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Original investigatiOn

e-Cigarette awareness, Use, and Harm Perceptions in italy: a national representative survey

Silvano Gallus ScD1, Alessandra Lugo ScD2, Roberta Pacifici ScD3, Simona Pichini PhD3, Paolo Colombo ScD4, Silvio Garattini MD1, Carlo La Vecchia, MD2

1Department of Epidemiology, IRCCS – Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy; 2Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; 3Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy; 4Istituto DOXA, Worldwide Independent Network/Gallup International Association, Milan, Italy

Corresponding Author: Silvano Gallus, ScD, Department of Epidemiology, IRCCS – Istituto di Ricerche Farmacologiche Mario Negri, Via G. La Masa 19, 20159 Milan, Italy. Telephone: 390239014657; Fax: 390233200231; E-mail: silvano.gallus@ marionegri.it

Received December 12, 2013; accepted June 21, 2014

abstraCt

introduction: Only a few studies have provided information on awareness, use, and harm perceptions of e-cigarettes in Europe. We fill the knowledge gap in Italy.

Methods: We used data from a face-to-face survey conducted in 2013 of a sample of 3,000 individuals, representative of the Italian population aged ≥15 years (51.1 million inhabitants).

results: Awareness of e-cigarettes was 91.1%; it was lowest among women (87.8%), the elderly (78.4%), those with less education (84.1%), and never-smokers (89.0%). Ever e-cigarette use was 6.8% overall and was inversely related to age, whereas no significant difference was observed according to sex. With regard to smoking status, 2.6% of never-smokers, 7.0% of ex- smokers, and 20.4% of current smokers tried the e-cigarette at least once. Regular e-cigarette use was 1.2% overall, 1.5% among men, and 0.9% among women, and it was highest among young (2.4%) and current smokers (3.7%). Among 36 e-cigarette regu- lar users, 22.0% did not change their smoking habit, 67.7% reduced traditional cigarette consumption, and 10.4% quit smoking.

Conclusions: After fewer than 3 years from the opening of the first Italian e-cigarette shop, more than 45 million Italians have heard about e-cigarettes, 3.5 million have tried e-cigaretts, and more than 600,000 Italians regularly use e-cigarettes. Three out of 4 e-cigarette users reported to have favorably modified their smoking habit; however, 90% of users did not quit smoking as a consequence of starting vaping e-cigarettes. Almost 900,000 Italian never-smokers, particularly young never-smokers, have tried this new and potentially addictive product at least once.

intrOdUCtiOn

Approximately, one decade ago, the electronic nicotine delivery system, also known as electronic cigarette or e-cigarette, was first introduced into the market in China by the Beijing com- pany Ruyan (Dawkins, Turner, Roberts, & Soar, 2013; Dockrell, Morrison, Bauld, & McNeill, 2013; Pauly, Li, & Barry, 2007). The e-cigarette is a product that allows the inhalation of a chem- ical mixture including propylene glycol, nicotine, and flavors (Kuehn, 2009; Pauly et  al., 2007; World Health Organization [WHO], 2013). Given the shape, the method of inhalation, the taste, and the possible content of nicotine, the e-cigarette gives to its consumer (known as “vaper”) a sensation which is similar to that experienced by inhaling the tobacco smoke of a tradi- tional cigarette (Sugerman, 2014; WHO, 2013).

Over the last few years, e-cigarette rose in popular- ity (Ayers, Ribisl, & Brownstein, 2011) and since October

2010, the e-cigarette spread in the Italian market, also given the persistent promotion of this product on several media. In various advertisements, e-cigarette manufacturers state that the use of e-cigarette improves smoking cessation, decreases smoking consumption, does not produce adverse effects on health (given the lack of tobacco combustion during inhala- tion), and is socially and legally accepted in public or private places (Richardson, Ganz, Stalgaitis, Abrams, & Vallone, 2014; Richardson, Ganz, & Vallone, 2014; Sugerman, 2014). Consequently, many current smokers were likely induced to e-cigarette consumption. Thus, the number of shops selling exclusively e-cigarettes has appreciably grown over the last 2 years, and today more than 1,500 retailers of e-cigarettes are available throughout Italy.

