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doi:10.1093/eurpub/ckz215
.........................................................................................................
European adult smokers’ perceptions of the
harmfulness of e-cigarettes relative to combustible
cigarettes: cohort findings from the 2016 and 2018
EUREST-PLUS ITC Europe Surveys
Shannon Gravely
1
, Pete Driezen
1
, Christina N. Kyriakos
2,3
, Mary E. Thompson
1
,
James Balmford
4
, Tibor Demje´n
5
, Esteve Ferna´ ndez
6,7,8,9
, Ute Mons
10
, Yannis Tountas
11
,
Kinga Janik-Koncewicz
12,13
,Witold Zato
nski
12,13
, Antigona C. Trofor
14,15
,
Constantine I. Vardavas
2,3
, Geoffrey T. Fong
1,16
on behalf of the EUREST-PLUS Consortium*
1 University of Waterloo, Waterloo, Canada
2 European Network for Smoking and Tobacco Prevention, Brussels, Belgium
3 University of Crete, Heraklion, Greece
4 Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg
im Breisgau, Germany
5 Smoking or Health Hungarian Foundation, Budapest, Hungary
6 Tobacco Control Unit, Catalan Institute of Oncology (ICO), L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
7 Tobacco Control Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat,
Catalonia, Spain
8 School of Medicine and Health Sciences, Bellvitge Campus, Universitat de Barcelona, L’Hospitalet de Llobregat,
Catalonia, Spain
9 Consortium for Biomedical Research in Respiratory Diseases (CIBER en Enfermedades Respiratorias, CIBERES), Madrid,
Spain
10 Cancer Prevention Unit and WHO Collaborating Centre for Tobacco Control, German Cancer Research Center (DKFZ),
Heidelberg, Germany
11 National and Kapodistrian University of Athens, Athens, Greece
12 Health Promotion Foundation, Warsaw, Poland
13 European Observatory of Health Inequalities, President Stanisław Wojciechowski State University of Applied Sciences,
Kalisz, Poland
14 University of Medicine and Pharmacy ‘Grigore T.Popa’, Iasi, Romania
15 Aer Pur Romania, Bucharest, Romania
16 Ontario Institute for Cancer Research, Toronto, Canada
Correspondence: Shannon Gravely, Department of Psychology, International Tobacco Control Policy Evaluation Project
(The ITC Project), University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada, Tel: þ1 519 888
4567, ext: 37970, e-mail: shannon.gravely@uwaterloo.ca
*The members of the EUREST-PLUS Consortium are listed in the Acknowledgements.
Background: This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to
combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of
the EU Tobacco Products Directive (TPD), and 2 years post-TPD. Methods: Data were drawn from the EUREST-PLUS
ITC Europe Surveys, a cohort study of adult smokers (18 years) from Germany, Greece, Hungary, Poland, Romania
and Spain. Data were collected in 2016 (pre-TPD: N¼6011) and 2018 (post-TPD: N¼6027). Weighted generalized
estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to com-
bustible cigarettes (less harmful, equally harmful, more harmful or ‘don’t know’). Results: In 2016, among
respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be
less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were
aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of
respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018
(61.8%, P>0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally
or more harmful than cigarettes, but ‘don’t know’ responses significantly decreased from 12.9% to 9.8%
(P¼0.036). The only significant change within countries was a decrease in ‘don’t know’ responses in Spain
(19.3–9.4%, P¼.001). Conclusions: The majority of respondents in these six EU countries perceived e-cigarettes
to be equally or more harmful than combustible cigarettes.
.........................................................................................................
Introduction
Smoked tobacco is the most dangerous form of tobacco consump-
tion.
1,2
The smoke from combustible cigarettes, by far the most
common form of tobacco use in most countries, includes over 4000
chemicals and at least 70 known carcinogens.
1
It is well-established
that cigarettes kill a third to half of all people who use them, and
those who die from smoking lose over a decade of life.
3,4
It has long
been known that people smoke tobacco for the nicotine, but die
from the poisonous chemicals in tobacco smoke (e.g. hydrogen
cyanide, ammonia and high levels of nitrosamines and
formaldehyde).
1,5
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In the past, the tobacco industry developed what they claimed to be
‘safer’ cigarettes in response to smokers’ growing health concerns.
Filtered light/low-tar cigarettes were marketed as lower-harm alter-
natives, but provided no such reduction in harm, mainly because of
compensatory smoking behaviours.
6
These industry efforts provided
smokers with a false sense of reduced risk, and there is epidemio-
logical evidence that they undermined smoking cessation.
7
Novel nicotine vaping products, such as electronic cigarettes (e-
cigarettes), may have a role to play in reducing the health-related
harms of tobacco smoking by assisting cessation attempts and
supporting long-term abstinence from smoking. Recent compre-
hensive reviews of the available scientific evidence by the National
Academy of Sciences, Engineering and Medicine (NASEM),
8
Public Health England (PHE)
9
and the Royal College of
Physicians (RCP) London,
10
as well as position statements by other
bodies
11
have concluded that although e-cigarettes contain harm-
ful constituents, overall, they are less harmful than combustible
cigarettes.
Despite the scientific evidence that e-cigarettes are less harmful
than combustible cigarettes, people’s perceptions of the risks asso-
ciated with e-cigarette use have been shown to be over-estimated,
particularly in recent years, including among smokers who could
benefit from them.
9,12
Several observational studies have shown the
main reasons for smokers using e-cigarettes were as a harm reducing
alternative to cigarettes or to help them to quit smoking.
13–16
Moreover, the belief that e-cigarettes are less harmful than combust-
ible cigarettes has been shown to be associated with using e-ciga-
rettes during a smoking cessation attempt, in reducing cigarette
consumption, and in quitting smoking altogether.
