Electronic cigarette (e-cig) and heated tobacco product (HTP) use in Italy, 2023| Tabaccologia

Poly-use in adolescents: the GYTS and ESPAD®Italia surveys

From the surveys conducted in Italy among adolescents, (GYTS, ESPAD®Italia), poly-use, i.e. the concomitant use of several products (traditional cigarettes, HTP and/or e-cig) has become very common. In fact, in GYTS, carried out among youths aged 13-15 years, 2% only of the interviewed sample in 2022 exclusively smoked traditional cigarettes, while 13% used cigarettes combined with HTP and/or e-cig (Figure 1) [1]. Therefore, as many as 87% of smokers [=13%/(13%+2%)] used other products. Furthermore, 6% exclusively used e-cigs, while exclusive HTP is recorded in 2% only. Poly-use among youths aged 15-19 years from ESPAD®Italia was lower; in fact, in 2021 15% of the sample continued to exclusive use traditional cigarettes, while 12% combined cigarettes with other products. Therefore, only 44% of smokers [12%/(12%+15%)] used other products (HTP/e-cig) in addition to traditional cigarettes [2].

In both surveys, smoking habits decreased over the years: in GYTS from 21% in 2010 to 15% in 2022, while in ESPAD®Italia from 34% in 2018 to 28% in 2021. This could indicate that more than a process of renormalization of the traditional cigarette (according to this hypothesis, e-cigs lead to an increase in tobacco consumers, given that those who start vaping have a 4-5 times higher risk of starting to smoke), we are witnessing a process of partial replacement of traditional cigarettes with other products. Evidently, vaping is more fashionable and also cheaper than smoking; HTP is also more glamorous, but costs the same as traditional cigarettes. In fact, adolescents used e-cigs more frequently than HTPs. Further studies are needed to investigate the renormalization or substitution aspects of traditional cigarettes.

The new generation of electronic cigarettes: disposable puff bars

The latest generation of e-cigs, such as disposable puffs, and e-cigs with nicotine salts, have not been marketed for use in adult smokers who want to quit. In fact, they are advertised on social networks with teenagers as target population, they have captivating flavours and colours, they are made in the guise of felt-tip pens or lip glosses that can easily be confused with stationery products in school cases. The nicotine concentration in some products available online is higher than the 2% limit set by current legislation. Disposable puff-bar can deliver from 600 to 1,500 puffs, delivering a nicotine content equivalent to 35 and 70 cigarettes, respectively. While a smoker of a pack of traditional cigarettes a day takes around 170 puffs a day, a vaper, who also has difficulty reporting an exact number of puffs taken in a day, usually reports a higher number of puffs, around 200-400 puffs per day, with the possibility of inhaling higher doses of nicotine than those obtained from smoking traditional cigarettes [3]. The use that is reported by adolescents seems more of a performance type during school hours to increase concentration or to relieve stressful situations, so much so that its use has also been recorded in athletes who play team sports. It would be necessary to conduct qualitative studies to evaluate how these products are used by adolescents.

It is impressive to compare traditional cigarette packages with those of the latest generation of e-cigs at a tobacconist: while in the first case, the shocking images and texts have their impact, in new e-cigs the greater impact is due to the variety of colours and attractive packaging (Figure 2). There is an urgent need to regulate the labelling of these new products which are sold at a negligible price compared to traditional cigarettes. Precisely for these characteristics, in Great Britain in 2021-2022, vaping doubled among youths aged 11-17 years, reaching 7% for the first time since in 2015, when the English health system was the only one in the world to suggest the use at a population level of e-cigs to quit. This increase among British teenagers has alarmed, so much so that English researchers are conducting studies to evaluate the introduction of plain packaging also in e-cigs, as they have already done for traditional cigarettes [4]. Plain packaging is the natural evolution of the labelling present in Italian tobacco packages, and provides for the introduction, in addition to shock images and danger warnings, of a single colour for all brands, with no images that allow recognition of the brand. Plain package was first introduced in 2012 in Australia.

Australia will once again be the first country to introduce pioneering measures, this time on e-cigs. In fact, on May 1, 2023, the Australian Minister of Health released a document on strategies to combat smoking in the coming years, where he announced drastic measures on the use of e-cigs in Australia, releasing an interview where he declared: “We have been deceived. We were promised that e-cigs were used to quit, but instead they have become a way to start smoking. We want vaping to return to the purpose for which we were told it was developed” [5]. The envisaged measures provide for:

1. a ban on the importation of vaping products without a medical prescription;
2. restrictions on the addition of flavours and other ingredients;
3. the introduction of the plain package;
4. the lowering of the nicotine concentration limits;
5. the prohibition of disposable e-cigs.