A debate recently grew whether e-cigarette can be consid- ered a safe alternative to tobacco smoking (Borland, 2011; Etter, 2013; Wagener, Siegel, & Borrelli, 2012) or another

© The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].

doi:10.1093/ntr/ntu124 Advance Access publication July 31, 2014

nicotine & tobacco research, volume 16, number 12 (december 2014) 1541–1548

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way to make nicotine addiction socially acceptable (Chapman, 2013). Although there is a broad consensus that e-cigarette vapor is much less toxic than cigarette smoke (Benowitz & Goniewicz, 2013), most of the public health experts and tobacco control activists, the FDA and the WHO itself, warned the public against this new emerging phenomenon, given (a) the paucity of clinical studies analyzing safety of the liquid or the vapor inhaled in the lungs of vapers, (b) the inadequate evidence that e-cigarettes are effective to let smokers quit or reduce traditional cigarette consumption, and (c) the lack of a legislative regulation for this new product (Bains, Agombar, Clarke, & Patel, 2012; Bauld, 2012; Benowitz & Goniewicz, 2013; Chapman, 2013; Etter, Bullen, Flouris, Laugesen, & Eissenberg, 2011; Flouris & Oikonomou, 2010; Hampton, 2014; Kuehn, 2009; Pauly et al., 2007; Popova & Ling, 2013; Sugerman, 2014; WHO, 2013; Yamin, Bitton, & Bates, 2010). Moreover, various cartridges of e-cigarettes contain a liquid which substantially vary in the amount of different chemicals, including nicotine, and purchasers have often no adequate information to understand the real content and composition of the refills (Benowitz & Goniewicz, 2013; Cameron et  al., 2013; Cheah, Chong, Tan, Morsed, & Yee, 2012; Flouris & Oikonomou, 2010; Goniewicz, Kuma, Gawron, Knysak, & Kosmider, 2013; Trtchounian & Talbot, 2011; WHO, 2013; Williams & Talbot, 2011). Of concerns is also the fact that fla- vors can be particularly attractive to adolescents, who could consequently start e-cigarette use as a gateway to tobacco smoking (Benowitz & Goniewicz, 2013; Choi, Fabian, Mottey, Corbett, & Forster, 2012; Hampton, 2014; Sugerman, 2014; WHO, 2013).

Only a limited number of studies, mostly from the United States, have been conducted so far to understand awareness, use, and harm perception in representative surveys of adults (Pepper & Brewer, 2013). To our knowledge, within Europe, only one study on adults from the United Kingdom (Dockrell et al., 2013), three studies on smokers from the United Kingdom (Adkison et  al., 2013) and the Czech Republic (Kralikova, Kubatova, Truneckova, Kmetova, & Hajek, 2012; Kralikova, Novak, West, Kmetova, & Hajek, 2013), and one study on adolescents and young adults from Poland (Goniewicz & Zielinska-Danch, 2012) have been published. We therefore fill the knowledge gap in Italy, a country where smoking prevalence was 20.8% in 2012 (Gallus, Lugo, Colombo, Pacifici, & La Vecchia, 2013), and where a comprehensive legislation came into force in 2005 to ban smoking in workplaces and all indoor public places, includ- ing restaurants and pubs (Gallus et al., 2006).

The objective of the present study is therefore to quan- tify the proportion of awareness, use, and harm perception of e-cigarettes using data from a representative population-based survey conducted in Italy.

MetHOds

Data were collected through a survey on smoking conducted in Italy during February–May 2013 by DOXA, the Italian branch of the WIN/GIA (Worldwide Independent Network/ Gallup International Association). The overall sample con- sisted of 3,000 individuals aged ≥15  years (1,442 men and 1,558 women), representative of the general Italian population aged 15 years and over (51.1 million inhabitants), in terms of sex, age, geographic area, and socioeconomic characteristics.

Participants were selected through a representative multi- stage sampling. The first stage was used to select municipali- ties (the smallest Italian administrative division) in all of the 20 Italian regions (the largest Italian administrative division) in order to be representative of the geographic areas sampled. Thus, taking as criteria two characteristics, region and size of municipality, we identified 116 municipalities, providing a reproduction of the Italian universe of municipalities (method known as proportional stratified sample). In the second stage, in each municipality, an adequate number of electoral wards was randomly extracted (each ward corresponding to a given district of the municipalities), so that the various types of more or less affluent areas of the municipality were represented in the right proportions (i.e., central and suburban districts, out- skirts and isolated houses). In the third stage, individuals were randomly sampled from electoral rolls, within strata defined by sex and age group, in order to be representative of the demographic structure of the population. For adolescents aged 15–17 years, we used the same sampling approach for the first two stages. For the third stage, adolescents, whose names are not included in the electoral lists, were selected, among neigh- bors of adult respondents, by means of a “quota” method (by sex and exact age).

