOR (95% CI)
Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom
2.51 [1.88-3.34] 3.45 [2.42-4.93] 0.85 [0.63-1.16] 1.39 [1.02-1.90] 1.56 [1.02-2.38] 1.63 [1.24-2.13] 1.28 [0.94-1.73] 1.92 [1.39-2.64] 1.29 [0.93-1.77] 1.19 [0.91-1.55] 2.00 [1.50-2.66] 1.99 [1.47-2.70] 1.03 [0.72-1.46] 1.20 [0.87-1.65] 1.14 [0.81-1.59] 1.98 [1.49-2.64] 1.55 [1.07-2.23] 1.08 [0.68-1.71] 0.92 [0.54-1.55] 2.06 [1.48-2.86] 0.91 [0.68-1.21] 1.37 [0.93-2.00] 1.10 [0.79-1.53] 1.26 [0.86-1.84] 1.78 [1.21-2.63] 1.56 [1.11-2.20] 1.52 [1.05-2.20] 1.60 [1.23-2.10]
Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom
3.11 [1.37-7.10] 7.13 [2.45-20.71] 0.39 [0.08-1.98] 0.35 [0.09-1.35] 0.90 [0.32-2.55] 1.58 [0.62-4.07] 0.91 [0.47-1.76] 1.04 [0.33-3.28] 0.93 [0.29-2.93] 1.13 [0.69-1.85] 1.58 [0.77-3.22] 2.27 [1.06-4.84] 1.61 [0.38-6.87] 0.79 [0.43-1.46] 1.88 [0.16-22.15] 1.39 [0.43-4.45] 3.22 [0.28-36.53] 1.23 [0.32-4.78] no data 1.21 [0.56-2.63] 0.61 [0.25-1.50] 0.98 [0.37-2.62] 4.67 [0.54-40.68] 0.58 [0.14-2.47] 2.83 [0.29-27.37] 0.78 [0.21-2.92] 0.58 [0.10-3.27] 1.41 [0.93-2.14]
-2
-1
0
1
-2
2
-1
0
1
2
Fig. 1. Changes in regular and ever e-cigarette use between 2014 and 2017 in EU member states. x-axis is shown on log scale. aOR and 95% CI from logistic regression models adjusted for smoking and age.
Across the whole of the EU in 2014 12.5% of those who had ever used e-cigarettes were current regular users, and this figure was 12.1% in 2017 (Fig. 2). The proportion of ever users who were using regularly in 2017 ranged from 2.0% in Bulgaria to 25.8% in the United Kingdom. Among those who reported ever use of e-cigarettes in 2017, 28.3% were ever regular users (range from 7.6% in Slovenia to 43.9% in Malta) (Supplementary Table 2). Sensitivity analyses categorising current cigarette smokers as light or heavy smokers found that heavy smokers were more likely to have ever used e-cigarettes than light smokers (26.59, 23.12 to 30.59 for heavy smokers, and 19.68, 17.10 to 22.65 among light smokers) (Supplementary Table 3). No differences were detected between these groups for regular use of e-cigarettes.
(3.6%, 2.5 to 5.2) had the highest prevalence of current regular e-cigarette use and Malta had the lowest at 0%. The United Kingdom (4.7%, 3.4 to 6.3) and France (3.7%, 2.6 to 5.3) also had the highest prevalence in 2017, while Italy (0.2%, 0.0 to 0.7) and Bulgaria (0.2%, 0.1 to 0.8) had the lowest. Among those who responded that they ‘currently’ use e-cigarettes in 2017, 86.7% were regular users (daily or weekly) and the rest reported using e-cigarettes every month or less than monthly. After adjusting for age and smoking status both ever use (OR = 1.46, 1.37 to 1.55) and current regular use of e-cigarettes were more common in 2017 than 2014 (OR = 1.32, 1.11 to 1.55). In analyses by individual EU member state there were no cases where ever use of ecigarettes was found to be less common in 2017 than 2014 (Fig. 1). Belgium had the largest increase in ever use of e-cigarettes (OR = 3.45, 2.42 to 4.93) and statistically significant increases were identified in fifteen EU member states. There were no statistically significant changes in regular e-cigarette use in the majority of EU member states, although increases were identified in three EU member states. These were Austria (OR = 3.11, 1.37 to 7.10), Belgium (OR = 7.12, 2.45 to 20.71) and Greece (OR = 2.27, 1.06 to 4.84). Men were more likely than women to have ever tried e-cigarettes (Adjusted Odds Ratio 1.25, 1.15 to 1.60) (Table 2). Younger people were also more likely to have ever tried e-cigarettes (p for trend across age groups < 0.001) as were those with more years in education (1.59, 1.36 to 1.86 for those completing education at age ≥ 20 years compared with ≤15 years). Both former (7.49, 6.51 to 8.61) and current tobacco smokers (22.88, 20.16 to 25.97) were more likely to have ever tried e-cigarettes than never smokers. In analyses among those who had ever tried e-cigarettes, younger people were less likely to have become ever regular users of e-cigarettes (p for trend across age groups < 0.001). We did not detect differences in odds of having been an ever regular e-cigarette user across sex, education, area of residence or difficulty in paying bills. Among those who had tried e-cigarettes, former smokers were more likely to have been ever regular e-cigarette users than never smokers (3.66, 2.47 to 3.12), as were current smokers (2.14, 1.48 to 3.12).
