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Tobacco control policies and socio-economic inequalities in smoking cessationEvaluating natural experimentsBosdriesz, J.R.

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Download date: 21 Nov 2020

5

Sociodemographic differences in the use of electronic nicotine

delivery systems in the European Union

Gaby Ooms

Jizzo Bosdriesz France Portrait

Anton Kunst

Published in Nicotine & Tobacco Research

2016;18(5):724-729

Chapter 5

96

ABSTRACT

Introduction

Electronic nicotine delivery systems (ENDS) are rapidly increasing in popularity.

However, little is known about sociodemographic differences in use of ENDS. This

study aims to assess the sociodemographic characteristics associated with ENDS

ever-use and use as a cessation tool in the European Union.

Methods

We analysed data from the 2012 Eurobarometer wave 77.1, with 25,922 respondents

aged 15 years or above from all 27 member states. We estimated the prevalence of

ever-use and use as a cessation tool, and performed binary logistic regression to

analyse associations with sociodemographic characteristics.

Results

Overall, 7.2% reported having ever used ENDS. Of all smokers who ever tried to

quit, 7.0% used ENDS. Ever-use was inversely associated with being older than 34

years (odds ratio [OR] = 0.63, 95% confidence interval [CI] = 0.51–0.76 for 35-44

years, and OR = 0.34, 95% CI = 0.25–0.46 for at least 65 years), and positively

associated with being higher educated (OR = 1.50, 95% CI = 1.22–1.84) or a student

(OR = 2.34, 95% CI = 1.77–3.08). ENDS were more often used to quit smoking by

students (OR = 2.05, 95% CI = 1.10–3.82), and were less likely to be used by those

aged 65 or older (OR = 0.30, 95% CI = 0.15–0.61). No significant differences were

found according to sex, social class, marital status or type of community.

Conclusions

In 2012, ever-use of ENDS was low in the European population in general.

However, younger people or those with a high education used ENDS more

frequently. These results indicate a need for more appropriate product information

targeted at these groups. This study shows that in the European Union in 2012,

regular use of ENDS was rare, especially among non-smokers. Only age and

education were strongly associated with ENDS use. The increased prevalence of

ever-use among the younger age groups is relevant, as in this age group smoking

habits are established. The higher ever-use of ENDS among younger and higher

educated people found in this study indicated a need to target appropriate product

information, stressing the ENDS use does not imply zero harm.

Differences in the use of e-cigarettes in Europe

97

5

INTRODUCTION

Electronic nicotine delivery systems (ENDS), also called electronic cigarettes or e-

cigarettes, are battery-powered devices that vaporize nicotine for inhalation,

allegedly eliminating the toxic effects of smoked tobacco. ENDS are marketed as

safer, healthier alternatives to traditional cigarettes.1 ENDS were introduced into the

European market in 2006, and public interest has been rapidly increasing since.2–4 In

the United States (US), 16% of the adult population had heard of ENDS in 2009,

increasing to 40% in 2010, and 58% in 2011.2,5,6

In the US, in 2009 ever-use was only 0.6%; this increased to 6% in 2011.2,7

Prevalence of ENDS use differs considerably between countries, as research

indicates that ever-use in high school students in Poland is 23.5%, while in Korea

ever-use in adolescents is 9.4%.8,9 A study among populations of 27 European Union

(EU) member states reported that ever-use of ENDS was higher among smokers

than non-smokers.10

Data concerning the use of ENDS as a cessation tool is limited. Eurobarometer

results indicate that 7.1% of European smokers who had tried to quit used ENDS

as a cessation tool.10 Most users say that they use ENDS to quit or cut down on

traditional cigarette use.2,4,7 However, among US university students no relationship

exists between the intention to quit and ENDS use.11

Prevalence of ENDS use and use as a cessation tool may strongly differ between

population subgroups. In population studies among US, United Kingdom (UK),

Canadian and Australian adults, younger age,2,4,6,7,12 higher income, higher education,

and higher occupational class are associated with higher ENDS use.6,7,9 Results on

male-female differences in the adult population of the US, UK, Canada and

Australia, as well as the Korean adolescent population, are mixed.2,7,9,12 One study in

the UK reported that only age was associated with ENDS use.4 This shows that

published evidence on the sociodemographic characteristics associated with ENDS

is inconsistent. Moreover, prevalence studies are oftentimes not representative of

the total population, as many samples consist of subpopulations, such as university

students.

