Characteristics and correlates of electronic cigarette product attributes and undesirable events during e-cigarette use in six countries of the EUREST-PLUS ITC Europe Surveys
More details
Hide details
European Network on Smoking and Tobacco Prevention (ENSP), Brussels, Belgium
University of Crete (UoC), Heraklion, Greece
University of Athens (UoA), Athens, Greece
King’s College London (KCL), London, United Kingdom
Smoking or Health Hungarian Foundation (SHHF), Budapest, Hungary
Institut Català d’Oncologia (ICO) and Bellvitge Biomedical Research Institute (IDIBELL), Catalonia, Spain
School of Medicine and Health Sciences, Universitat de Barcelona, Catalonia, Spain
Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Heidelberg, Germany
University of Medicine and Pharmacy ‘Grigore T.Popa’, Iasi, Romania
Aer Pur Romania, Bucharest, Romania
Health Promotion Foundation (HPF), Warsaw, Poland
London School of Hygiene and Tropical Medicine, London, United Kingdom
University of Waterloo (UW), Waterloo, Canada
Ontario Institute for Cancer Research, Toronto, Canada
Christina N. Kyriakos   

European Network for Smoking and Tobacco Prevention (ENSP), Belgium, Chaussee d’Ixelles 144, 1050 Brussels, Belgium
Publish date: 2018-08-05
Tob. Induc. Dis. 2018;16(Suppl 2):A1
*EUREST PLUS Consortium List as collaborators: European Network on Smoking and Tobacco Prevention (ENSP), Belgium: Constantine Vardavas, Andrea Glahn, Christina N. Kyriakos, Dominick Nguyen, Cornel Radu-Loghin, Polina Starchenko University of Crete (UoC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Sophia Papadakis, Manolis Tzatzarakis, Alexander Vardavas Kantar Public (TNS), Belgium: Nicolas Bécuwe, Lavinia Deaconu, Sophie Goudet, Christopher Hanley, Oscar Rivière Smoking or Health Hungarian Foundation (SHHF), Hungary: Tibor Demjén, Judit Kiss, Anna Piroska Kovacs Catalan Institut of Oncology (ICO); Bellvitge Biomedical Research Institute (IDIBELL), Spain: Esteve Fernández, Yolanda Castellano, Marcela Fu, Olena Tigova, Sarah Nogueira Kings College London (KCL), United Kingdom: Ann McNeill, Katherine East, Sara C. Hitchman Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ), Germany: Ute Mons, Sarah Kahnert University of Athens (UoA), Greece: Yannis Tountas, Panagiotis Behrakis, Filippos T. Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia Peleki, Ioanna Petroulia, Chara Tzavara University of Medicine and Pharmacy ‘Grigore T.Popa’ Iasi, Romania: Antigona Trofor, Marius Eremia, Lucia Lotrean, Florin Mihaltan European Respiratory Society (ERS), Switzerland; Goethe University Frankfurt, Germany: Gernot Werde, Tamaki Asano, Claudia Cichon, Amy Far, Céline Genton, Melanie Jessner, Linnea Hedman, Christer Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Valérie Vaccaro, Brian Ward University of Maastricht (UniMaas), Netherlands: Marc Willemsen, Hein de Vries, Karin Hummel, Gera Nagelhout Health Promotion Foundation (HPF), Poland: Witold A. Zatoński, Aleksandra Herbeć, Kinga Janik- Koncewicz, Krzysztof Przewoźniak, Mateusz Zatoński University of Waterloo (UW); Ontario Institute for Cancer Research, Canada: Geoffrey T. Fong, Thomas Agar, Pete Driezen, Shannon Gravely, Anne C.K. Quah, Mary E. Thompson
This study assessed characteristics and correlates associated with e-cigarette product attributes and identified correlates of experiencing undesirable events during e-cigarette use among adult smokers across six European Union (EU) Members States (MS) prior to the implementation of the Tobacco Products Directive (TPD) in 2016.

We conducted a cross-sectional survey with a nationally representative sample of adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) reporting e-cigarette use; randomly selected through a multistage cluster sampling design from June to September 2016. Stepwise logistic regressions were used to identify factors associated with use of flavors, noticing health warnings, mixing e-liquids, experiencing ‘dry puff’, e-liquid leaking during use and e-liquid spilling during refill.

