Electronic Cigarettes in Italy: a Tool for Harm Reduction Or a Gateway To
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Research paper Tob Control: first published as 10.1136/tobaccocontrol-2018-054726 on 18 January 2019. Downloaded from Electronic cigarettes in Italy: a tool for harm reduction or a gateway to smoking tobacco? Xiaoqiu Liu,1 Alessandra Lugo,1 Enrico Davoli,1 Giuseppe Gorini,2 Roberta Pacifici,3 Esteve Fernández,4 Silvano Gallus1 1Department of Environmental ABStract as a smoking cessation tool.8 Indeed, the safety of Health Sciences, Istituto di Introduction More than a decade after electronic e-cigarette use, particularly its long-term effects, Ricerche Farmacologiche Mario remains unclear9 10: while these e-cigarettes emit Negri IRCCS, Milano, Italy cigarettes (e-cigarette) hit the European market, we are 2Oncological Network, still debating whether they may help or hinder tobacco less toxicants and carcinogens than conventional Prevention and Research control. It is therefore useful to explore the potential net cigarettes, they are still measurable and vary widely Institute (ISPRO), Florence, Italy with individual puffing topography and puff dura- 3 effect of e-cigarette use in the general population. National Centre on Addiction 11 12 13 Methods We annually conduct a face-to-face survey tion, and from study to study. Although some and Doping, Istituto Superiore di Sanità, Rome, Italy on smoking in Italy on a representative sample of the studies showed that e-cigarettes may help smokers 4Institut Català d’Oncologia general population aged 15 years or over (52.4 million). cut down or stop smoking conventional ciga- (ICO)-Institut d’Investigació A total of 15 406 subjects were interviewed in 2014– rettes,14–16 others found e-cigarettes even stop cessa- Biomèdica de Bellvitge 2018. We investigated the consequences of using tion or give low cessation rates, similar to those of (IDIBELL), School of Medicine, 10 17–19 Universitat de Barcelona, e-cigarettes on tobacco smoking behaviour among ever smokers who have tried to quit with no aid. L’Hospitalet de Llobregat, and regular e-cigarette users. There is also concern that e-cigarettes may under- Barcelona, Spain Results In all, 5.7% of our sample reported ever mine efforts to ‘denormalise’ smoking.20 Finally, e-cigarette use. Multivariate analyses showed more use non-smokers trying e-cigarettes can succumb to Correspondence to by men, ex-smokers and current smokers. E-cigarette nicotine addiction, particularly young people.1 21 22 Dr Silvano Gallus, Department use decreased with age and increased with education To get a better picture of the potential net benefit of Environmental Health Sciences, Istituto di Ricerche and calendar year. Only 1.1% of subjects were regular of e-cigarette use in reducing tobacco consumption Farmacologiche Mario Negri e-cigarette users. This prevalence rose from 0.4% in at a population level, we analysed data from our IRCCS , Milano 20156, Italy; 2014–2015 to 1.8% in 2016–2017 and was 1.3% in annual population-based surveys conducted in Italy silvano. gallus@ marionegri. it 2018. Among 522 ever users, 13.2% stopped smoking from 2014 to 2018, where a specific section was copyright. after trying e-cigarettes and 22.2% started smoking devoted to e-cigarette use. Received 7 September 2018 Revised 10 December 2018 or relapsed after using e-cigarettes. The corresponding Accepted 20 December 2018 estimates among regular users were 24.7% and 28.0%, respectively. METHODS Conclusions Among Italian e-cigarette users, those Surveys were conducted by DOXA, the Italian (re)starting smoking after using e-cigarettes outnumber branch of the Worldwide Independent Network/ those who stop smoking after using e-cigarettes. From Gallup International Association, in collaboration a public health point of view, e-cigarettes may have an with the Italian National Institute of Health and http://tobaccocontrol.bmj.com/ unfavourable net effect. Consequently, if we are not the Mario Negri Institute for Pharmacological able to prevent sales of e-cigarettes to non-smokers, this Research. Each year, the survey is based on around product will more likely stimulate smoking tobacco than 3000 subjects, representative of the general Italian reduce harm. population aged 15 years and over (52.4 million inhabitants in 2018), in terms of sex, age, area of residence and socioeconomic characteristics.23 For the present analysis, the sample comprised 15 406 INTRODUCTION individuals aged 15 years or more (7393 men and The electronic cigarette (e-cigarette) is a battery-pow- 8013 women), enrolled in the survey conducted in ered device that heats a liquid containing propylene 2014–2018. glycol, glycerin and/or water with flavours, to Participants were selected by a representative generate an inhalable aerosol containing nicotine multistage sampling. The first stage involved the on October 1, 2021 by guest. Protected or not. E-cigarettes were marketed in most high-in- selection of municipalities in all the 20 Italian