A recent study has described the association of age, sex and place of residence with

ENDS use in different European countries.10 In Europe, younger age, smoking, and

past-year quit attempt were associated with higher ENDS ever-use.10 However, there

Chapter 5

98

is no evidence on the role of several sociodemographic characteristics, including

marital status, occupational class and educational level, in Europe.

The aim of this study was therefore to assess for a broader range of

sociodemographic characteristics their association with ENDS ever-use. In addition,

we assessed differences in its use as a cessation tool in the EU. We used data from

Eurobarometer wave 77.1, a dataset that provides information for nationally

representative samples of individuals living in the 27 EU member states.

METHODS

Data were obtained from Eurobarometer wave 77.1, conducted from February to

March 2012. It included respondents aged 15 years or above, from all 27 member

states. Details on the sample design are given elsewhere.13,14 The interviews were

conducted face-to-face in the appropriate national language. The initial sample

consisted of 26,751 respondents, from whom those with data missing on any of the

used variables were excluded from the analyses (829 respondents), resulting in a final

study sample of 25,922 respondents.

ENDS use was assessed by the question “Have you ever tried Electronic cigarettes?”

Possible answers distinguished between “use or used it regularly”, “use or used it

occasionally”, “tried it once or twice”, and “no”. All frequencies of use were

combined into ever users. For all ENDS users, we assessed whether they used

ENDS as a cessation tool, using the question “which of the following did you use

in order to quit or to try to quit smoking?”, which included “electronic cigarettes”

as a possible answer. The smoking status of respondents was classified as current

smoker, former smoker or never smoker. Harm perceptions were measured with the

question “Do you think ENDS are harmful or not to the health of those who use

them?” Answers were yes, no, or don’t know; yes and don’t know were combined.

Sociodemographic variables included in the study were sex, age (categories 15-24,

25-34, 35-44, 45-54, 55-64, and 65 or older), type of community (village, town, and

city), occupation, education, and marital status. Occupation was categorized into

four social classes using the Erikson-Goldthorpe-Porocarero scheme:15 manual class

(e.g. farmers, and manual workers), middle class (e.g. craftsmen, business

proprietors, and desk workers), upper class (e.g. professionals), and inactive (e.g.

students, unemployed, and retired). Education was measured as the age at which the

Differences in the use of e-cigarettes in Europe

99

5

respondent completed full-time education: 15 years or less, 16-19 years, 20 or more

years, current students, and no full-time education. Marital status is categorized into

unmarried, married or with a partner, divorced or separated, and widowed.

Analysis of the data was carried out using IBM SPSS Statistics 21. For all analyses a

weight variable (adjusting for sex, region of residence, the respective subgroups

living in a country, and each member state’s share in the EU population) was used

to improve the representativeness.16 Binary logistic regression analyses were

performed to investigate associations between sociodemographic variables, and

both ever-use and use as a cessation tool. These analyses were performed for the

total population, controlling for smoking status as well as stratified by smoking

status. In addition, harm perception and country of residence were added to the

model to control for confounding. All independent variables were entered into the

model simultaneously. Relationships are represented as odds ratios (ORs) and 95%

confidence intervals (95% CIs).

RESULTS

Regular use of ENDS was low at 0.7% for the total population, 1.8% for smokers,

and 0.2% for non-smokers. Total ever-use among the European population was

7.2%; among current smokers it was much higher (20.3%) than among non-smokers

(2.1%). Of smokers who had tried to quit, 7.0% used ENDS as a cessation tool,

compared to 50.5% of regular ENDS users (results not shown).

