Prevalence and correlates of current daily use of electronic cigarettes in the European Union: analysis of the 2014 Eurobarometer survey.

The study purpose was to analyze current daily and current daily nicotine-containing electronic cigarette (EC) use in the European Union (EU). Special Eurobarometer 429, a cross-sectional survey performed in a representative sample of 28 member states of the EU in November and December of 2014, was analyzed. The prevalence of current daily and current daily nicotine-containing EC use was 1.08% (95% CI 0.95-1.20%) and 1.00% (95% CI 0.88-1.12%), respectively, and was mainly observed in current and former smokers. Minimal current daily (0.08%, 95% CI 0.03-0.12%) and current daily nicotine-containing EC use (0.04%, 95% CI 0.01-0.08%) was observed among never smokers. Smoking cessation with the help of ECs was reported by 47.12% (95% CI 41.28-52.96%) of current daily and 49.14% (95% CI 43.12-55.17%) of current daily nicotine-containing EC users. Additionally, 33.18% (95% CI 27.67-38.69%) and 31.40% (95% CI 25.80-36.99%) reported reduction in smoking consumption, respectively. The strongest correlates of daily EC use were being current and former smokers. In the EU in late 2014, current daily EC use was predominantly observed in current and former smokers and was associated with high self-reported rates of smoking cessation and reduction. Current daily EC use by never smokers was extremely infrequent.

Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries.

AIMS: To assess prevalence of electronic cigarette (e-cigarette) use, reported changes in smoking status due to e-cigarette use and correlates of e-cigarette use in the European Union (EU) member states in 2014. DESIGN: Cross-sectional survey of EU citizens representative of the population (Special Eurobarometer 429). SETTING: All 28 Member States of the EU. PARTICIPANTS: A total of 27 460 EU citizens aged ≥ 15 years (after excluding those who responded 'Do not know' to the questions about smoking status and e-cigarette use). MEASUREMENTS: Descriptive analysis [%, 95% confidence interval (CI)] of e-cigarette use prevalence (current use, past use and past experimentation) according to smoking status, self-reported changes in smoking status according to patterns of e-cigarette use and logistic regression analysis to examine correlates of e-cigarette use, especially socio-demographic factors and smoking status. FINDINGS: Ever e-cigarette use was reported by 31.1% (95% CI = 30.0-32.2%) of current smokers, 10.8% (95% CI = 10.0-11.7%) of former smokers and 2.3% (95% CI = 2.1-2.6%) of never smokers. Past experimentation [7.2% (95% CI = 6.9-7.5%)] was more common than current [1.8% (95% CI = 1.6-1.9%)] and past use [2.6% (95% CI = 2.4-2.8%)]. Extrapolated to the whole population, approximately 48.5 million EU citizens were ever e-cigarette users, with 76.8% using nicotine-containing e-cigarettes. An estimated 6.1 and 9.2 million EU citizens had quit and reduced smoking with the help of e-cigarettes, respectively. Initiation with e-cigarettes was reported by 0.8% (95% CI = 0.6-0.9%) of participants who reported ever use of any tobacco-related product. Only 1.3% (95% CI = 1.1-1.5%) of never smokers used nicotine-containing e-cigarettes, with 0.09% (95% CI = 0.04-0.14%) reporting daily nicotine use. Smoking cessation with the help of e-cigarettes was reported by 35.1% (95% CI = 30.7-39.5%) of current e-cigarette users, while a further 32.2% (95% CI = 29.9-36.5%) reported smoking reduction. Being current [odds ratio (OR) = 21.23, 95% CI = 18.32-24.59) or former smokers (OR = 6.49, 95% CI = 5.49-7.67) were the strongest correlates of ever e-cigarette use. CONCLUSIONS: E-cigarette use in the European Union appears to be largely confined to current or former smokers, while current use and nicotine use by people who have never smoked is rare. More than one-third of current e-cigarette users polled reported smoking cessation and reduction.

Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes).

Tobacco smoking is the largest single preventable cause of many chronic diseases and death. Effective treatments exist; however, few smokers use them and most try to quit by themselves. Most of the tobacco cigarette's toxicity is related to the combustion process. Models of harm reduction applied to tobacco suggest that switching from inhalation of combustible products to a noncombustible nicotine delivery product would likely result in a vast reduction in tobacco-related death and illness. Currently available evidence raises no doubt that electronic cigarettes (e-cigs) are by far less harmful than smoking (although probably not absolutely safe) and have the potential to be the most effective tobacco harm reduction products due to their unique property of resembling smoking and providing satisfaction to the user. A lot of controversy is surrounding e-cigs and their regulation, much of which is based on the precautionary principle. Although monitoring and further research is definitely needed, the arguments used to implement severe restrictions or bans are mostly hypothetical, weakly supported by evidence, and, in some cases, derived from mispresentation or misinterpretation of the study findings. Regulators should keep in mind that the target population is smokers who want to reduce or quit their deadly tobacco consumption. To achieve this goal, smokers should be honestly informed on the relative harmfulness of the different products. E-cigs are not tobacco products and are not used as medications. For this reason, a specific regulatory scheme is needed, separate from tobacco or medicinal products regulation. Regulation should implement specific quality criteria for products, rules for the exclusion of chemicals of reasonable concern, and appropriate testing for possible contaminants. Additionally, manufacturing standards derived from the food industry should be implemented and adjusted for specific conditions related to e-cigs. Finding the appropriate balance between safety and acceptability of use by smokers will be important in achieving the maximum public health benefit. Labeling should be specified, with warnings about exposure to skin or through ingestion and discouragement of use by nonsmokers, related to the presence of nicotine. Finally, advertising and marketing should not be banned, but appropriately regulated in order to encourage use by the intended population while avoiding use by never-smokers. E-cigs should be appealing to smokers (but not to nonsmokers), while availability and pricing should be strong competitive advantages of e-cigs relative to tobacco cigarettes.

Quit and smoking reduction rates in vape shop consumers: a prospective 12-month survey.

AIMS: Here, we present results from a prospective pilot study that was aimed at surveying changes in daily cigarette consumption in smokers making their first purchase at vape shops. Modifications in products purchase were also noted. DESIGN: Participants were instructed how to charge, fill, activate and use their e-cigarettes (e-cigs). Participants were encouraged to use these products in the anticipation of reducing the number of cig/day smoked. SETTINGS: Staff from LIAF contacted 10 vape shops in the province of the city of Catania (Italy) that acted as sponsors to the 2013 No Tobacco Day. PARTICIPANTS: 71 adult smokers (≥18 years old) making their first purchase at local participating vape shops were asked by professional retail staff to complete a form. MEASUREMENTS: Their cigarette consumption was followed-up prospectively at 6 and 12 months. Details of products purchase (i.e., e-cigs hardware, e-liquid nicotine strengths and flavours) were also noted. FINDINGS: Retention rate was elevated, with 69% of participants attending their final follow-up visit. At 12 month, 40.8% subjects could be classified as quitters, 25.4% as reducers and 33.8% as failures. Switching from standard refillables (initial choice) to more advanced devices (MODs) was observed in this study (from 8.5% at baseline to 18.4% at 12 month) as well as a trend in decreasing thee-liquid nicotine strength, with more participants adopting low nicotine strength (from 49.3% at baseline to 57.1% at 12 month). CONCLUSIONS: We have found that smokers purchasing e-cigarettes from vape shops with professional advice and support can achieve high success rates.

A critique of a World Health Organization-commissioned report and associated paper on electronic cigarettes.

The World Health Organization (WHO) recently commissioned a report reviewing evidence on electronic cigarettes and making policy recommendations. A version of it was subsequently published as an academic paper. We identify important errors in the description and interpretation of the studies reviewed, and find many of its key conclusions misleading.

