Research article
Electronic Nicotine Delivery Systems: International Tobacco Control Four-Country Survey

https://doi.org/10.1016/j.amepre.2012.10.018Get rights and content

Background

Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet.

Purpose

Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries.

Methods

Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n=1581); the U.S. (n=1520); the United Kingdom (UK; n=1325); and Australia (n=1513).

Results

Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (≥20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking.

Conclusions

Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.

Introduction

Electronic nicotine delivery systems (ENDS; also called e-cigarettes) initially emerged in China in 2003 and have since become widely available globally, particularly over the Internet. ENDS heat and vaporize a solution containing nicotine, and many are designed to resemble traditional tobacco cigarettes. Some advocates of tobacco harm reduction have pointed to these products as viable substitutes for cigarettes because they produce fewer toxins in the vapor delivered to the user.1, 2, 3, 4, 5 However, concerns exist regarding unknown long-term safety; inadequate data on contents and emissions, especially with long-term use; and unsupported product claims as a smoking-cessation aid.6, 7, 8, 9

There also may be unintended consequences associated with ENDS use, including the potential to induce nicotine addiction in nonsmokers or maintain addiction in current smokers who might otherwise quit. Additionally, concerns have been raised that ENDS may undermine comprehensive indoor smoking restrictions and smokefree air policies.10 Because of these concerns, ENDS have been banned in Canada (www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2009/2009_53-eng.php) and Australia (www.tga.gov.au/consumers/ecigarettes.htm); however, they are legal in the U.S. and the United Kingdom (UK). Despite bans on retail sale, access is difficult to control because the products are marketed heavily over the Internet.

Because ENDS are relatively new, data on usage patterns are sparse.11 Surveys of self-selected ENDS users suggest that many are former or current cigarette smokers who use the products to reduce or quit smoking.2, 12, 13 A survey of a broader U.S. population showed that awareness of ENDS increased from 16.4% in 2009 to 32.2% in 2010, concurrent with a rise in ever-use (0.6% in 2009 to 2.7% in 2010).14 Ever-use was concentrated primarily among tobacco users. A nationally representative sample of U.S. adults found that 40.2% were aware of ENDS, and awareness and use was highest among current smokers (ever use: 11.4% current smokers, 2.0% former smokers, 0.8% never smokers).15 An online survey of approximately 2500 smokers in England in 2010 found that around 60% were aware of ENDS, 9% had tried them, and 3% were current users.16 The current authors are not aware of any studies to date that have examined cross-national patterns of ENDS use, and no studies have examined use in markets where ENDS are nominally banned. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former cigarette smokers in the U.S., Canada, Australia, and the UK.

Section snippets

Methods

Data come from Wave 8 of the International Tobacco Control (ITC) Four-Country Survey conducted July 2010 to June 2011 in the U.S., Canada, Australia, and the UK via telephone interviews and web surveys. Additionally, where available, data from Wave 7 (conducted October 2008 to July 2009) were analyzed to explore changes in smoking behavior between ENDS users and non-users. Details about the study design, sampling frames, and overall aims of the project are described elsewhere.17, 18

At initial

Prevalence of Awareness, Trial, and Usage

Across countries, nearly half (46.6%, n=2757) of respondents reported having heard of ENDS. Analyses revealed differences in ENDS awareness by country, χ2(3, n=5921)=932.5 (p<0.001). Greatest awareness was reported in countries where the use of ENDS is mostly permitted; nearly three quarters (73.4%) of respondents in the U.S. and more than half (54.4%) of respondents in the UK indicated awareness of these devices. Where ENDS were banned, awareness was lower but still substantial, with 39.5% and

Discussion

Nationally representative samples of current and former smokers surveyed in the four largest English-speaking countries showed substantial awareness of ENDS, ranging from 73% in the U.S. to 20% in Australia. Among those aware, 16% had tried ENDS (7.6% of the total sample), and among those who had tried ENDS, 39% (2.9% of the sample) were current users. Across countries, awareness of these relatively new products was higher among younger, non-minority populations with higher incomes. Trial and

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