12,15,17–20
One re-
cent study from the Population Assessment of Tobacco and Health
(PATH) Study in the USA found that adult dual users of e-cigarettes
and cigarettes who perceived e-cigarettes to be less harmful than
combustible cigarettes were more likely to switch to exclusive e-
cigarette use, more likely to remain dual users and less likely to
relapse back to exclusive cigarette smoking 1 year later compared
to dual users with other perceptions of e-cigarette harm.
21
Therefore, inaccurate perceptions of the relative risk of e-cigarettes
and combustible cigarettes, particularly among smokers who are
unable or unwilling to completely give up nicotine, may deter smok-
ers from switching to using e-cigarettes.
Various countries around the world have taken quite different
approaches to the regulation of e-cigarettes. A number of countries
have banned e-cigarettes with and/or without nicotine, some coun-
tries have not implemented any regulations, while others have
regulated nicotine-containing e-cigarettes for consumer safety pur-
poses (e.g. set a minimum age of purchase, restricted use in public
places).
22
In 2016, the European Union (EU) implemented stron-
ger regulations for e-cigarettes under Article 20 of the EU Tobacco
Products Directive (TPD). Some of the key measures that may have
impacted harm perceptions for e-cigarettes include: mandated
textual health warnings (e.g. ‘This product contains nicotine which
is a highly addictive substance’), a ban on promotional and mis-
leading elements on packaging, advertising and promotion bans
and some safety and quality requirements (e.g. capped nicotine
levels, volume restrictions on tanks and refills, child-resistant refill
containers). These changes took place alongside TPD-mandated
enhancements to health warnings on tobacco packaging, which
became larger (65%) with graphic picture warnings on the front
and back.
It is important to monitor harm perceptions, as it can help us to
understand changing patterns of product use. It has been shown that
stricter e-cigarette regulations influence perceptions about relative e-
cigarette and cigarette harm,
23
and product regulations may shape
or change beliefs about nicotine products. This study aimed to
examine perceptions of the harmfulness of e-cigarettes relative to
combustible cigarettes in six EU countries at two time-points: first
in 2016, prior to the implementation of the TPD, and then again in
2018, after the implementation of the TPD.
Methods
Study design, sample and procedure
The ‘ITC 6 European Country (ITC 6E) Survey’ was undertaken
within the context of a European Commission Horizon-2020
funded study ‘(EURESTPLUS- HCO-06-2015)’, which aimed to
evaluate the impact of the EU TPD and the World Health
Organization (WHO) Framework Convention on Tobacco
Control (FCTC).
The ITC 6E Survey is a prospective cohort study of adult smokers
(aged 18) from six EU Member States: Germany, Greece, Hungary,
Poland, Romania and Spain. It was designed to produce nationally
representative samples in each of the six countries. Before the im-
plementation of the TPD (pre-TPD, Wave 1: June to September
2016), approximately 1000 adult smokers who reported having
smoked at least 100 cigarettes in their lifetime, and smoked at least
monthly, were recruited from each country. Respondents were
selected from households in urban, intermediate or rural regions,
and sampled using a stratified two-stage area sampling design with a
random-walk technique. A maximum of two smokers (one male and
one female) from each household were eligible to participate. After
providing written consent, 6011 respondents completed the survey
via a computer-assisted personal interview conducted in each coun-
try’s official language. Household response rates ranged from 30%
in Germany to 64% in Hungary. The survey took on average 35 min
to complete.
Following the implementation of the TPD (post-TPD, Wave 2:
February to May 2018), 6027 respondents completed the study.
These respondents consisted of two sample types: (i) re-contacted
(cohort) respondents (n¼3195) from pre-TPD who were followed
up regardless of their current smoking status (retention rates ranged
from 36% in Hungary to 71% in Germany and Spain, with an
average of 53% for the full sample); and (ii) new respondents (cur-
rent smokers) to replenish those who were lost to attrition. The
replenishment sample (n¼2832) was recruited from newly selected
households, and approached in the same manner as pre-TPD, with
the random-walk procedure beginning at a new (random) starting
point. Within the context of this manuscript, we present the com-
parison of the entire population at both time points (repeated cross-
sectional design).
The study was approved by the Research Ethics Board of the
University of Waterloo in Canada, and by local ethics boards in
the participating countries. Further details about the study protocol
can be found elsewhere.
24
Data weighting
After all data were collected and cleaned, each respondent was
assigned a sampling weight according to their wave of recruitment.
For those present in both 2016 and 2018, the sampling weight was
their 2016 wave cross-sectional weight, rescaled to sum to the sam-
ple size for each country. For respondents newly recruited in 2018,
the sampling weight was based on the cross-sectional weight rescaled
to sum to the sample size of the 2018 wave recruits in each country.
Weights were calibrated using national surveys from each of the
respective countries.
Measurements
Sociodemographic variables
Sociodemographic measures were sex [female versus (vs.) male], age
group (18–24, 25–39, 40–54 and 55 years), employment status
(employed vs. otherwise) and degree of urbanization (urban, inter-
mediate and rural). In each country, household income information
was collected in the local currency. Different thresholds were used in
each country to classify respondents as low, moderate or high in-
come (Supplementary table S1). Respondents who refused to
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provide household income were retained for analysis by including
an ‘income not reported’ category. Education was also classified as
low, moderate or high using the International Standard
Classification of Education.
Smoking variables
All respondents were initially recruited as current smokers. Cohort
respondents were asked to report their smoking status at the time of
the Wave 2 survey and were categorized herein as either a daily
smoker, non-daily smoker or ‘quitter’. All respondents at the time
of initial recruitment were asked to report: (i) their current frequency
of smoking (daily, weekly and monthly); and (ii) number of cigarettes
smoked per day (CPD: 10, 11–20, 21–30 and 31; quitters ¼0)
which was used as a proxy measure of nicotine dependence.