4. Discussion This analysis of two representative surveys of the European population has found that in 2017 1.8% of the total population of the EU were current regular e-cigarette users, corresponding to 7.6 million people. There was wide variation among EU member states in the proportions of ever users of e-cigarettes having transitioned to regular use, and this was most common in the UK. Although younger people were more likely to try e-cigarettes, they were less likely to become ever regular users, and both current and former smokers were more likely to be ever regular users than never smokers. We find that there was a slight rise in current regular e-cigarette users between 2014 and 2017. Much previous research necessarily relied upon examining ever-use (or experimentation with) e-cigarettes, rather than the measure of regular use we employ here (Vardavas et al., 2014). Nonetheless our estimates are similar to those reported in previous work classifying regular use across the EU (Farsalinos et al., 2016). Our findings of an increase in the use of e-cigarettes is in line with reports from a number of locations, including other studies in Europe and the United States (Zhu et al., 2017; Goniewicz et al., 2014; Dockrell et al., 2013; Eastwood et al., 2015). Assessment of levels of regular use is more useful than previous 15
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Table 2 Factors associated with ever e-cigarette use and ever becoming a regular user among those who had ever tried e-cigarettes (n = 3460) among respondents of the 2017 Special Eurobarometer for Tobacco Survey. % of the general population having ever tried e-cigs Total n Sex Female (ref) Male Age (years) ≥55 (ref) 40–54 25–39 15–24 Education (age at completion) ≤15 (ref) 16–19 ≥20 Area of residence Rural Urban Difficulty in paying bills Almost never/Never (ref) From time to time/Most of the time Smoking status Never smoker (ref) Former smoker Current smoker
Ever use aOR (95% CI)
27,801
% among ever users who became regular users
Becoming a regular use aOR (95% CI)
27,901
11.7% 17.7%
1.25 (1.15–1.36)
27.3% 29.6%
1.08 (0.91–1.28)
7.0% 15.3% 20.8% 25.0%
2.10 (1.88–2.36) 3.71 (3.31–4.16) 8.23 (7.10–9.53)
38.1% 38.0% 23.8% 16.9%
1.09 (0.87–1.38) 0.71 (0.56–0.89) 0.61 (0.46–0.82)
8.8% 16.6% 15.0%
1.42 (1.22–1.65) 1.59 (1.36–1.86)
33.1% 31.1% 24.2%
0.94 (0.69–1.27) 0.80 (0.58–1.09)
13.5% 15.1%
1.10 (1.00–1.20)
30.6% 28.0%
0.99 (0.82–1.19)
12.4% 18.9%
1.30 (1.18–1.42)
31.3% 25.1%
0.86 (0.72–1.04)
2.7% 15.7% 37.9%
7.49 (6.51–8.61) 22.88 (20.16–25.97)
12.8% 41.3% 27.0%
3.66 (2.47–5.43) 2.14 (1.48–3.12)
Fig. 2. Proportion of ever e-cigarette users who were current regular users at the time of the 2014 (n = 27,801) and 2017 (n = 27,901) Special Eurobarometer for Tobacco Survey (left) and ever regular users in 2017 (right).
of tobacco use (World Health Organization, 2013). The assessment of weekly and daily use of e-cigarettes was recommended by a panel of experts on the assessment of e-cigarette use in the population in order to improve our understanding of the potential population health
studies which have relied on experimentation with e-cigarettes, and thus produced higher levels of use. Many people who experiment with e-cigarettes are infrequent users (Amato et al., 2015), and studying current regular use is in line with recommendations for the monitoring 16
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4.1. Strengths and limitations
impacts of e-cigarettes (Delnevo and Bauer, 2009; Pearson et al., 2017). Frequency of e-cigarette use is important because both any potential negative impacts from e-cigarette use and positive impacts such as quitting tobacco use are more common among those using e-cigarettes regularly (Amato et al., 2015; Hitchman et al., 2015; Biener and Hargraves, 2015; Pulvers et al., 2015). Our data also highlights that younger people are more likely to be ever users, but not regular users of e-cigarettes, which is in accordance with other data on prevalence of use (Filippidis et al., 2017; Vardavas et al., 2015; Bauld et al., 2017). These findings also support the idea that younger people may be experimenting with e-cigarettes, in common with experimentation with other products in early life. We were also able to assess the extent to which people experimenting with e-cigarettes transition to regular use of these products. We find that the proportion of current regular users among those who reported having ever tried e-cigarettes was around 1 in 8 in both 2014 and 2017. However, when considering ever regular use -i.e. at any point in time- we estimated that among those who have tried e-cigarettes, about 3 in 10 were daily or weekly users at least at some point in time. These findings suggest that for the majority of e-cigarette users, regular use is relatively short-lived. While these percentages may be low, it is important to note that even these low percentages correspond to a large number of people in the EU regularly using e-cigarettes. Unfortunately although we did however find that current and former smoking is an important predictor, the nature of our data did not allow us to investigate whether this is because people only use e-cigarettes regularly while trying to quit tobacco smoking (successfully or not), or because it is a gateway to smoking or for any other reason. This is crucial for the evaluation of their role in public health; therefore more research is required in this area. We detected large differences across EU member states in both the prevalence of ever and regular use as well as the proportion of those