The highest prevalence of ENDS use was found among those aged 15-24 years

(12.7%), and among students (11.9%), as seen in Table 1. Ever-use is significantly

lower among those older than 35 compared to the youngest group. For example, the

OR for those aged 45-54 is 0.54, 95% CI = 0.44–0.66. Higher education is also

associated with higher ever-use, with the highest odds for current students (OR =

2.34, 95% CI = 1.77–3.08). ENDS ever-use was not significantly associated with

sex, social class, type of community or marital status.

Among non-smokers, ever-use of ENDS was higher among those with higher

education or students, and among younger respondents. Women had significantly

lower odds of ever having used ENDS than men, and widowed people were more

likely to ever have used ENDS compared to unmarried people. Among current

smokers, the ever use of ENDS did not differ significantly by sex or marital status.

Chapter 5

100

Tab

le 1

Mult

ivar

iab

le a

sso

ciat

ion

s o

f E

ND

S u

se w

ith

so

cio

-dem

ogr

aph

ic c

har

acte

rist

ics

To

tal

po

pu

lati

on

1 N

on

-sm

ok

ers

C

urr

en

t sm

ok

ers

N

N

(%

) %

2

OR

(95%

CI)

%

2

OR

(95%

CI)

%

2

OR

(95%

CI)

Ag

e

15-2

4

3,5

28

13.6

12.7

1.0

0

4.5

1.0

0

32.8

1.0

0

25-3

4

4,0

10

15.5

12.4

0.9

1 (

0.7

6–

1.0

9)

4.0

1.0

5 (

0.7

0–

1.5

5)

26.1

0.8

6 (

0.7

0–

1.0

6)

35-4

4

4,5

31

17.5

8.3

0.6

3 (

0.5

1–0.7

6)

2.2

0.5

7 (

0.3

6–

0.8

9)

19.7

0.6

2 (

0.4

9–

0.7

7)

45-5

4

4,6

82

18.1

6.8

0.5

4 (

0.4

4–

0.6

6)

2.0

0.6

0 (

0.3

8–

0.9

4)

16.3

0.5

1 (0

.40–

0.6

4)

55-6

4

3,7

70

14.5

3.9

0.3

8 (

0.3

0–

0.4

8)

1.0

0.3

4 (

0.2

0–

0.5

9)

12.9

0.3

7 (

0.2

8–

0.4

9)

65+

5,4

01

20.8

1.6

0.3

4 (

0.2

5–

0.4

6)

0.7

0.4

1 (0

.23–

0.7

2)

8.9

0.3

4 (

0.2

3–

0.4

9)

Sex

M

ale

12,5

30

48.3

8.4

1.0

0

2.6

1.0

0

20.6

1.0

0

Fem

ale

13,3

92

51.7

6.1

0.9

1 (

0.8

2–

1.0

1)

1.7

0.7

3 (

0.6

0–

0.9

0)

20.1

0.9

8 (

0.8

7–

1.1

1)

So

cia

l cla

ss

Man

ual

cla

ss

3,5

58

13.7

9.3

1.0

0

2.5

1.0

0

19.8

1.0

0

M

idd

le c

lass

7,9

52

30.7

9.1

1.1

5 (

0.9

9–

1.3

5)

2.7

1.0

9 (

0.7

8–

1.5

1)

23.2

1.1

8 (

0.9

9–

1.4

0)

U

pp

er c

lass

1,3

28

5.1

5.3

0.8

3 (

0.6

2–

1.1

2)

2.1

0.7

5 (

0.4

4–

1.2

7)

17.5

0.8

5 (

0.5

9–

1.2

2)

In

acti

ve

13,0

85

50.5

5.7

0.9

0 (

0.7

6–

1.0

6)

1.8

0.8

4 (

0.5

7–

1.2

5)

18.6

0.8

9 (

0.7

4–

1.0

8)

Ed

ucati

on

15-

5,2

99

20.4

3.3

1.0

0

0.6

1.0

0

11.4

1.0

0

16-1

9

11,1

89

43.2

8.1

1.