Field substitution was used as the preferred strategy to deal with nonrespondence (Baldissera et al., 2014). Therefore, non- respondents, including potential participants refusing to partici- pate, unavailable (i.e., units nonresponding up to three attempts of direct contact) and ineligible participants (e.g., hospitalized, deceased, prisoners or moved away units), were substituted by their neighbors (living in the same floor/building/street) with the same sex and age group. In the phase of processing the data, statistical weights were also generated to balance the sample with its universe, and therefore to assure representativeness of the Italian population aged 15 years or over.

Ad hoc trained interviewers conducted interviews in Italian using a structured questionnaire in the context of a computer- assisted personal in-house interview. Besides general informa- tion on sociodemographic characteristics, data were collected on smoking status (never/ex-/current smokers). Ever smokers (current and ex-smokers) were participants who had smoked 100 or more cigarettes in their lifetime. Ex-smokers were par- ticipants who had quit smoking since at least 1 year, and cur- rent smokers were individuals continuing smoking or having stopped since less than 1  year. Current smokers were asked if they had an intention to quit within the next 6  months and whether they had made at least one quit attempt. Ex-smokers were asked to report the time since quitting. A specific section of the questionnaire focused on e-cigarettes. Participants were asked about their awareness and use of e-cigarettes using the following single question: “Have you ever heard about e-ciga- rettes, have you ever tried them or do you have the intention to try them?” Participants were admitted to answer only one of the following choices: (a) I have never heard about e-cigarettes; (b) I heard about e-cigarettes, I have never tried them, and I have no intention to try them; (c) I heard about e-cigarettes, I have never tried them, and I  have intention to try them; and (d) I heard about e-cigarettes and I tried them. Participants report- ing they “have heard about e-cigarettes and have tried them” were labeled as “ever users” of e-cigarettes. Ever users were further asked: “Do you regularly use e-cigarettes?” Moreover, regular e-cigarette users were asked about the features of their e-cigarettes, including the type of e-cigarette most frequently

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used, and about the characteristics of use, including the number of e-cigarettes (sessions of consumption) per day (using the question: “How many times per day do you use e-cigarettes?”) and the consequence of e-cigarette use on smoking behavior. All participants were asked about their opinion (true or false) on seven different statements concerning e-cigarettes; they (a) are not harmful for health; (b) are less harmful than traditional cigarettes because they do not contain nicotine; (c) are less harmful because there is no tobacco combustion; (d) are less harmful because they contain only nicotine; (e) are more harm- ful than traditional cigarettes; (f) are an efficient tool to quit smoking; and (g) allow smoking even where it is forbidden. Participants were also asked about their attitudes toward the ban of e-cigarette use in (a) public indoor places (e.g., bars, restaurants, shops) and (b) on trains (four-item score: strongly in favor, moderately in favor, moderately against, and strongly against).

Data Analysis

Multivariate p values for awareness of e-cigarettes and their regular use were computed through unconditional multiple logistic regression models adjusted for sex, age, level of educa- tion, smoking status, and geographic area. Odds ratios (OR) for use of e-cigarettes (“ever users” vs. “never users”) and the corresponding 95% confidence intervals (CI) were derived using the same unconditional multiple logistic regression mod- els. All the analyses were performed with SAS version 9.2

statistical package (SAS Institute). All the estimates provided are weighted for statistical weights.

resUlts

Table 1 shows the distribution of 3,000 Italians aged ≥15 years according to their awareness and use of e-cigarettes. Overall, 8.9% (95% CI = 7.8%–9.9%) of survey participants had never heard about e-cigarettes, 84.4% (95% CI  =  83.1%–85.7%) had heard about them but had never tried (74.3% without any intention to try and 10.1% with an intention to try), 5.6% (95% CI  =  4.8%–6.5%) had tried without a regular use, and 1.2% (95% CI = 0.8%–1.6%; 36 participants) reported a regular use of e-cigarettes. Men more frequently heard about e-cigarettes (94.8%) than women (87.8%; multivariate p < .001). Awareness of e-cigarettes increased with decreasing age (p for trend < .001) and increasing level of education (p for trend < .001). Compared to never-smokers (89.0%), awareness of e-cigarettes was significantly higher among current (96.0%; p = .002) and ex-smokers (94.3%; p  =  .004). Compared to southern Italy (88.7%), awareness of e-cigarettes was significantly higher in northern (92.1%; p = .004) and central Italy (93.1%; p = .004).