experimenting with e-cigarettes who go on to become regular users. A large number of factors are likely to influence these relationships, including the local characteristics of the e-cigarette and tobacco markets, relative costs of nicotine products, tobacco control policies and, regulation and promotion of e-cigarettes (Yong et al., 2017; Laverty et al., 2016; Cobb et al., 2015). Our data shows that the UK is a clear outlier with high levels of regular use and transition from experimentation to regular use and the UK has been noted to have a regime very favourable to e-cigarettes. The rate of transition from ever to regular use in the UK is ten times higher than in member states like Bulgaria, Croatia, Italy, Romania and Sweden. Although some differences in the products that are popular in these member states may exist, these large differences in conversion rates suggest the importance of environmental factors in sustaining regular e-cigarette use. Associations between tobacco policies, and prices and e-cigarette use have been noted in previous research in the US and Europe (El-Shahawy et al., 2018; Stoklosa et al., 2016; Huang et al., 2014). For example, the UK has the highest prevalence of regular e-cigarette use of any member state in our sample and Public Health England have been notably positive about e-cigarettes (McNeil et al., 2018). While we have been unable to examine specifically which factors are linked to more e-cigarette use, this would be a useful focus of further work. Although we have defined regular use here as people using e-cigarettes daily or weekly this does not fully reflect potential differences in frequency of use. There may be large variations in patterns of use even among people using e-cigarettes daily, for example in their puffing behaviours (Cooper et al., 2016). This variation may be crucial, as there may be a dose-response relationship between e-cigarette use and outcomes related to it, such as adverse health effects and success/failure of smoking cessation attempts. More attention is needed in this area, even though it can be difficult to ascertain this given different types and forms of e-cigarettes and rapid changes in this area (Zhu et al., 2014).
This study presents recent data from March 2017 with more granular data on patterns of e-cigarette use than previous studies. The Eurobarometer surveys are large and representative both at national levels and for the whole EU, and the sampling strategy is designed to allow comparison between EU Member States. The questions ascertaining e-cigarette use were essentially the same in both waves, allowing good comparisons over time as well as being noted to be required for cross-national comparisons (Amato et al., 2015). Nonetheless, the data presented here is self-reported, in common with the majority of e-cigarette studies. The questions on e-cigarette use also did not differentiate types of e-cigarettes, such as cigalikes or modifiable tank types. Additionally, the Eurobarometer surveys are not longitudinal, and so any conclusions regarding causality should be treated with caution. While we were able to conduct analyses at the level of the member state, we have not explicitly included potential factors which may be related to use, such as Gross Domestic Product or tobacco control policies. Finally, the 2017 Eurobarometer did not ask participants specifically whether they were using e-cigarettes which contained nicotine or not, so we were unable to provide this breakdown. Nonetheless, the 2014 Eurobarometer survey did ask about nicotine in e-cigarettes and found that the vast majority do contain nicotine (Farsalinos et al., 2016; Dawkins et al., 2013). 5. Conclusion There have been slight rises in the proportion of people regularly using e-cigarettes in the EU, and this varies considerably by EU Member States indicating the potential influence of the regional legislative and social environment on regular e-cigarette use at a population level. Competing interests The authors declare no competing interests. Acknowledgements AAL is funded by the National Institute of Health Research (NIHR RP 2014-04-032). The Public Health Policy Evaluation Unit at Imperial College is grateful for the support of the National Institute of Health Research School of Public Health Research. This work is partially supported through a grant from the European Commission (Horizon2020 HCO-6-2015; EUREST-PLUS: 681109; Vardavas). Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ypmed.2018.08.028. References Amato, M.S., Boyle, R.G., Levy, D., 2015. How to define e-cigarette prevalence? Finding clues in the use frequency distribution. Tob. Control. 25 (e1), e24–e29. https://doi. org/10.1136/tobaccocontrol-2015-052236. Anon, 2014. Directive of the European Union on the Approximation of the Laws, Regulations and Administrative Provisions of the Member States Concerning the Manufacture, Presentation and Sale of Tobacco and Related Products and Repealing Directive 2001/37/EC. http://e. Bauld, L., MacKintosh, M.A., Eastwood, B., et al., 2017. Young people's use of e-cigarettes across the United Kingdom: findings from five surveys 2015–2017. Int. J. Environ. Res. Public Health 14 (9). https://doi.org/10.3390/ijerph14090973. Beard, E., West, R., Michie, S., Brown, J., 2016. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ 354. http://www.bmj.com/content/354/bmj.i4645. abstract. Biener, L., Hargraves, J.L., 2015. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine Tob. Res. 17 (2), 127–133. https://doi.org/10.1093/ntr/
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