In Australia from 2021, e-cigs can only be purchased in pharmacies with a doctor’s prescription. After the above-mentioned measures will be introduced, prescriptions for nicotine vaping products will be easier to obtain, with stricter standards so that people can be certain of the contents of the products. The Australian Federal Government will provide Australian $234 million, including 63 million for an anti-smoking and anti-vaping media campaign and 30 million for programs to help smokers quit, with training among healthcare workers.

Teens who vape are three times as likely to take up smoking, which explains why those under 25 are the only cohort in the Australian community currently experiencing an increase in smoking prevalence [5].

E-cigs to quit smoking

A new update of the Cochrane review on the use of e-cigs for smoking cessation has been released in 2022: 78 studies were included, 17 of which were new compared to the previous edition [6]. The comparisons that are made in the review included a very small number of studies, greatly limiting the strength of the conclusions. The comparison between e-cig with nicotine versus NRT, uses 6 studies only, with a significant relative risk (RR)=1.63 in favour of e-cigs with nicotine; the comparison between e-cig with nicotine versus e-cig without nicotine included only 5 studies, with a significant RR of 1.94 in favour of e-cig with nicotine. Finally, the comparison between e-cig with nicotine versus no support or only behavioural support included 7 studies, with a significant RR of 2.66 in favour of e-cig with nicotine. Thus, the Cochrane review concluded that nicotine e-cigs are effective for smoking cessation when administered in clinical settings such as those in the Cochrane review trials. It follows that recommending the use of e-cigs to quit should only be done in a clinical context, such as in smoking cessation services. This review does not allow us to recommend the use of e-cigs as a consumer product, apart from a clinical context, advising the individual smoker to buy the e-cig that best satisfies him or her, and to proceed in the attempt with no aid. It should be emphasized, as the Association of Physicians for a Smoke-Free Canada argues, that actually the performance of e-cigs in a clinical setting is not outstanding anyway: in fact, only 1 in 10 smokers succeeds in quitting, whereas there are smoking cessation treatments approved by the Italian Medicines Agency or combinations of pharmacological treatments that have much higher efficacy, having higher success rates 6 months-1 year after treatment [7].

It should be noted that the trials reviewed by Cochrane were designed to test drugs that are administered in a clinical setting, and not to validate consumer products that are sold in stores, apart from a doctor-patient relationship. Another distinction seems important to me: the best-selling e-cigs in Italy are not included among those tested in Cochrane review trials. E-cigs are very different from each other; demonstrating that a certain type of e-cig is effective for quitting does not mean by extension that they are all effective, even more so for e-cigs with nicotine salts for which there is not even a trial available that evaluated their effectiveness to quit. Finally, in trials on e-cigs, more than 80% of vapers continued to vape at the end of treatment, while with quit drugs only a small percentage continued to use them after cessation [8]. Continuing to vape after quitting exposes the quitters to a double risk of relapse to traditional cigarettes [9].

Use of e-cig and HTP in Italy among adults aged 18-69 from the PASSI survey

We have recently published two articles in peer-reviewed journals that highlight: (i) the smoking cessation performance of using e-cigs to quit as a consumer product, i.e. used not in a clinical context, and purchased by the smoker who wants to quit with no clinical support [10]; (ii) the trend of e-cig and HTP use among Italian adults [11].

The first study includes 19,234 smokers who have tried to quit in the last year, from the PASSI 2014-2021 survey. If we look at how they quit, 83% tried to quit with no aid; 13% tried to quit using e-cigs as a consumer product, while only 2% tried using approved drugs to quit and/or smoking cessation services (CAF). Those who quit with no aid managed to quit in 9.8%; those who have stopped using e-cigs recorded a similar performance, around 11.0%, while only those few who have used drugs and/or CAF recorded a significantly higher performance of 15.7% compared to those quitting with no aid. Thus, quitting using e-cigs as a consumer product has the same probability of success as trying to quit with no aid [10].

The second study reports trends in the use of e-cig and HTP, in relation to smoking habits among adults aged 18-69 interviewed by the PASSI survey (Figure 3) [11]. Smoking prevalence decreased from 28.6% in 2011 to 24.8% in 2018 and then recorded a plateau around 25% until 2022. The use of e-cigs, recorded since 2014, increased from 2.6% in 2014 to 4.7 % in 2022, while HTP use, recorded since 2018, increased from 0.7% to 2.8% in 2022. Actually, most of e-cig or HTP users also smoke traditional cigarettes: in 2022, 63% of HTP users and 61% of e-cig users also smoked traditional cigarettes (dual users). Unlike the use recorded in children (Figure 1), adults remained more loyal to traditional cigarettes; in fact, in 2022, as many as 82% of smokers continued to exclusively smoke traditional cigarettes (Figure 3). Therefore, it is presumable that the use of new products will take root more in the new generations, while the older ones will continue to smoke traditional cigarettes, the tobacco product they started using during adolescence.