Regular e-cigarette use was similar in men (1.5%) and women (0.9%; multivariate p = .910) and in various categories of education (p for trend = .504). E-cigarettes were more fre- quently used by the young (prevalence of regular use was 2.4% in 15–24 years old individuals, 1.6% in 25–44, 1.0% in 45–64

table 1. Awareness and Use of E-cigarettes on the Overall Samplea, by Selected Characteristics: Italy 2013

Awareness of e-cigarettes (%)b

N No awareness of e-cigarettes (%)b

Never tried without intention to try

Never tried with intention to try

Tried but no regular use Regular use

Total 3,000 8.9 74.3 10.1 5.6 1.2 Sex Men 1,442 5.2 74.6 11.8 6.9 1.5 Women 1,558 12.2 73.9 8.5 4.5 0.9 Age (years) 15–24 349 5.2 70.9 12.3 9.2 2.4 25–44 994 4.6 74.2 13.0 6.7 1.6 45–64 948 5.2 77.0 10.4 6.5 1.0 ≥65 709 21.6 72.4 4.4 1.3 0.3 Level of education Low 1,193 15.9 72.1 7.8 3.2 1.0 Intermediate 1,362 4.2 73.8 11.8 8.6 1.6 High 445 4.1 81.4 11.0 3.1 0.5 Smoking status Never-smoker 1,992 11.0 80.3 6.1 2.5 0.1 Ex-smoker 392 5.7 82.7 4.6 4.3 2.8 Current smoker 616 4.0 49.3 26.3 16.6 3.7 Geographic area Northern Italy 1,380 7.9 74.9 10.2 6.0 0.9 Central Italy 596 6.9 76.6 11.5 4.7 0.3 Southern Italy and islands 1,024 11.3 72.0 9.0 5.6 2.1

aSample of 3,000 Italians aged ≥15 years, representative of the general Italian population in terms of sex, age, geographic area, and socioeconomic characteristics. All the estimates in the table were derived using statistical weights to reassure sample representativeness. bRow percentages.

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and 0.3% in ≥65 year old adults; p for trend = .001). Compared to never-smokers (0.1%), regular use of e-cigarette was higher in current (3.7%; p < .001) and ex-smokers (2.8%; p < .001), while, compared to central Italy (0.3%), regular use was higher in southern Italy (2.1%; p = .018) and similar in northern Italy (0.9%; p = .132).

Among 36 regular users, 95.5% reported to use e-cigarettes with nicotine and only 4.5% used e-cigarettes with vapor and flavors only (without nicotine). Regular users reported to use e-cigarettes from 1 to 70 times per day (mean: 10.0 overall, 10.8 among men and 8.7 among women). As a consequence of starting using e-cigarettes, 78.0% of regular users reported to have modified their smoking behavior, 67.7% having reduced traditional cigarette consumption and 10.4% having quit smok- ing (Table 2).

Table  3 shows the distribution of participants by lifetime use of e-cigarettes (“ever users” vs. “never users”) according to selected characteristics, overall and among current smokers. The proportion of participants reporting to have ever tried e-cigarettes was 6.8% (95% CI = 5.9%–7.7%; n = 205). E-cigarette trial was inversely related to age, the ORs compared to participants aged 15–24 years being 0.56 for 25–44, 0.49 for 45–64, and 0.16 for ≥65  years (p for trend < .001). Individuals with intermediate compared to low education reported to have tried e-cigarettes more frequently (OR = 1.91), whereas no significant difference was observed according to sex and geographic area. Overall, 2.6% (95% CI  =  1.9%–3.3%; n  =  52) of never-smokers, 7.0% (95% CI = 4.5%–9.6%; n = 28) of ex-smokers, and 20.4% (95% CI = 17.2%–23.6%; n = 126) of current smokers tried at least once e-cigarettes. Compared to never-smokers, the OR for ex-smokers was 3.79 and that of current smokers was 9.20. The pattern of cur- rent smokers largely reflects that of the overall population.