Current daily or weekly prevalence of e-cigarette use among this sample of adult smokers was 7.5%. The most common attributes of e-cigarettes used included those that are flavored, contain nicotine, and are of tank style. Noticing health warnings on e-cigarette packaging and leaflets, respectively, was low (10.2% and 28%, respectively). Use of e-liquid refill nozzle caps, described as easy for a child to open, was associated with spilling during refill (OR=6.73; 95% CI: 2.02–22.37). Participants who adjusted occasionally or regularly the power (voltage) or temperature of their e-cigarette had greater odds of ever experiencing a ‘dry puff’ (OR=6.01; 95% CI: 2.68–13.46). Mixing different e-liquids was associated with leaking during use (OR=7.78; 95% CI: 2.45–24.73) and spilling during refill (OR=8.54; 95% CI: 2.29–31.88).

Ongoing evaluation of factors associated with e-cigarette attributes and of the correlates of experiencing e-cigarette undesirable events during use, related to product design, is crucial to monitoring the impact of the implementing Acts of the EU TPD.

Filippidis FT, Laverty AA, Gerovasili V, Vardavas CI. Two-year trends and predictors of e-cigarette use in 27 European Union member states. Tob Control. 2017;26(1):98-104. doi:10.1136/tobaccocontrol-2015-052771
Vardavas CI, Filippidis FT, Agaku IT. Determinants and prevalence of e-cigarette use throughout the European union: A secondary analysis of 26 566 youth and adults from 27 countries. Tob Control. 2015;24(5):442-448. doi:10.1136/tobaccocontrol-2013-051394
East K, Hitchman SC, Bakolis I, et al. The Association Between Smoking and Electronic Cigarette Use in a Cohort of Young People. Journal of Adolescent Health. 2018;62(5). doi:10.1016/j.jadohealth.2017.11.301
Mcneill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update A report commissioned by Public Health England. London: Public Heal Engl; 2015:111. Accessed May 2, 2018.
Benowitz NL, Goniewicz ML. The Regulatory Challenge of Electronic Cigarettes. JAMA. 2013;310(7):685. doi:10.1001/jama.2013.109501
Lotrean LM, Varga B, Popa M, Loghin CR, Man MA, Trofor A. Opinions and practices regarding electronic cigarette use among Romanian high school students. Gac Sanit. 2016;30(5). doi:10.1016/j.gaceta.2016.05.001
Pisinger C, Døssing M. A systematic review of health effects of electronic cigarettes. Prev Med. 2014;69:248-260. doi:10.1016/j.ypmed.2014.10.009
Rath JM, Teplitskaya L, Williams VF, Pearson JL, Vallone DM, Villanti AC. Correlates of e-cigarette ad awareness and likeability in U.S. young adults. Tob Induc Dis. 2017;15(1). doi:10.1186/s12971-017-0125-z
European Parliament and the Council of the European Union. Directive 2014/40/EU. Off J Eur Union. 2014;2014(April):1-38. Accessed 2 May, 2018.
Commission Implementing Decision (EU) 2016/586 of 14 April 2016 on technical standards for the refill mechanism of electronic cigarettes (notified under document C(2016) 2093). Accessed December 6, 2017.
Commission Implementing Decision (EU) 2015/2183 of 24 November 2015 establishing a common format for the notification of electronic cigarettes and refill containers (notified under document C(2015) 8087). Accessed December 6, 2017.
REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL on the Potential Risks to Public Health Associated with the Use of Refillable Electronic Cigarettes. Accessed May 2, 2018.
EAHC/2013/Health/17: Potential Risks from Electronic Cigarettes and their Technical Specifications in Europe (PRECISE).
Zhao J, Nelson J, Dada O, Pyrgiotakis G, Kavouras IG, Demokritou P. Assessing electronic cigarette emissions: linking physico-chemical properties to product brand, e-liquid flavoring additives, operational voltage and user puffing patterns. Inhal Toxicol. 2018:1-11. doi:10.1080/08958378.2018.1450462
El-Hellani A, Salman R, El-Hage R, et al. Nicotine and carbonyl emissions from popular electronic cigarette products: Correlation to liquid composition and design characteristics. Nicotine Tob Res. 2018;20(2):215-223. doi:10.1093/ntr/ntw280
Villanti AC, Johnson AL, Ambrose BK, et al. Flavored tobacco product use in youth and adults: Findings from the first wave of the path study (2013-2014). American Journal of Preventive Medicine. 2017;53(2):139-151. doi:10.1016/j.amepre.2017.01.026
Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in Electronic Cigarettes. JAMA. 2014;312(23):2493. doi:10.1001/jama.2014.14830