E-cigarette variables
All respondents were asked to report if they had ever heard of e-
cigarettes (‘yes’ or ‘no’, with ‘I don’t know’ responses classified as
‘no’). Those who had heard of e-cigarettes were asked if they had
ever tried an e-cigarette (‘yes’ or ‘no’), and if so, if they were cur-
rently using one. Responses were: ‘yes’ (daily, weekly, monthly or
less than monthly) or ‘not at all’ (‘don’t know’ responses were clas-
sified as ‘no’). These were classified herein as ‘currently using an e-
cigarette’ vs. ‘currently a non-user’.
Outcome
Perceived harmfulness of e-cigarettes compared to combustible ciga-
rettes: All respondents who were aware of e-cigarettes were asked:
‘In your opinion, is using e-cigarettes or vaping devices less harmful
to health, more harmful to health, or no different than smoking
ordinary cigarettes?’ Response options were categorized as: ‘less
harmful’, ‘equally harmful’, ‘more harmful’ or ‘don’t know’. In add-
ition, for some analyses (and consistent with previous research
30
),
response options were categorized as: more/equally harmful vs. less
harmful vs. don’t know. Respondents who did not answer this ques-
tion were excluded from all analyses.
Statistical analysis
Unweighted statistics were used to describe respondents’ baseline
characteristics from each country (table 1).
Next, generalized estimating equation (GEE) (adjusted) multi-
nomial regression models were used to test whether the perceived
harmfulness of e-cigarettes changed from 2016 to 2018. An initial
GEE model tested the main effect of the survey year (wave) on
perceptions of harmfulness. A second GEE model tested for an inter-
action between country and wave to examine whether perceptions
changed significantly from 2016 to 2018 in each of the six countries.
Both the main effect and interaction models controlled for sex, age,
degree of urbanization, income, education, smoking status, CPD, e-
cigarette use status (current e-cigarette user vs. non-user) and time-
in-sample (TIS: the number of times a respondent participated in
the study). The model that tested the interaction also included the
main effects of both country and wave. False discovery rate (FDR)
adjustments were used to account for multiple comparisons.
Finally, two separate GEE logistic regression models tested
whether there were differences in relative perceptions of harmfulness
by (i) country (Hungary was used as the reference group as respond-
ents there had the highest perception that e-cigarettes are less harm-
ful, in line with scientific consensus); and (ii) e-cigarette use status
(‘current e-cigarette user’ vs. ‘tried but not currently using an e-
cigarette’ vs. ‘never tried/used an e-cigarette’). Weighted estimates
for 2016 and 2018 were pooled and averaged for each response, and
then were dichotomized by ‘less harmful’ vs. ‘other’ (equally/more
harmful/don’t know) (Model 1), and then ‘equally/more harmful’
vs. ‘other’ (less harmful/don’t know) (Model 2). Both models
adjusted for sex, age, education, income, degree of urbanization,
smoking status, CPD, survey wave (2016 vs. 2018) and TIS.
All analyses were conducted using SAS-callable SUDAAN Version
11.0.1 to account for the sampling design. All GEE analyses were
conducted using weighted data.
Ethics approval
The survey protocols and all materials, including the survey ques-
tionnaires, were cleared for ethics by the ethics research committee
at the University of Waterloo (Ontario, Canada), and ethics com-
mittees in Germany (Ethikkommission der Medizinischen Fakulta¨t
Heidelberg), in Greece (Medical School, University of Athens—
Research and Ethics Committee), in Hungary (Medical Research
Council—Scientific and Research Committee), in Poland (State
College of Higher Vocational Education—Committee and Dean of
the Department of Health Care and Life Sciences), in Romania
(Iuliu Hatieganu University of Medicine and Pharmacy) and in
Spain (Clinical Research Ethics Committee of Bellvitge, Hospital
Universitari de Bellvitge, Catalonia).
Results
Eligible respondents
In 2016, 6011 smokers completed the survey. Of those, 4266 had both
heard of e-cigarettes and responded to the outcome variable (relative
harm perceptions). In 2018, 6027 respondents completed the survey
(re-contact: n¼3195; replenishment: n¼2832), of whom 4327 com-
pleted the relative harm perception question. Of the 3195 respondents
re-contacted at Wave 2 (53.2% of Wave 1 respondents), 415 reported
having quit smoking and 298 answered the relative harm perception
question. Overall, there were a total of 6675 individual responses to
the relative harm perception question across the 2016 and 2018 survey
waves. A study flow diagram is presented in Supplementary figure S1.
Table 1 presents unweighted baseline respondent characteristics
for those included in the current study. Overall, the average age of
the sample was 44.1 614.1 years, 47.5% were female, 96.3% were
daily smokers and 4.3% of the sample were current e-cigarette users
(ranging from 2% in Spain to 8% in Germany).
Perceptions of harmfulness of e-cigarettes compared
to combustible cigarettes
Supplementary table S2 and Figure 1a–c present the estimates (over-
all and by country) for perceptions of harmfulness of e-cigarettes
compared to cigarettes in 2016–2018. The main effect model (which
tested the main effect of survey wave), was significant (v
2
¼8.24,
P¼0.041); however, after the FDR adjustment for multiple compar-
isons, there were no significant changes in any perceptions between
2016 and 2018. In addition, the interaction of country and wave was
not significant (v
2
¼24.68, P¼0.054).
Perceptions of harm of e-cigarettes compared to
combustible cigarettes by country
Less harmful
There was no overall change across the six countries for relative
perceptions of e-cigarettes as being less harmful compared to com-
bustible cigarettes. Hungary (34.1%) and Greece (33.5%) had the
highest proportion of respondents who reported that e-cigarettes are
less harmful in 2016, and Hungary in 2018 (35.1%). Romania (in
2016 and 2018) and Spain (in 2016) had the lowest proportions of
respondents who believed this (figure 1a).
Equally or more harmful
The perception that e-cigarettes are ‘equally harmful’ was fairly
stable across all countries over time; however, the perception that
European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes 3of8
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e-cigarettes are ‘more harmful’ increased in five of the six countries
(excluding Spain), but the differences were not statistically signifi-
cant (Supplementary table S2).