Trial of e-cigarettes was more common in current smokers with an intention to quit smoking within the following 6 months (36.0%), compared to those with no plans to quit (15.5%; p < .001) and in smokers who had made at least one quit attempt (29.3%) compared to those who had not made a quit attempt (16.5%; p < .001). Among ex-smokers who tried the e-ciga- rette, 92.6% had quit smoking in the previous 3 years.

The majority of Italians believe that e-cigarettes allow smok- ing even where it is forbidden (71.9%), they are less harmful than traditional cigarettes since there is no tobacco combustion (64.7%) and they are a useful tool to quit smoking (57.3%). Overall, 47.7% of Italians believe that e-cigarettes are less harmful because they contain only nicotine, 32.4% that they are not harmful for health, but 23.1% that they are more harm- ful than traditional cigarettes. Similar patterns were observed according to different smoking status.

Figure 1 shows the prevalence of participants who moder- ately or strongly support banning e-cigarettes in public places. The proportion of Italians aged ≥15  years in favor of a com- plete ban of e-cigarette use in public indoor places (including bars, restaurants, and shops) was 64.8% overall, 70.4% among never-smokers, 60.0% among ex-smokers, and 50.4% among current smokers. The prevalence of participants supporting the ban of e-cigarettes on trains was 64.0% overall, 69.4% among never-smokers, 59.9% among ex-smokers, and 49.7% among current smokers. After exclusion of the few participants who were unaware of e-cigarettes, estimates on perceptions and atti- tudes did not substantially change.

disCUssiOn

According to this representative sample, more than 45 million Italians (91.1% of Italians aged ≥15 years) have heard about the e-cigarettes, 3.5 million (6.8%) have already tried, and more than 600,000 Italians (1.2%) regularly use it.

According to awareness, in Italy, we found the highest pro- portion of the adult population having heard about e-cigarettes (Pepper & Brewer, 2013). This may be due in part to a time effect, but certainly also to the persistent promotion of e-cig- arettes on several media in Italy. Our proportion among cur- rent smokers (96%) was similar only to that observed among smokers in the Czech Republic in 2012 (97%) (Kralikova et al., 2013). All the studies providing data on the trend of awareness of e-cigarettes systematically showed a substantial increase with calendar period. Thus, in the United States, the number of

table 2. Characteristic of Regular E-cigarettes Users: Italy 2013

Total

N % (95% CI)

36 100.0

Type of e-cigarette most frequently used With nicotine 34 95.5 (87.7–100.0) Only vapor (without nicotine) 0 0.0 Vapor and flavor (without nicotine) 2 4.5 (0.0–11.3) Number of e-cigarettes per day <5 10 27.4 (12.8–42.0) 5–14 19 54.5 (38.2–70.9) ≥15 7 18.1 (5.5–30.7) Consequences on smoking behaviors Started smoking manufactured cigarettes

(from never-smoker to current smoker) 0 0.0

Did not change my smoking habit 8 22.0 (8.4–35.6) Slightly reduced number of cigarettes smoked per day 16 44.5 (28.1–60.8) Drastically reduced number of cigarettes smoked per day 8 23.2 (9.3–37.0) Quitted smoking 4 10.4 (0.4–20.4)

Note. CI = confidence interval.

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adults having heard about e-cigarettes doubled between 2009 (16%) and 2010 (32%) (Regan, Promoff, Dube, & Arrazola, 2013) and markedly increased between 2010 (40%) and 2011 (58%) (King, Alam, Promoff, Arrazola, & Dube, 2013). In the United Kingdom, smokers who heard about e-cigarettes increased from 60% in 2010 to 77% in 2012 (Dockrell et al., 2013). Also in Italy, we observe such a trend. In fact, awareness of e-cigarettes was 72% among current and ex-smokers in a companion survey conducted by DOXA in 2012 (Gallus et al., 2013; OSSFAD, 2012). This estimate increased to more than

95% among ever smokers in 2013. In our study, awareness of e-cigarette was highest among current smokers, men, young- est, and highly educated subjects. This is in broad agreement with previous studies (Adkison et  al., 2013; Choi & Forster, 2013; King et al., 2013; Regan et al., 2013).