Pharmacotherapies and harm-reduction options for the treatment of tobacco dependence.

INTRODUCTION: Tobacco dependence, a chronic relapsing condition, requires repeated interventions and multiple attempts to quit. AREAS COVERED: Strategies for assisting smoking cessation include behavioural counselling and pharmacotherapy. Three drugs are currently used as first-line pharmacotherapy: nicotine replacement therapy (NRT), bupropion and varenicline. Compared to placebo, the drug effect varies from RR = 2.27 for varenicline, to 1.69 for bupropion, and 1.60 for any form of NRT. Cytisine (similar to varenicline) has a RR = 3.98 compared to placebo (two trials). Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments. EXPERT OPINION: Effective medications exist, and clinicians should encourage and offer treatment to every smoker. However, most smokers try to quit by themselves, with only about 3% quitting successfully each year. Alternative interventions are needed. Harm reduction has not received much support to date. Safer alternative to tobacco smoking (smoke-free products, long-term use of cessation drugs, or electronic cigarettes) could save lives and reduce the burden of tobacco-related deaths and diseases. Despite some encouragement to develop a research agenda for e-cigarettes, particularly on the safety issues, too little attention has been brought to this area of research.

Tobacco, nicotine and harm reduction.

ISSUES: Tobacco smoking, sustained by nicotine dependence, is a chronic relapsing disorder, which in many cases results in lifelong cigarette use and consequent death of one out of two lifelong smokers from a disease caused by their smoking. Most toxicity due to cigarette smoking is related to the burning process. APPROACH: Models of harm reduction applied to tobacco suggest that use of non-combustible, less toxic, nicotine-containing products as a substitute for cigarette smoking would reduce the death toll arising from tobacco use. Available options include medicinal nicotine and smokeless tobacco products. KEY FINDINGS: The potential role of nicotine replacement therapy (NRT) products in a harm reduction strategy is currently severely restricted by strict regulations on dose, safety and potential addictiveness. As a result, NRT products are designed to provide much less nicotine, and deliver it to the brain more slowly, than cigarettes, which are widely accessible and poorly regulated. Smokeless tobacco (snus) has proved to be an acceptable reduced hazard alternative to smoking in Sweden, but supply of snus is illegal elsewhere in the European Union. IMPLICATIONS: To increase accessibility and reach more smokers, barriers to the use of NRT use need to be removed and more effective NRTs need urgently to be developed. Smokeless tobacco could also play an important role in harm reduction, but current European Union regulations and concerns over exploitation by tobacco companies currently preclude wider use. CONCLUSION: To improve public health there is an urgent need for an appropriate regulatory framework and regulatory authority at the European level, controlling both tobacco and nicotine products to ensure that the least harmful products are the most accessible.

Smoking cessation or reduction with nicotine replacement therapy: a placebo-controlled double blind trial with nicotine gum and inhaler.

BACKGROUND: Even with effective smoking cessation medications, many smokers are unable to abruptly stop using tobacco. This finding has increased interest in smoking reduction as an interim step towards complete cessation. METHODS: This multi-center, double-blind placebo-controlled study evaluated the efficacy and safety of nicotine 4 mg gum or nicotine 10 mg inhaler in helping smokers (N = 314) to reduce or quit smoking. It included smokers willing to control their smoking, and participants could set individual goals, to reduce or quit. The study was placebo-controlled, randomized in a ratio of 2:1 (Active:Placebo), and subjects could choose inhaler or gum after randomization. Outcome was short-term (from Week 6 to Month 4) and long-term (from Month 6 to Month 12) abstinence or reduction. Abstinence was defined as not a single cigarette smoked and expired CO readings of <10 ppm. Smoking reduction was defined as a reduction in number of cigarettes per day by 50% or more versus baseline, verified by a lower-than-baseline CO reading at each visit during the same periods. RESULTS: Significantly more smokers managed to quit in the Active group than in the Placebo group. Sustained abstinence rates at 4 months were 42/209 (20.1%) subjects in the Active group and 9/105 (8.6%) subjects in the Placebo group (p = 0.009). Sustained abstinence rates at 12 months were 39/209 (18.7%) and 9/105 (8.6%), respectively (p = 0.019). Smoking reduction did not differ between the groups, either at short-term or long-term. Twelve-month reduction results were 17.2% vs. 18.1%, respectively. No serious adverse events were reported. CONCLUSION: In conclusion, treatment with 10 mg nicotine inhaler or 4 mg nicotine chewing gum resulted in a significantly higher abstinence rate than placebo. In addition a large number of smokers managed to reduce their cigarette consumption by more than 50% compared to baseline.