Perceiving e-cigarettes to be either ‘equally’ or ‘more harmful’
increased in Greece (58.5% to 62.1%), Hungary (52.9% to 57.0%)
and Spain (58.7% to 64.4%). Germany (62.7%) had the highest
proportion of respondents who reported this in 2016, and Spain
in 2018 (64.4%) (figure 1b).
Don’t know
‘Don’t know’ responses decreased over time in four of the six coun-
tries; however, only in Spain did this reach statistical significance
(19.3–9.4%, P0.01). The largest proportion of respondents who
reported uncertainty were from Spain in 2016 (19.3%), and
Romania in 2018 (22.5%) (figure 1c).
Perceptions of harmfulness of e-cigarettes compared
to combustible cigarettes (combined across both
waves) by country and e-cigarette use status
Within the pooled analysis, compared to respondents from Hungary,
respondents from Spain [odds ratio (OR) 0.56, 95% confidence inter-
val (CI) 0.40–0.77] and Romania (OR 0.45, 95% CI 0.33–0.62) were
significantly less likely to believe that e-cigarettes are less harmful than
combustible cigarettes. Respondents from Germany were significantly
more likely to believe that e-cigarettes are equally or more harmful
than respondents from Hungary (OR 1.43, 95% CI 1.04–1.96). There
was no interaction effect between country and survey wave (F¼1.61,
P¼0.16) (Supplementary table S3).
E-cigarette use status was related to perceptions of harmfulness,
such that current e-cigarette users (OR 4.03, 95% CI 3.05–5.33), and
those who reported having tried but not currently using e-cigarettes
(OR 1.47, 95% CI 1.26–1.73), were significantly more likely to be-
lieve that e-cigarettes are less harmful than those who had never
tried an e-cigarette. In addition, current e-cigarette users were sig-
nificantly less likely to believe that e-cigarettes were equally or more
harmful than cigarettes (OR 0.40, 95% CI 0.31–0.52) compared to
those who had never tried an e-cigarette (Supplementary table S3).
There was no significant interaction between e-cigarette use and
survey wave for either model: Model 1: less harmful (F¼0.001,
P¼0.99) and Model 2: equally/more harmful (F¼0.91, P¼0.40).
Discussion
The current study examined perceptions of harmfulness of e-ciga-
rettes compared to combustible cigarettes and found that the ma-
jority of respondents in these six EU countries perceived e-cigarettes
to be equally or more harmful than combustible cigarettes, both
Table 1 Unweighted baseline characteristics of smokers present in 2016 and/or 2018
Germany, n(%) Greece, n(%) Hungary, n(%) Poland, n(%) Romania, n(%) Spain, n(%) Overall, N(%)
Wave of recruitment
2016 635 (75.5) 737 (61.0) 679 (60.4) 685 (67.1) 679 (73.7) 851 (76.9) 4266 (68.6)
2018 206 (24.5) 471 (39.0) 446 (39.6) 336 (32.9) 242 (26.3) 255 (23.1) 1956 (31.4)
Sex
Female 427 (50.8) 568 (47.0) 535 (47.6) 551 (54.0) 371 (40.3) 502 (45.4) 2954 (47.5)
Male 414 (49.2) 640 (53.0) 590 (52.4) 470 (46.0) 550 (59.7) 604 (54.6) 3268 (52.5)
Average age (SD) 44.8 (14.5) 45.3 (13.8) 44.8 (13.9) 43.6 (14.2) 43.3 (14.0) 42.4 (14.0) 44.1 (14.1)
Age group
18–24 80 (9.5) 84 (7.0) 82 (7.3) 87 (8.5) 110 (11.9) 142 (12.8) 585 (9.4)
25–39 244 (29.0) 340 (28.1) 341 (30.3) 368 (36.0) 270 (29.3) 334 (30.2) 1897 (30.5)
40–54 282 (33.5) 474 (39.2) 400 (35.6) 289 (28.3) 306 (33.2) 388 (35.1) 2139 (34.4)
55þ235 (27.9) 310 (25.7) 302 (26.8) 277 (27.1) 235 (25.5) 242 (21.9) 1601 (25.7)
Degree of urbanization
Urban 296 (35.2) 210 (17.4) 390 (34.7) 377 (36.9) 316 (34.3) 595 (53.8) 2184 (35.1)
Intermediate 344 (40.9) 710 (58.8) 436 (38.8) 317 (31.0) 234 (25.4) 377 (34.1) 2418 (38.9)
Rural 201 (23.9) 288 (23.8) 299 (26.6) 327 (32.0) 371 (40.3) 134 (12.1) 1620 (26.0)
Income
Not reported 107 (12.7) 237 (19.6) 390 (34.7) 332 (32.5) 90 (9.8) 4 (40.7) 1606 (25.8)
Low 252 (30.0) 184 (15.2) 164 (14.6) 140 (13.7) 157 (17.0) 279 (25.2) 1176 (18.9)
Moderate 259 (30.8) 619 (51.2) 287 (25.5) 351 (34.4) 394 (42.8) 303 (27.4) 2213 (35.6)
High 223 (26.5) 168 (13.9) 284 (25.2) 198 (19.4) 280 (30.4) 74 (6.7) 1227 (19.7)
Education
Low 427 (51.0) 321 (26.6) 652 (58.1) 130 (12.9) 218 (23.9) 432 (39.1) 2180 (35.2)
Moderate 339 (40.5) 639 (52.9) 388 (34.6) 757 (75.0) 596 (65.3) 575 (52.0) 3294 (53.2)
High 72 (8.6) 247 (20.5) 83 (7.4) 123 (12.2) 99 (10.8) 98 (8.9) 722 (11.7)
Smoking status
Daily smoker 763 (90.7) 1175 (97.3) 1104 (98.1) 986 (96.6) 888 (96.4) 1073 (97.0) 5989 (96.3)
Non-daily smoker 78 (9.3) 33 (2.7) 21 (1.9) 35 (3.4) 33 (3.6) 33 (3.0) 233 (3.7)
Type smoked
FM only 608 (72.3) 882 (73.0) 586 (52.1) 827 (81.1) 861 (93.5) 803 (72.6) 4567 (73.4)
RYO only 95 (11.3) 310 (25.7) 454 (40.4) 76 (7.5) 15 (1.6) 209 (18.9) 1159 (18.6)
Both 138 (16.4) 16 (1.3) 85 (7.6) 117 (11.5) 45 (4.9) 94 (8.5) 495 (8.0)
CPD
<10 315 (37.5) 330 (27.3) 396 (35.2) 337 (33.2) 322 (35.0) 463 (41.9) 2163 (34.8)
11–20 400 (47.6) 572 (47.4) 613 (54.5) 579 (57.0) 484 (52.6) 538 (48.6) 3186 (51.3)
21–30 97 (11.5) 166 (13.7) 86 (7.6) 74 (7.3) 72 (7.8) 64 (5.8) 559 (9.0)
31þ28 (3.3) 140 (11.6) 30 (2.7) 25 (2.5) 43 (4.7) 41 (3.7) 307 (4.9)
E-cigarette use status
Current user 71 (8.4) 64 (5.3) 38 (3.4) 34 (3.4) 36 (3.9) 27 (2.4) 270 (4.3)
Tried but not currently using 177 (21.1) 270 (22.4) 142 (12.6) 228 (22.6) 281 (30.5) 264 (23.9) 1362 (21.9)
Never-user 593 (70.5) 874 (72.4) 944 (84.0) 747 (74.0) 604 (65.6) 815 (73.7) 4577 (73.7)