Ever use of e-cigarette also substantially increased in Italy in 1  year only. In fact, ever smokers having tried e-cigarettes were 7.3% in 2012 (OSSFAD, 2012) and 15.2% in 2013. In agreement with several other studies (Adkison et  al., 2013; Choi & Forster, 2013; Pearson, Richardson, Niaura, Vallone,

table 3. Distribution of the Overall Sample and the Sample of Current Smokers by Lifetime Use of E-Cigarettes (Ever vs. Never Users), by Selected Characteristics: Italy 2013

Overall sample Current smokers

E-cigarette use, N (%)a ORb for e-cigarette ever users vs. never users (95% CI)

E-cigarette use, N (%)a ORb for e-cigarette ever users vs. never

users (95% CI)Ever users Never users Ever users Never users

Total 205 (6.8) 2795 (93.2) – 126 (20.4) 491 (79.6) – Sex Men 121 (8.4) 1321 (91.6) 1c 76 (20.2) 301 (79.8) 1c

Women 84 (5.4) 1475 (94.6) 0.89 (0.65–1.22) 49 (20.6) 190 (79.4) 0.96 (0.64–1.45) Age (years) 15–24 40 (11.6) 309 (88.4) 1c 23 (32.6) 48 (67.4) 1c

25–44 82 (8.2) 912 (91.8) 0.56 (0.36–0.86) 49 (20.3) 194 (79.8) 0.55 (0.30–0.99) 45–64 71 (7.5) 877 (92.5) 0.49 (0.31–0.78) 47 (20.4) 184 (79.6) 0.59 (0.32–1.08) ≥65 11 (1.6) 698 (98.4) 0.16 (0.08–0.33) 6 (8.7) 65 (91.4) 0.26 (0.10–0.72) Level of education Low 50 (4.2) 1143 (95.8) 1c 35 (15.1) 198 (84.9) 1c

Intermediate 139 (10.2) 1223 (89.8) 1.95 (1.35–2.81) 77 (25.0) 230 (75.0) 1.70 (1.06–2.73) High 16 (3.6) 429 (96.4) 0.71 (0.39–1.29) 14 (17.9) 63 (82.1) 1.15 (0.57–2.34) Smoking status Never-smokers 52 (2.6) 1940 (97.4) 1c

Ex-smokers 28 (7.0) 365 (93.0) 3.79 (2.30–6.27) Current smokers 126 (20.4) 491 (79.6) 9.20 (6.47–13.07) Geographic area Northern Italy 94 (7.0) 1283 (93.0) 1c 55 (19.7) 225 (80.3) 1c

Central Italy 30 (5.0) 566 (95.0) 0.68 (0.43–1.06) 18 (14.8) 104 (85.2) 0.69 (0.38–1.24) Southern Italy and islands 78 (7.7) 946 (92.3) 1.07 (0.76–1.49) 52 (24.4) 162 (75.6) 1.33 (0.85–2.06)

Note. OR = odds ratio; CI = confidence interval. aRow percentages. bORs were estimated using unconditional multiple logistic regression models after adjustment for sex, age, level of education, smoking status, and geographic area. cReference category.

Figure 1. Percent distribution and corresponding 95% confidence interval of never, current, and ex-smokers according to support of a ban of e-cigarettes in selected areas (Italy 2013). Overall, 14% to 17% of subjects had no opinion on the statements and were therefore excluded by the present analysis.

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& Abrams, 2012; Popova & Ling, 2013), we observed a higher prevalence of e-cigarette users among the youngest age group, where 11.6% had tried at least once an e-cigarette. Of concern is also the non-negligible proportion of adolescents having tried the e-cigarette in our sample (7.4%; 95% CI  =  2.2%–12.6%, based on 99 adolescents aged 15–17  years). We found more- over that e-cigarette users had most frequently an intermedi- ate level of education, in line with a U.S.  study (McMillen, Maduka, & Winickoff, 2012). Current smokers with an inten- tion to quit within the next 6 months more frequently reported e-cigarette use, in agreement with one study from the United States (Pearson et al., 2012). However, at least other three stud- ies did not find any relation between e-cigarette use and inten- tion to quit tobacco smoking (Adkison et al., 2013; Popova & Ling, 2013; Sutfin, McCoy, Morrell, Hoeppner, & Wolfson, 2013).