come countries around 2010, and its popularity and regions, based on the region and the size of the use soon spread widely.1 Some public and private municipality. We selected 116 municipalities in organisations, including Public Health England, 2014, 110 in 2015, 2016 and 2017 and 119 in © Author(s) (or their have endorsed e-cigarette use, on the basis of the 2018 as representative of the regions sampled. In employer(s)) 2019. No widely accepted standpoint that they could be bene- the second stage, an adequate number of electoral commercial re-use. See rights and permissions. Published ficial for heavy smokers who are not able to quit with wards was randomly extracted in each municipality, 2 3 by BMJ. standard support. This endorsement, conflicting so that the more or less affluent areas of the munic- with the conclusions of the WHO4 and the US ipality were represented in the right proportions. In To cite: Liu X, Lugo A, National Academies of Sciences, Engineering, and the third stage, individuals were randomly sampled Davoli E, et al. Tob Control 5 Epub ahead of print: [please Medicine, has provoked much debate and concern from electoral rolls, within strata defined by sex 6–8 include Day Month Year]. over the spread and use of e-cigarettes. and age. Adolescents aged 15–17 years, who were doi:10.1136/ The debate is mainly due to uncertainty about the not included in the electoral lists, were randomly tobaccocontrol-2018-054726 harmful effects of e-cigarettes and their effectiveness selected by a ‘quota’ method based on the sex and Liu X, et al. Tob Control 2019;0:1–5. doi:10.1136/tobaccocontrol-2018-054726 1 Research paper Tob Control: first published as 10.1136/tobaccocontrol-2018-054726 on 18 January 2019. Downloaded from age proportions among them. A statistical weight was generated number of conventional cigarettes per day; (7) I quit smoking; for each subject to ensure the representativeness of the Italian (8) I did not smoke conventional cigarettes before and I do not population aged 15 years or more. smoke now’. Almost all e-cigarette users (97%) provided a valid Ad hoc trained interviewers conducted the survey using response to this question. In 2017–2018, a single-choice ques- a structured questionnaire in a computer-assisted personal tion to current e-cigarette users only investigated the type of interview. Besides general information on sociodemographic e-cigarette used (with or without nicotine). characteristics, smoking status (never smoker, ex-smoker and Descriptive statistics were used for the main results, including current smoker) and other tobacco-related data were collected. prevalence and the corresponding 95% confidence interval Ever smokers (current smokers and ex-smokers) were partici- (CI) by categorical variables. In view of the small numbers, we pants who had smoked 100 or more cigarettes in their lifetime. grouped the survey year as 2014–2015, 2016–2017 and 2018. Ex-smokers were participants who had quit smoking for at least Statistical weights were used to reassure the representativeness 1 year, and current smokers were individuals smoking at the time of our sample in terms of age, sex, area of residence and socio- of the interview or having stopped for less than 1 year. Partici- economic characteristics. Odds ratios (OR) and the 95% CIs for pants were asked about their use of e-cigarettes, using the ques- ever—and regular—e-cigarette use were calculated using multi- tion: ‘Do you use electronic cigarettes or other electronic devices variate logistic regression models, adjusting for sex, age, level for vaping (disposable or prefilled or refillable cartridges with of education, smoking status, area of residence and survey year. liquid), even only occasionally?’ (1) Yes, occasionally; (2) Yes, A sensitivity analysis limited to data from 2017 and 2018 was usually; (3) I used it in the past; (4) No. We define herewith as done to explore whether the answers on the consequence of occasional e-cigarette users reporting the first answer, regular e-cigarette use differed between current and past users. Another users the second answer, past users the third answer, current users sensitivity analysis was done on nicotine-containing e-cigarette first and second answers combined, and ever users first, second users, that is, current users in 2014–2015, 2017–2018, to assess and third answers combined. Occasional and regular e-cigarette the consequence of their use of e-cigarettes on tobacco smoking. users (and past e-cigarette users in 2017 and 2018) were further All analyses were done with SAS V.9.4 statistical package. investigated about the consequences of e-cigarette use on their tobacco smoking habits with the following question: ‘Which of the following best describes the consequence of using electronic RESULTS cigarettes on your current cigarette smoking consumption? (1) I The distribution of 15 406 Italians aged 15 years or more started smoking conventional cigarettes (I did not smoke before, according to their use of e-cigarettes is shown in table 1.