Current e-cigarette user: daily, weekly or monthly use.
CPD, cigarettes per day; FM, factory made cigarettes; RYO, roll-your-own cigarettes; SD, standard deviation.
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prior to the implementation of the TPD (2016), as well as at the
post-TPD (2018) time period. These findings do not align with the
existing scientific evidence indicating that e-cigarettes are less harm-
ful than cigarettes and other combustible tobacco products,
8,10
but
they are consistent with the growing perceptions in other countries
that e-cigarettes are at least equally as harmful as cigarettes.
12,13
It is
notable, however, that smokers from these six EU countries gener-
ally have much more negative perceptions of e-cigarettes than smok-
ers from other high income, westernized countries.
25,26
There is a paucity of published literature examining whether per-
ceptions of the relative harmfulness of e-cigarettes compared to
combustible cigarettes differ under different regulatory frameworks.
One study by Yong et al.
23
examined whether current and former
smokers’ relative perceptions of e-cigarette harm varied under dif-
ferent e-cigarette regulatory environments. The results showed that
the perception that e-cigarettes are less harmful than conventional
cigarettes was considerably higher in the UK where the use of e-
cigarettes to replace combustible cigarettes is encouraged for harm
reduction purposes than in Australia, which has much stricter regu-
latory policies as e-cigarettes with nicotine are prohibited.
27
The
authors suggested that these results may be attributable to the less
restrictive e-cigarette policies in the UK, e.g. allowing e-cigarettes
with nicotine to be sold on the open market.
After the implementation of the stricter TPD regulations, there
were small but mostly non-significant changes in perceptions of the
harmfulness of e-cigarettes compared to combustible cigarettes,
including a slight increase in the perception that e-cigarettes are
equally or more harmful than cigarettes. Overall, there was a small
decrease over time in the proportion who reported being uncertain;
this was evident in four of the six countries, but significant only in
Spain. After the TPD, Romania had the highest rate of uncertainty
about the harm of e-cigarettes relative to cigarettes, where nearly a
quarter of the respondents were unsure. Notably, after the TPD,
Romania also had the lowest proportion of respondents who
reported that e-cigarettes were less harmful.
This study did not show significant differences between countries
in changes over time regarding perceptions of harm. However, when
responses were averaged across waves, Hungary and Greece had the
highest proportion of respondents who perceived e-cigarettes to be
less harmful than combustible cigarettes, a perception consistent
with the current scientific evidence. Respondents from Romania
and Spain were significantly less likely to believe that e-cigarettes
are less harmful than conventional cigarettes than respondents from
Hungary, which may be a reflection of differing social norms such as
perceived public approval. For example, in a recent EUREST-PLUS
ITC paper by East et al.,
28
Romania and Spain had the lowest pro-
portion of smokers who reported believing that the public approves
of e-cigarettes, and Hungary had the highest proportion. This sug-
gests that perceptions of public acceptance towards e-cigarettes may
be associated with e-cigarette harm perceptions.
The high proportion of respondents who perceive e-cigarettes to
be equally or more harmful than cigarettes in the EU, and the
shifting towards this opinion in several other countries, may be
associated with multiple factors, such as divided opinions among
the scientific community, the lack of accurate, consistent and pro-
active risk communications to the public, information from media
26.1%
17.4%
27.2%
35.1%
32.9%
30.9%
28.4%
22.0%
23.5%
30.2%
34.1%
33.5%
27.9%
28.6%
0% 10% 20% 30% 40% 50%
Spain
Romania
Poland
Hungary
Greece
Germany
Overall
(a)(b)
(c)
2016 2018
64.4%
60.0%
61.7%
57.1%
61.9%
63.7%
61.8%
58.8%
58.0%
60.3%
52.6%
58.5%
62.7%
58.4%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Spain
Romania
Poland
Hungary
Greece
Germany
Overall
2016 2018
9.4%
22.5%
11.1%
7.9%
5.0%
5.4%
9.8%
19.3%
18.5%
9.6%
13.0%
8.0%
9.0%
12.9%
0% 10% 20% 30% 40% 50%
Spain
Romania
Poland
Hungary
Greece
Germany
Overall
2016 2018
Figure 1 (a) Perception that e-cigarettes are less harmful than cigarettes. (b) Perception that e-cigarettes are equally or more harmful than
cigarettes. (c) Don’t know if e-cigarettes are more, equally or less harmful than cigarettes
European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes 5of8
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reports, or the growing interest of multinational tobacco firms in the
e-cigarette market. Perhaps most importantly, reporting about the
associations of e-cigarettes with health problems and safety concerns
may not only impact peoples’ absolute harm perceptions of e-ciga-
rettes but may negatively impact peoples’ relative harm perceptions
compared to combustible cigarettes, thereby leading the public to
become more cautious and sceptical about e-cigarettes as a harm
reducing alternative to combustible cigarettes.