32 (

1.10

–1.

59)

2.0

1.

78 (

1.13

–2.8

2)

20.4

1.2

1 (

0.9

9–

1.4

9)

20+

7,0

98

27.4

7.4

1.

50 (

1.22–

1.84)

2.5

2.2

7 (

1.40–

3.6

7)

22.4

1.

31

(1.0

4–

1.65)

Sti

ll st

ud

yin

g

2,2

27

8.6

11.9

2.3

4 (

1.77–

3.0

8)

5.1

3.4

2 (

1.83–

6.4

1)

37.8

2.2

1 (1

.61–

3.0

5)

Typ

e o

f co

mm

un

ity

Vill

age

8,8

68

34.2

6.2

1.0

0

1.9

1.0

0

18.1

1.0

0

T

ow

n

10,3

50

39.9

6.8

1.0

6 (

0.9

3–

1.2

0)

2.1

1.0

1 (

0.7

9–

1.3

0)

19.4

1.0

6 (

0.9

1–

1.2

3)

Cit

y 6,7

04

25.9

9.2

1.1

3 (

0.9

9–

1.2

9)

2.5

1.0

4 (

0.8

0–

1.3

6)

24.3

1.1

5 (

0.9

8–

1.3

4)

Mari

tal

statu

s U

nm

arri

ed

5,5

39

21.4

10.8

1.0

0

3.3

1.0

0

25.5

1.0

0

M

arri

ed/

par

tner

16,6

58

64.3

6.5

1.0

3 (

0.9

0–

1.1

8)

2.1

1.2

9 (

0.9

7–

1.7

2)

18.8

0.9

7 (

0.8

3–

1.1

3)

Div

orc

ed/

sep

arat

ed

1,7

87

6.9

8.8

1.1

1 (

0.8

9–

1.3

9)

1.5

1.1

3 (

0.6

3–

2.0

2)

19.9

1.1

0 (

0.8

6–

1.3

9)

Wid

ow

ed

1,9

39

7.5

2.0

0.7

2 (

0.4

9–

1.0

6)

0.1

0.1

1 (0

.02–

0.6

6)

12.4

0.9

5 (

0.6

3–

1.4

2)

Sm

ok

ing

st

atu

s Sm

oker

7,2

51

28.0

-

- -

- -

- N

on

-sm

oker

18,6

71

72.0

-

- -

- -

-

EN

DS =

ele

ctro

nic

nic

oti

ne

del

iver

y sy

stem

. A

ll var

iab

les

ente

red

sim

ult

aneo

usl

y in

to a

mult

ivar

iate

mo

del

. T

he

mo

del

was

co

rrec

ted

fo

r co

un

try

of

resi

den

ce

and

har

m p

erce

pti

on

. 1 C

orr

ecte

d f

or

smo

kin

g st

atus.

2 P

erce

nta

ge o

f re

spo

nd

ents

wh

o e

ver

use

d E

ND

S. Sig

nif

ican

t as

soci

atio

ns

(p<

0.0

5)

are

hig

hlig

hte

d in

b

old

.

Differences in the use of e-cigarettes in Europe

101

5

Table 2 Multivariable associations of ENDS use as a cessation tool with socio-demographic characteristics

Model 1 Model 2 %2 OR (95% CI) OR (95% CI)

Age 15-24 5.1 1.00 1.00 25-34 5.8 1.45 (0.90 – 2.33) 1.59 (0.98 – 2.58) 35-44 5.2 1.30 (0.79 – 2.13) 1.50 (0.91 – 2.48) 45-54 3.7 1.04 (0.63 – 1.73) 1.27 (0.76 – 2.13) 55-64 2.8 0.72 (0.42 – 1.25) 0.86 (0.50 – 1.51) 65+ 0.9 0.24 (0.12 – 0.47) 0.30 (0.15 – 0.61)