Testing the Cigarette Dependence Scale in 4 samples of daily smokers: psychiatric clinics, smoking cessation clinics, a smoking cessation website and in the general population.

AIM: To assess the properties of the Cigarette Dependence Scale (CDS-12) in various samples of daily smokers and to provide reference scores in a general population sample. METHODS: Surveys in 4 samples of daily cigarette smokers: psychiatric out-patients in Geneva, Switzerland (n=226), clients of smoking cessation clinics in France (n=370), visitors of a French-language smoking cessation website (n=13,697) and a representative sample of the general population of Geneva (n=292). RESULTS: In all 4 samples, Cronbach's alpha coefficients were >0.87 and factor analyses indicated that CDS-12 was unidimensional. CDS-12 was slightly skewed towards higher values, and it was associated with expired carbon monoxide, but this association was not strong (9% of variance explained, p<0.001). CDS-12 scores were highest in clients of smoking cessation clinics (mean=47.7, SD=10.2), followed by psychiatric patients (mean=44.4, SD=8.4), visitors of smoking cessation websites (mean=43.3, SD=11.6) and the general population sample (mean=36.9, SD=12.3). Except for tolerance, each element in the DSM-IV and ICD-10 definitions of dependence is reflected by at least one item in CDS-12, even though the match with these definitions is sometimes indirect. CONCLUSIONS: This paper presents reference scores and validity and reliability tests for CDS-12 in a diversity of samples of daily smokers. This information should be useful to clinicians and researchers.

Impact of messages on concomitant use of nicotine replacement therapy and cigarettes: a randomized trial on the Internet.

AIMS: To assess the impact of messages recommending the concomitant use of nicotine replacement therapy (NRT) and cigarettes on smokers' intention to quit smoking. DESIGN: Randomized trial. SETTING: Internet. PARTICIPANTS: A total of 2027 people who answered an e-mail sent to 9074 current and former smokers recruited on a smoking cessation website. INTERVENTION: Participants were divided randomly into four groups, each of which received a unique message (in French) by e-mail. The 'control' message said that nicotine replacement therapy (NRT) attenuates withdrawal symptoms in smokers who want to quit. The 'temporary abstinence' message added that NRT can also be used by current smokers to manage smoke-free situations. The 'reduction' message indicated that NRT can be used by current smokers who do not want to quit but want to smoke fewer cigarettes. The 'side-effects' message discouraged concomitant use of NRT and cigarettes. MEASUREMENTS: Perceived impact of these messages on motivation to quit smoking. FINDINGS: The e-mail was answered by 2027 people (25% of 8124 valid addresses). Smokers who received the 'reduction' message were slightly more likely than controls to report that this message increased their motivation to quit (66% versus 60%, P = 0.02). In contrast, smokers who received the 'side-effects' message were less likely than controls to report that this message increased their motivation (45% versus 60%, P < 0.001). The 'temporary abstinence' message had no detectable impact on motivation to quit. CONCLUSIONS: Among smokers recruited via a smoking cessation website, messages encouraging concomitant use of NRT and cigarettes may have either no effect or a positive effect on motivation to quit smoking.