Perceptions of potential risks and benefits of e-cigarette use vary
widely among the general public, as well as among those who smoke
compared to those who use e-cigarettes. Research has consistently
found that e-cigarette users are more likely to believe that e-ciga-
rettes are less harmful than combustible cigarettes compared to
never-e-cigarette users, smokers and non-smokers.
12,13,25,29
Consistent with this, current e-cigarette users in this study were
significantly more likely than those who had never used an e-cigar-
ette and those who have tried e-cigarettes (but not currently using
them) to believe e-cigarettes are less harmful (56.4% vs. 25.1%).
It has been reported that e-cigarettes are a popular smoking quit
aid in the EU.
20
A recent randomized trial in England indicated that
second-generation e-cigarettes nearly doubled the percentage of
smokers who were abstinent from cigarettes after one year (18%)
compared to nicotine replacement therapy (NRT) (10%) when both
products were accompanied by behavioural support,
30
an updating
of the initial evidence from two previous clinical trials showing the
efficacy of first-generation e-cigarettes for quitting.
31
Some observa-
tional studies have found that (daily) e-cigarette use can be helpful
in attempts to stop smoking or reduce cigarette consumption,
32
as
well as smoking cessation,
33–36
but other studies have not found an
effect.
37
However, it must be also remembered that a scientific con-
sensus on the potential risks and benefits of e-cigarette use still has
not been reached, and the public health debate continues. Similarly,
it should be noted that there are other safe, well-researched and
effective cessation products that can help smokers to quit, including,
but not limited to NRT and Varenicline.
38
Study limitations
This repeated cross-sectional study included a large sample of
European smokers from six countries; however, there may be some
limitations to consider. As respondents in this study were recruited as
smokers, the results are not generalizable beyond the smoking popu-
lation (e.g. to former or non-smokers). Second, the proportion of
current e-cigarette users in the sample was small, therefore we could
not examine whether smokers who perceived e-cigarettes to be less
harmful were more likely to initiate e-cigarette use compared to those
who held perceptions that e-cigarettes were equally or more harmful.
Third, data were self-reported, and thus may have been subject to
misclassification due to social desirability bias.
Conclusion
Overall, this study has demonstrated that on average, smokers in
these six EU countries overestimated the relative harmfulness of e-
cigarettes compared to combustible cigarettes. As the global use of e-
cigarettes continues to increase, leveraging different modes of health
communication to discourage e-cigarette use among never-smokers,
especially youth, is critical. However, equally critical is the provision
of balanced information to those smokers who are interested in
using e-cigarettes in place of combustible cigarettes. Such commu-
nication should be framed to distinguish relative and absolute
harms, providing an evidence-based appraisal of the relative risk
of e-cigarettes in comparison to combustible cigarettes.
Supplementary data
Supplementary data are available at EURPUB online.
Acknowledgements
Provenance and peer review: Commissioned; externally peer-reviewed.
EUREST-plus consortium members: European Network on Smoking
and Tobacco Prevention (ENSP), Belgium: Constantine I. Vardavas,
Andrea Glahn, Christina N. Kyriakos, Dominick Nguyen, Katerina
Nikitara, Cornel Radu-Loghin and Polina Starchenko. University of
Crete (UOC), Greece: Aristidis Tsatsakis, Charis Girvalaki, Chryssi
Igoumenaki, Sophia Papadakis, Aikaterini Papathanasaki, Manolis
Tzatzarakis and Alexander I. Vardavas. Kantar Public, Belgium:
Nicolas Be´cuwe, Lavinia Deaconu, Sophie Goudet, Christopher
Hanley and Oscar Rivie` re. Smoking or Health Hungarian
Foundation (SHHF), Hungary: Tibor Demje´n, Judit Kiss and Anna
Piroska Kovacs. Tobacco Control Unit, Catalan Institute of Oncology
(ICO) and Bellvitge Biomedical Research Institute (IDIBELL),
Catalonia: Esteve Ferna´ndez, Yolanda Castellano, Marcela Fu, Sarah
O. Nogueira and Olena Tigova. Kings College London (KCL), UK:
Ann McNeill, Katherine East and Sara C. Hitchman. Cancer
Prevention Unit and WHO Collaborating Centre for Tobacco
Control, German Cancer Research Center (DKFZ), Germany: Ute
Mons and Sarah Kahnert. National and Kapodistrian University of
Athens (UoA), Greece: Yannis Tountas, Panagiotis Behrakis, Filippos
T. Filippidis, Christina Gratziou, Paraskevi Katsaounou, Theodosia
Peleki, Ioanna Petroulia and Chara Tzavara. Aer Pur Romania,
Romania: Antigona Carmen Trofor, Marius Eremia, Lucia Lotrean
and Florin Mihaltan. European Respiratory Society (ERS),
Switzerland: Gernot Rohde, Tamaki Asano, Claudia Cichon, Amy
Far, Ce´ line Genton, Melanie Jessner, Linnea Hedman, Christer
Janson, Ann Lindberg, Beth Maguire, Sofia Ravara, Vale´rie Vaccaro
and Brian Ward. Maastricht University, the Netherlands: Marc
Willemsen, Hein de Vries, Karin Hummel and Gera E. Nagelhout.