Sex Male 3.5 1.00 1.00 Female 3.9 0.99 (0.80 – 1.24) 1.03 (0.83 – 1.29)

Social class Manual class 3.9 1.00 1.00 Middle class 5.0 1.27 (0.92 – 1.75) 1.23 (0.89 – 1.71) Upper class 2.5 0.59 (0.31 – 1.12) 0.61 (0.32 – 1.16) Inactive 2.9 1.06 (0.75 – 1.52) 1.08 (0.76 – 1.54)

Education 15- 2.3 1.00 1.00 16-19 3.5 0.85 (0.60 – 1.22) 0.81 (0.56 – 1.16) 20+ 4.4 1.08 (0.73 – 1.59) 1.01 (0.68 – 1.49) Still studying 7.7 2.07 (1.12 – 3.85) 2.05 (1.10 – 3.82)

Type of community Village 3.6 1.00 1.00 Town 3.3 0.88 (0.68 – 1.14) 0.87 (0.67 – 1.13) City 4.4 1.02 (0.77 – 1.35) 1.03 (0.78 – 1.37)

Marital status Unmarried 4.4 1.00 1.00 Married/ partner 3.8 1.23 (0.90 – 1.66) 1.27 (0.93 – 1.72) Divorced/ separated 2.9 0.90 (0.55 – 1.47) 0.88 (0.53 – 1.44) Widowed 1.7 1.04 (0.50 – 2.20) 1.11 (0.52 – 2.35)

Harm perception No 6.3 - 1.00 Yes/ Don’t know 2.3 - 0.39 (0.31 – 0.49)

ENDS = electronic nicotine delivery system. All variables were entered simultaneously into the multivariate model. The model was corrected for country of residence. 1 Used ENDS as a cessation tool. 2 Percentage of respondents who have used ENDS as a cessation tool. Significant associations (p<0.05) are highlighted in bold.

Table 2 shows that the prevalence of using ENDS as a cessation tool ranged from

0.9% (people aged 65 years or older) to 7.7% (students). No significant associations

were found with social class, sex, type of community, and marital status. Students

(OR = 2.05, 95% CI = 1.10–3.82) were more likely, and people aged 65 or older

Chapter 5

102

were significantly less likely (OR = 0.30, 95% CI = 0.15–0.61) to use ENDS as a

cessation tool than others.

DISCUSSION

This is one of the first studies on sociodemographic differences in ENDS ever-use

and use as a cessation tool in the 27 EU member states. In 2012, ever-use was

associated with being younger (than 35 years), a higher education, and being a

student. ENDS were more often used as a cessation tool by smokers who were

students, and less likely to be used by those aged 65 or older.

Our study uses a large scale survey that covers the 27 EU countries, and the results

aim to be representative for the whole EU population. As the Eurobarometer survey

is based on self-reported data, it may be subject to reporting bias.9 The validity of

self-reported cigarette smoking has been assessed,17 but not yet for the use of ENDS.

Another limitation is that no information about the response rate in the

Eurobarometer study was given in the published report and accompanying meta-

data. The Eurobarometer did not include a definition of ENDS. Of the respondents

who said they had ever used ENDS, 0.2% did not know what ENDS were.

However, because this is a small percentage, we do not believe it leads to a distortion

in our findings. Moreover, the Eurobarometer did not specify between the use of

nicotine or nicotine-free ENDS. However, as the survey was conducted in 2012, it

is likely that the ENDS did contain nicotine, as ENDS in comparative studies during

this time always contained nicotine.1,7,18

There are concerns that ENDS could be a gateway to using traditional cigarettes,

because they resemble traditional cigarettes and they can cause nicotine

addiction.2,4,6,8,11,19 Of young ENDS ever-users in our study, 14.2% had never

smoked traditional cigarettes, and regular ENDS use among this age group was

8.0%. This proportion is comparable to that found in the US in 2009 (12%) and

Poland (14%).11,20 Thus, for a substantial minority of its users, ENDS could work as

a gateway product. However, it is important to note that in 2012 only 0.2% of the

total non-smokers in the EU used ENDS regularly.