Kennedy RD, Awopegba A, De León E, Cohen JE. Global approaches to regulating electronic cigarettes. Tob Control. 2017;26(4):440-445. doi:10.1136/tobaccocontrol-2016-053179
Vardavas CI, Bécuwe N, Demjén T, et al. Study Protocol of European Regulatory Science on Tobacco (EUREST-PLUS): Policy implementation to reduce lung disease. Tobacco Induced Diseases. 2018:16(August). doi:10.18332/tid/93305
ITC Project. (2017, January). ITC 6 European Country Wave 1 (2016) Technical Report. University of Waterloo, Waterloo, Ontario, Canada, and European Network on Smoking and Tobacco Prevention, Brussels, Belgium.
Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. E-cigarette awareness, use, and harm perceptions in US adults. Am J Public Health. 2012;102(9):1758-1766. doi:10.2105/AJPH.2011.300526
Zare S, Nemati M, Zheng Y. A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type. PLoS One. 2018;13(3):e0194145. doi:10.1371/journal.pone.0194145
European Commission. Special Eurobarometer 458 Report: Attitudes of Europeans towards Tobacco and Electronic Cigarettes. 2018. doi:10.2875/804491
Brown J, West R, Beard E, Michie S, Shahab L, McNeill A. Prevalence and characteristics of e-cigarette users in Great Britain: Findings from a general population survey of smokers. Addict Behav. 2014;39(6):1120-1125. doi:10.1016/j.addbeh.2014.03.009
WHO. Who Report on the Global Tobacco Epidemic, 2017. 2017.
Levy DT, Yuan Z, Li Y. The prevalence and characteristics of E-cigarette users in the U.S. Int J Environ Res Public Health. 2017;14(10). doi:10.3390/ijerph14101200
Morean ME, Butler ER, Bold KW, et al. Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults. PLoS One. 2018;13(1). doi:10.1371/journal.pone.0189015
Bonhomme MG, Holder-Hayes E, Ambrose BK, et al. Flavoured non-cigarette tobacco product use among US adults: 2013-2014. Tob Control. 2016;25:ii4-ii13. doi:10.1136/tobaccocontrol-2016-053373
Berg CJ. Preferred flavors and reasons for e-cigarette use and discontinued use among never, current, and former smokers. Int J Public Health. 2016;61(2):225-236. doi:10.1007/s00038-015-0764-x
Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: Characterizing youth, young adult, and adult users. Prev Med Reports. 2017;5:33-40. doi:10.1016/j.pmedr.2016.11.001
Laverty AA, Vardavas CI, Filippidis FT. Design and marketing features influencing choice of e-cigarettes and tobacco in the EU. Eur J Public Health. 2016;26(5):838-841. doi:10.1093/eurpub/ckw109
Ford A, MacKintosh AM, Bauld L, Moodie C, Hastings G. Adolescents’ responses to the promotion and flavouring of e-cigarettes. Int J Public Health. 2016;61(2):215-224. doi:10.1007/s00038-015-0769-5
Cameron JM, Howell DN, White JR, Andrenyak DM, Layton ME, Roll JM. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tob Control. 2014;23(1):77-78. doi:10.1136/tobaccocontrol-2012-050604
Dawkins L, Turner J, Roberts A, Soar K. “Vaping” profiles and preferences: An online survey of electronic cigarette users. Addiction. 2013;108(6):1115-1125. doi:10.1111/add.12150
Vardavas CI, Girvalaki C, Filippidis FT, et al. Characteristics and outcomes of e-cigarette exposure incidents reported to 10 European Poison Centers: A retrospective data analysis. Tob Induc Dis. 2017;15(1). doi:10.1186/s12971-017-0141-z
European Commission. Special Eurobarometer 429. Attitudes of Europeans towards Tobacco and Electronic Cigarettes. 2015. doi:10.2875/670456.
Talih S, Balhas Z, Salman R, Karaoghlanian N, Shihadeh A. “Direct Dripping”: A High-Temperature, High-Formaldehyde Emission Electronic Cigarette Use Method. Nicotine Tob Res. 2016;18(4):453-459. doi:10.1093/ntr/ntv080
Gillman IG, Kistler KA, Stewart EW, Paolantonio AR. Effect of variable power levels on the yield of total aerosol mass and formation of aldehydes in e-cigarette aerosols. Regul Toxicol Pharmacol. 2016;75:58-65. doi:10.1016/j.yrtph.2015.12.019
Islami F, Stoklosa M, Drope J, Jemal A. Global and Regional Patterns of Tobacco Smoking and Tobacco Control Policies. Eur Urol Focus. 2015;1(1):3-16. doi:10.1016/j.euf.2014.10.001
Food and Drug Administration, HHS. Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. Final rule. Fed Regist. 2016;81:28973-29106. Accessed May 2, 2018.
US Food and Drug Administration. FDA announces comprehensive regulatory plan to shift trajectory of tobacco-related disease, death. Press Release July, 2017;28.
World Health Organization. Electronic Nicotine Delivery Systems: Report by WHO. 2014. doi:10.1161/CIRCULATIONAHA.114.008545.7.