Cohort study to evaluate the impact of e-cig or HTP use on the consumption of traditional cigarettes

Finally, we published an article on a cohort study involving 3,185 subjects, a representative sample of the Italian population aged 18-74, who responded to two surveys: a baseline survey conducted in April-May 2020 and a follow-up survey conducted over 6 months later, in November-December 2020. In this way, we were able to ask those who used e-cig or HTP at baseline whether or not they used traditional cigarettes in the follow-up survey [12]. Those who used e-cig or HTP at the baseline survey and were also non-smokers of traditional cigarettes had a 9- and 6-fold risk, respectively, of starting to smoke in the follow-up survey. Those who used e-cig or HTP at the baseline survey and were also ex-smokers of traditional cigarettes had a 4- and 3-fold risk, respectively, of relapsing smoking in the follow-up survey. Finally, those who used e-cig or HTP at the baseline survey and were also smokers of traditional cigarettes, had a significantly higher risk of continuing smoking of 10% and 17%, respectively. Thus, both e-cigs and HTP appear to favour smoking initiation among non-smokers, smoking relapse among ex-smokers, and continuing smoking among smokers. Due to the limited sample size, the results of this study should be confirmed by larger prospective studies. However, these results do not support the use of e-cig and HTP as a consumer product, at least in Italy.

The use of e-cigs has already been studied in a previous American longitudinal study, the PATH study [13], where, among 2,932 e-cig users at the baseline survey, 18% at the follow-up survey reported positive results (having stopped smoking and/or using e-cigs), versus 38% who reported negative results (having relapsed smoking), while a 44% had not recorded significant changes, since they continued to use the products they used in the baseline investigation.

Regarding HTP, the Cochrane Tobacco Addiction Group carried out a systematic review on the efficacy of HTP for smoking cessation, but had to conclude that the HTP efficacy remains uncertain, since no studies have been done on this, even funded by the tobacco companies. Instead, adverse events and exposure to toxic/carcinogenic substances among HTP users compared to smokers were studied, but results do not provide sufficient evidence. Of note, Cochrane concludes that independent research on HTP is needed, given that most studies have been funded by tobacco companies [14].

Messages to give to smokers

During 2022, the book by the Australian researcher Simon Chapman, past-editor of the scientific journal “Tobacco Control”, entitled “Quit smoking weapons of mass distraction”, was released [15]. Chapman points out that quitting smoking with no aid remains the most common method of quitting around the world, including England, not only because smokers are not always aware of other methods such as drugs, e-cigs or smoking cessation servieces, but because, from the few qualitative studies conducted on smokers, they perceive quitting with no aid as an adequate way of dealing with the problem, which appeals to their sense of identity, strength, and autonomy. The fact that most smokers quit with no aid is a positive message that should be used by public health as a frontline message in every clinic and in communication campaigns. Instead of focusing on how to quit, we should focus on getting more smokers to try to quit more frequently, whether these attempts are made with no aid or supported by anti-smoking medications, CAF, or e-cigs [15].

This type of strategy has been adopted by the latest generation of media campaigns to stop smoking, such as the English “Stoptober” campaigns which have been running annually since 2012 [16,17], the Dutch “Stoptober” campaigns which have been running annually since 2014 [18,19], and the French “Mois san Tabac” campaign, which has been running every year since 2016 [20]. These campaigns, based on the theory of social contagion, provide for the achievement of an intermediate goal, i.e. quitting smoking for 4 weeks, offering a range of supports, such as a toll-free quitline;, application on mobile or text messaging system, institutional website to support quitting, social network pages where people trying to quit meet, offering of support from a NHS smoking cessation service. In Great Britain in 2015, around 215,000 smokers registered to participate in this social competition, while around 50,000 participants were registered in the Netherlands in 2016. The impact in terms of the increase in smokers who try to quit during the campaign period was significant in all countries [16-20].

This type of campaign, with the whole range of supports on the web, should also be developed in Italy in the coming years, avoiding focusing exclusively on methods for quitting and on whether or not novel tobacco products are used.

Figures and tables

Figure 1.Current use (at least once in the last 30 days) of traditional cigarettes, heated tobacco products (HTP) and e-cigarettes (e-cig), Global Youth Tobacco Smoking Survey (GYTS), youths aged 13-15 years, 2010, 2014, 2018, 2022; ESPAD®Italy youths aged 15-19 years, 2018, 2019, 2021 [GYTS data courtesy of the National Center for Disease Prevention and Health Promotion (CNAPPS) – Istituto Superiore di Sanità, (ISS) Rome; ESPAD®Italia data courtesy of the Section of Epidemiology and Research on Health Services, National Research Council - Institute of Clinical Physiology (CNR-IFC), Pisa].

Figure 2.Labeling of traditional cigarette packages in Italy compared with labelling of the new generation of electronic cigarettes.

Figure 3.Prevalence of use of traditional cigarettes, e-cigs and HTP, PASSI, survey, 2011-2022.

References

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