Health Promotion Foundation (HPF), Poland: Witold A. Zato
nski,
Aleksandra Herbe
c, Kinga Janik-Koncewicz, Krzysztof Przewo
zniak
and Mateusz Zato
nski. University of Waterloo (UW), Canada:
Geoffrey T. Fong, Thomas K. Agar, Pete Driezen, Shannon Gravely,
Anne C. K. Quah and Mary E. Thompson.
Funding
The EUREST-PLUS project has received funding from the European
Union’s Horizon 2020 research and innovation programme under
grant agreement No 681109 (CIV) and the University of Waterloo
(GTF). Additional support was provided to the University of
Waterloo by a foundation grant from the Canadian Institutes of
Health Research (FDN-148477). G.T.F. was supported by a Senior
Investigator Grant from the Ontario Institute for Cancer Research.
E.F. is partly supported by Ministry of Universities and Research,
Government of Catalonia (2017SGR319) and by the Instituto Carlos
III and co-funded by the European Regional Development Fund
(FEDER) (INT16/00211 and INT17/00103), Government of Spain.
E.F. thanks CERCA Programme Generalitat de Catalunya for the
institutional support to IDIBELL.
Conflicts of interest: G.T.F. has served as an expert witness on behalf
of governments in litigation involving the tobacco industry. K.J-.K.
reports grants and personal fees from the Polish League Against
Cancer, outside the submitted work. All other authors have no
conflicts of interest to declare.
Key points
•The majority of smokers in the six EU countries included in
this study (Germany, Greece, Hungary, Poland, Romania and
Spain) perceived e-cigarettes to be equally or more harmful
than combustible cigarettes in 2016 and 2018 (60%), and
approximately 30% believed that e-cigarettes are less harmful
than cigarettes.
6of8 European Journal of Public Health
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References
1World Health Organization. Tobacco: Deadly in Any Form or Disguise. World
No Tobacco Day, 2006. Available at: https://www.who.int/tobacco/communica
tions/events/wntd/2006/Report_v8_ 4May06.pdf (24 July 2019, date last
accessed).
2National Center for Chronic Disease Pre vention and Health Promotion (US)
Office on Smoking and Health. The Health Consequences of Smoking—50 Years
of Progress: A Report of the Surgeon Genera l, 2014. Atlanta (GA): Centers for
Disease Control and Prevention (US). Available at: https://www.ncbi.nlm.n ih.
gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf (24 July 2019, date last
accessed).
3Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’
observations on male British doctors. BMJ 2004;328:1519.
4Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits
of stopping: a prospective study of one million women in the UK. Lancet 2013;381:
133–41.
5Russell MA. Low-tar medium-nicotine cigarettes: a new approach to safer smoking.
Br Med J 1976;1:1430–3.
6Thun MJ, Burns DM. Health impact of “reduced yield” cigarettes: a critical as-
sessment of the epidemiological evidence. Tob Control 2001;10 Suppl 1:i4–11.
7Tindle HA, Rigotti NA, Davis RB, et al. Cessation among smokers of “light” cig-
arettes: results from the 2000 national health interview survey. Am J Public Health
2006;96:1498–504.
8National Academies of Sciences, Engineering, and Medicine. Public Health
Consequences of E-Cigarettes. Washington, DC: The National Academies Press,
2018. Available at: http://nationalacademies.org/hmd/Reports/2018/public-health-
consequences-of-e-cigarettes.aspx (24 July 2019, date last accessed).
9McNeill A, Brose LS, Calder R, McRobbie H. Vaping in England: An Evidence
Update February 2019: A Report Commissioned by Public Health England.
London, UK: Public Health England, 2019. Available at: https://assets.publishing.
service.gov.uk/government/uploads/system/uploads/attachment_data/file/781748/
Vaping_in_England_an_evidence_update_February_2019.pdf (24 July 2019, date
last accessed).
10 Royal College of Physicians. Nicotine Without Smoke: Tobacco Harm Reduction.
London: RCP, 2016.
11 American Cancer Society. American Cancer Society Position Statement on
Electronic Cigarettes 2018. Available at: https://www.cancer.org/healthy/stay-away-
from-tobacco/e-cigarette-position-statement.html (24 July 2019, date last accessed).
12 Romijnders K, van Osch L, de Vries H, Talhout R. Perceptions and reasons
regarding e-cigarette use among users and non-users: a narrative literature review.
Int J Environ Res Public Health 2018;15:1190.
13 Huang J, Feng B, Weaver SR, et al. Changing perceptions of harm of e-cigarette vs
cigarette use among adults in 2 US National Surveys From 2012 to 2017. JAMA
Netw Open 2019;2:e191047.
14 Nicksic NE, Snell LM, Barnes AJ. Reasons to use e-cigarettes among adults and
youth in the Population Assessment of Tobacco and Health (PATH) study. Addict
Behav 2019;93:93–9.
15 Yong HH, Borland R, Cummings KM, et al. Reasons for regular vaping and for its
discontinuation among smokers and recent ex-smokers: findings from the 2016 ITC
Four Country Smoking and Vaping Survey. Addiction 2019;114:35–48.
16 Twyman L, Watts C, Chapman K, Walsberger SC. Electronic cigarette use in New
South Wales, Australia: reasons for use, place of purchase and use in enclosed and
outdoor places. Aust N Z J Public Health 2018;42:491–6.
17 Huerta TR, Walker DM, Mullen D, et al. Trends in e-cigarette awareness and
perceived harmfulness in the U.S. Am J Prev Med 2017;52:339–46.
18 Farsalinos KE, Romagna G, Tsiapras D, et al. Characteristics, perceived side effects
and benefits of electronic cigarette use: a worldwide survey of more than 19,000
consumers. Int J Environ Res Public Health 2014;11:4356–73.