In the EU in 2012, 7.2% of the population has ever used ENDS. Our results are

consistent with research from the US, where the prevalence of ever-use in 2011 was

6.2% among US adults.5 However, those aged 15-24 and 25 to 34 in Europe had a

Differences in the use of e-cigarettes in Europe

103

5

higher prevalence of ever-use compared to their counterparts in the US (12.2–12.4%

vs 6.6–8.1%).5 This difference might possibly be due to differences in policy, as in

some US states in 2011 it was already illegal to sell ENDS to persons under 18 years

old.21 In 2012 there was no ENDS age legislation in place in the EU, but ENDS

were either prohibited, medicinal, a tobacco product, or not regulated.22

Our finding that younger age was associated with a higher ever-use is consistent with

previous research.4,6,7,22,23 These findings are not surprising given that ENDS are

aggressively marketed among young people through social media and the

internet.12,24 Moreover, the use of ENDS on TV or in movies could popularize use

among younger age groups more than the elderly.25

A lower level of education was associated with a lower ever-use. Yet, evidence

supporting the association of education with ever-use is contradictory. One US study

also found that a lower education was associated with lower ever-use,7 but another

study found the opposite.12

Our finding that social class was not consistently associated with ever-use

corresponds with findings from the UK.4 However, using another measure of

socioeconomic position, namely income, a survey among smokers in Australia,

Canada, the UK and the US, found that those with a higher income were more likely

to try ENDS.7 On the contrary, another survey found that among US adults, a lower

income was associated with higher ENDS ever-use.12

We found that in Europe, 7.1% of those who have ever tried to quit smoking used

ENDS as a means to quit. Conversely, 26.2% of ever-users of ENDS said they have

used this as a tool to quit smoking. This percentage is consistent with previous

research.4,10 This suggests that the desire to quit smoking made a modest

contribution to the prevalence in the use of ENDS use in the EU in 2012.

The differences in ENDS use according to age and education might result from

differences in harm perception. Further analyses, not shown in this article, indicated

that ENDS were significantly less likely to be seen as harmful by the higher educated

or students (OR = 0.83, 95% CI = 0.71–0.97) as compared to the lower educated.

Conversely, older people were significantly more likely to consider ENDS as

harmful. Overall, about a third of Europeans believe ENDS are not harmful, while

another third is undecided. This may not be surprising, as while ENDS are

potentially harmful in their own right,8,26 they seem to be less harmful than

Chapter 5

104

traditional cigarettes.8,27,28 Moreover, the uncertainty could also reflect the conflicting

evidence in the scientific community regarding the safety of ENDS.29,30

Conclusions

In the EU in 2012, regular use of ENDS was rare, especially among nonsmokers.

Only age and education were strongly associated with ENDS use. The increased

prevalence of ever-use among the younger age groups is relevant, as in this age group

smoking habits are established.31 Among young and higher educated people, the

higher ever-use of ENDS indicates a need to target appropriate product information,

stressing that ENDS use does not imply zero harm.32

Acknowledgments

We used data from Eurobarometer surveys 27, 29, 32, 34.1, 38.0, 41.0, 43.0, 58.2,

64.1, 66.2, 72.3, 77.1, made available from the GESIS data archive, Cologne.

This study is part of the project ‘Tackling socio-economic inequalities in smoking

(SILNE)’, which is funded by the European Commission, Directorate-General for

Research and Innovation, under the FP7-Health-2011 program, with grant

agreement number 278273.

Author contributions

GO, JB, and AK conceived and designed the study. JRB prepared the data. GA

analysed and interpreted the data and led the writing, she is the guarantor of this

paper. JB, FP, and AK interpreted the data and provided critical revisions. All

authors have read and approved the final version of this paper.

Conflicts of interest

None declared.

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