Our study adds knowledge on the harm perception of the Italian adult population; while the majority of Italians (65%) believe that e-cigarettes are less harmful than traditional cig- arettes because of the lack of tobacco combustion in e-ciga- rette, 23% of adults still believe that e-cigarettes may be even more harmful than traditional ones. Finally, the large majority of Italians, but also half of current smokers, are favorable to ban e-cigarettes not only on trains, where a regulation ban- ning smoking only in selected wagons is available since 1975 (Legge 584, 1975), but also in all indoor public places, regu- lated by a total ban since 2005 (Gallus et al., 2006).

A limitation of the present survey is the relatively small number of e-cigarette users, which makes estimates unstable. Another limitation is that the questionnaire on e-cigarettes was not validated, and some questions on regular use, intensity of use of e-cigarettes, and its consequences on smoking sta- tus may have been misinterpreted by survey participants. The strengths of this study include the face-to-face survey design and the national representativeness of the sample.

In conclusion, we observe a diffuse awareness of e-ciga- rette—and an increasing diffusion of its use as well—in Italy in less than 3  years from the constitution of the first Italian shop selling e-cigarettes. On the one hand, our data suggest that e-cigarettes may be an alternative to tobacco smoking, since three out of four users reported to have favorably modified their smoking habit (68% reduced smoking consumption and 10% quitted smoking completely) after starting e-cigarette use. On the other hand, 90% of e-cigarette users did not quit smok- ing as a consequence of starting vaping e-cigarettes, and the majority of e-cigarette users remain therefore current smok- ers. This raises concerns on dual use, since decreasing cigarette consumption confers clearly less health benefit than quitting smoking completely (Chapman, 2013). More importantly, almost 900,000 Italian never smokers, particularly the young, have tried at least once this new and potentially addictive product. This suggests that e-cigarette use may be a gateway to nicotine addiction and consequently to tobacco smoking (Benowitz & Goniewicz, 2013; Choi et al., 2012; WHO, 2013).

There is substantial heterogeneity in the composition of various types of e-cigarettes (Benowitz & Goniewicz, 2013; Cameron et al., 2013; Cheah et al., 2012; Flouris & Oikonomou, 2010; Goniewicz, Kuma, et  al., 2013; Trtchounian & Talbot, 2011; WHO, 2013; Williams & Talbot, 2011), and each of these should be monitored on a toxicological and, in principle, epi- demiological level. In particular, the release of nicotine tends to be limited by e-cigarettes but is highly variable (Cameron

et al., 2013; Cheah et al., 2012). Flavors may also release toxic substances, but no adequate data have been published to date. More in general, there is a broad issue of safety and of effi- cacy also in comparative terms with other nicotine releasing devices (chewing gums, patches). A  randomized clinical trial administered to quantify the efficacy of e-cigarette to support smoking cessation was conducted in New Zealand (Bullen et al., 2013). Randomizing 657 smokers to (a) e-cigarette with nicotine, (b) nicotine patch, and (c) e-cigarette without nicotine (placebo), no significant differences in smoking cessation rates at 6 months were observed among the three groups. Cessation rates were 7.3% among users of e-cigarette, 5.8% among those with nicotine patch, and 4.1% among placebo users (Bullen et  al., 2013; Hampton, 2014). At least other two population- based longitudinal studies showed that e-cigarettes have no effect on smoking cessation (Grana, Popova, & Ling, 2014; Vickerman, Carpenter, Altman, Nash, & Zbikowski, 2013).

Despite the increasing number of studies on e-cigarettes (Bullen et  al., 2010; 2013; Caponnetto et  al., 2013; Chen, 2013; Goniewicz, Knysak et al., 2013; Pellegrino et al., 2012; Siegel, Tanwar, & Wood, 2011; Vardavas et al., 2012; Williams, Villarreal, Bozhilov, Lin, & Talbot, 2013; Zhang, Sumner, & Chen, 2013), questions raised over 5  years ago (Pauly et  al., 2007) on the safety of the e-cigarette use and the efficacy of the e-cigarette as a substitute to tobacco smoking have not been adequately elucidated, yet. Only providing answers to those questions it will be possible to understand any risk-benefit bal- ance of e-cigarette on a population level.

FUnding

The work of SG and CLV was partially supported by the Italian League Against Cancer (Milan) and the Italian Foundation for Cancer Research (FIRC).

deClaratiOn OF interests

None declared.

aCknOwledgMents

The survey was conducted with the contribution of the Italian Ministry of Health.

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