19 Brose LS, Brown J, Hitchman SC, McNeill A. Perceived relative harm of electronic
cigarettes over time and impact on subsequent use. A survey with 1-year and 2-year
follow-ups. Drug Alcohol Depend 2015;157:106–11.
20 Filippidis FT, Laverty AA, Mons U, et al. Change s in smoking cessation assistance in
the European Union between 2012 and 2017: pharmacotherapy versus counselling
versus e-cigarettes. Tob Control 2019;28:95–100.
21 Persoskie A, O’Brien EK, Poonai K. Perceived relative harm of using e-cigarettes
predicts future product switching among U.S. adult cigarette and e-cigarette dual
users. Addiction 2019;114:2197–205.
22 Institute for Global Tobacco Control. John Hopkins Bloomberg School of Public
Health. Country Laws Regulating E-Cigarettes: A Policy Scan. Baltimore, MD: Johns
Hopkins Bloomberg School of Public Health, 2018. Available at: https://www.glob
altobaccocontrol.org/e-cigarette_policyscan (24 July 2019, date last accessed).
23 Yong H-H, Borland R, Balmford J, et al. Prevalence and correlates of the belief that
electronic cigarettes are a lot less harmful than conventional cigarettes under the
different regulatory environments of Australia and the United Kingdom. Nicotine
Tob Res 2017;19:258–63.
24 Thompson ME, Driezen P, Boudreau C, et al. Methods of the International
Tobacco Control (ITC) EUREST-PLUS ITC Europe Surveys. Eur J Public Health
2020; doi: 10.1093/eurpub/ckz212 [Epub ahead of print].
25 Fong GT, Elton-Marshall T, Driezen P, et al. U.S. adult perceptions of the harm-
fulness of tobacco products: descriptive findings from the 2013-14 baseline wave 1
of the path study. Addict Behav 2019;91:180–7.
26 Elton-Marshall T, Fong GT, Li G, et al. Perceptions of the harmfulness of e-ciga-
rettes across 20 countries: findings from the ITC Project. Evidence on e-cigarettes
use and perceptions, and the implications for tobacco control: Canadian and
international perspectives. In: Proceedings of the Canadian Public Health
Association Symposium, 28–31 May 2018, Montreal (QC).
27 Kennedy RD, Awopegba A, De Leo´ n E, Cohen JE. Global approaches to regulating
electronic cigarettes. Tob Control 2017;26:440–5.
28 East KA, Hitchman SC, McDermott M, McNeill A, et al.; EUREST-PLUS consor-
tium. Social norms towards smoking and electronic cigarettes among adult smokers
in seven European Countries: findings from the EUREST-PLUS ITC Europe
Surveys. Tob Induc Dis 2018;16:A15.
29 Cooper M, Loukas A, Harrell MB, Perry CL. College students’ perceptions of risk
and addictiveness of e-cigarettes and cigarettes. J Am Coll Health 2017;65:103–11.
30 Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus
nicotine-replacement therapy. N Engl J Med 2019;380:629–37.
31 McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking
cessation and reduction. Cochrane Database Syst Rev 2014;12:CD010216.
32 Brose LS, Hitchman SC, Brown J, et al. Is the use of electronic cigarettes while
smoking associated with smoking cessation attempts, cessation and reduced cig-
arette consumption? A survey with a 1-year follow-up. Addiction 2015;110:1160–8.
33 Jackson S, Kotz D, West R, Brown J. Moderators of real-world effectiveness of
smoking cessation aids: a population study. Addiction 2019;114:1627–38.
34 Coleman B, Rostron B, Johnson SE, et al. Transitions in electronic cigarette use
among adults in the Population Assessment of Tobacco and Health (PATH) Study,
Waves 1 and 2 (2013-2015). Tob Control 2019;28:50–9.
•It does not appear that the implementation of the European
Tobacco Products Directive had a significant impact on rela-
tive harm perceptions over time.
•Overall, across both waves (2016 and 2018), respondents from
Hungary had the highest proportion of smokers who per-
ceived e-cigarettes to be less harmful than combustible ciga-
rettes (35.6%), followed by Greece (33.2%) and Germany
(29.7%). Respondents from Spain and Romania were the
most negative about relative harm (23.9% and 20.6% per-
ceived e-cigarettes as less harmful respectively).
•Respondents who self-reported current e-cigarette use were
four times more likely than never-e-cigarette users to perceive
e-cigarettes to be less harmful than cigarettes. Those who had
ever-tried (but not current e-cigarette users) were 1.5 times
more likely to believe e-cigarettes to be less harmful than
never-users.
•This study has demonstrated that smokers in the EU com-
monly overestimate the relative risk of e-cigarettes compared
to combustible cigarettes. Therefore, public health communi-
cation should be framed to reduce the confusion between
relative and absolute harms.
European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes 7of8
Downloaded from https://academic.oup.com/eurpub/advance-article-abstract/doi/10.1093/eurpub/ckz215/5810149 by guest on 20 May 2020
35 Farsalinos K, Niaura R. E-cigarettes and smoking cessation in the United States
according to frequency of e-cigarette use and quitting duration: analysis of the 2016
and 2017 National Health Interview Surveys. Nicotine Tob Res 2019; pii: ntz025. doi:
10.1093/ntr/ntz025.
36 Liu X, Lu W, Liao S, et al. Efficiency and adverse events of electronic cigarettes: a
systematic review and meta-analysis (PRISMA-compliant article). Medicine
(Baltimore) 2018;97:e0324.
37 Weaver SR, Huang J, Pechacek TF, et al. Are electronic nicotine
delivery systems helping cigarette smokers quit? Evidence from a
prospective cohort study of U.S. adult smokers, 2015-2016. PLoS One 2018;13:
e0198047.
38 Fiore M. United States. Tobacco Use and Dependence Guideline Panel. Treating
Tobacco Use and Dependence: 2008 Update. Rockville, MD: Dept. of Health and
Human Services, Public Health Service, 2008.
8of8 European Journal of Public Health
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