18B.3 Extent of use

Last updated:  May 2020  

Suggested citation: Greenhalgh, EM, Scollo, MM, & Jenkins, S. 18B.3 Extent of use. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from:  http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes

 

In many countries, including Australia, the use of e-cigarettes is growing, with the majority of users being current and former smokers.1-4

18B3.1 Trends in use of e-cigarettes in Australia

The National Drug Strategy Household Survey asked respondents about e-cigarettes for the first time in 2013, and in 2016, asked additional questions about frequency of use. Prevalence of e-cigarette usage among Australian smokers, non-smokers (including ex- and never smokers), and persons 12 years and over for both survey years is set out in table 18B.3.1.

Table 18B.3.1 
Lifetime e-cigarette use by smoking status and age, 2013 and 2016  

 

Source: National Drug Strategy Household Survey 2016 key findings, Table 81

*Estimate has a relative standard error of 25% to 50% and should be used with caution

# Statistically significant change between 2013 and 2016.

(a) Smoked daily, weekly or less than weekly.

(b) Includes both those who have never smoked more than 100 cigarettes and those who have smoked more than 100 cigarettes but report no longer smoking at time of survey 

Note: The question about lifetime use of electronic cigarettes was modified in 2016 and may have impacted how people responded question.

About 9% of the general population aged 18 and over reported in 2016 having ever used e-cigarettes. At 19.2%, lifetime use was highest among young adults aged between 18 and 24 years, with use gradually decreasing by age. Lifetime use of e-cigarettes significantly increased between 2013 and 2016 both among adult smokers (from about 18% to about 31%) and non-smokers (never + ex-smokers; from about 2% to about 5%), and across all age groups except for the oldest. In 2016, the highest rates of ever use appeared to be among 18–24-year-olds (49.1% and 13.6% of smokers and non-smokers, respectively, compared to 30.8% and 4.7% in the total adult population).

Frequency of e-cigarette use by smoking status in 2016 is presented in table 18B.3.2. The overall rate of use among never smokers remained low, with 96.1% of adult never smokers reporting that they had never tried e-cigarettes (compared with 98.7% in 20135). Among ex-smokers, 7.5% reported ever-use, compared with 3.1% in 2013.5

Although almost one-third of smokers had tried e-cigarettes in 2016, only 4.4% reported current use (daily, weekly, or monthly).

Table 18B.3.2 
Frequency of e-cigarette use, people aged 14 years or older, 2016 (per cent)

 

Source: National Drug Strategy Household Survey 2016 key findings, Table 91

*Estimate has a relative standard error of 25% to 50% and should be used with caution

** Estimate has a high level of sampling error (relative standard error of 51% to 90%), meaning that it is unsuitable for most uses 


Further analysis of the 2016 National Drug Strategy Household Survey showed that individuals who were male, younger, had higher psychological stress and were current smokers were more likely to be e-cigarette users. Smoking status had the strongest relationship with e-cigarette use.6 Another survey, this time looking at young Australian adults (18­25-years-olds), found positive expectancies about e-cigarettes were associated with increased curiosity and intention to use e-cigarettes.7

An online community survey of adults in New South Wales found that 13% had ever used an e-cigarette and, of those, 34% had used an e-cigarette in the past month. Among ever e-cigarette users, 4.6% reported regular daily use over the previous month. Participants who were younger, as well as current and ex-smokers, were more likely to have used e-cigarettes, while women with higher levels of education and income were less likely.8 

Among Australian secondary school students, in 2014, 13% reported that they had ever used an e-cigarette. Use increased with age, from 5% of 12-year-olds to 22% of 17-year-olds, and boys were significantly more likely than girls to report ever-use. Recent (past-month) use was reported by 3% of students, and also increased with age: 5% of 17-year-old students indicated they had recently used an e-cigarette compared with 2% of 12-year-olds.9 Three per cent of all students had used e-cigarettes exclusively, while 11% reported having concurrently used e-cigarettes with tobacco cigarettes and/or shisha-tobacco. Of the 14% of students who had ever used an e-cigarette, 12% used them exclusively, 55% had used shisha-tobacco, and 65% had smoked tobacco cigarettes at least once in their lifetime. Of the 20% of students who had smoked tobacco cigarettes in their lifetime, 47% had ever used e-cigarettes.10

Researchers have also examined the extent of e-cigarette use and understanding among Australian Aboriginal and Torres Islander smokers, and found that in 2013–14, about one fifth (21%) had tried e-cigarettes. Forty-one per cent had never tried e-cigarettes, and the remaining 38% had not heard of the products.11

 

18B.3.2 International trends in use of e-cigarettes

International Tobacco Control (ITC) Surveys data show wide variation in the prevalence of use of e-cigarettes between countries surveyed, which may be attributable to a range of factors, including but not solely differences in regulatory approaches.  In a study published in 2014, there was considerable cross-country variation by year of data collection and for self-reports of ever having tried e-cigarettes (Australia, (20% in 2013), Malaysia (19% in 2011), Netherlands (18% in 2013), United States (15% in 2010), Republic of Korea (11% in 2010), United Kingdom (10% in 2010), Mexico (4% in 2012), Canada (4% in 2010), Brazil (3% in 2013), and China (2% in 2009)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).12, 13 Another ITC study found that in 2014, prevalence of current e-cigarette use in the UK was more than twice that of Australia (28.2% vs. 11.9%), and prevalence of daily use in the UK was about four times that of Australia (9.2% vs. 2.5%).14 Findings from the 2016 ITC survey of adult smokers and/or e-cigarette users in the US, England, Australia and Canada showed that 11% were dual users (people who both smoke and use e-cigarettes).15 The same survey showed that daily vapers most commonly used refillable nicotine vaping products, generally containing flavours and nicotine.16 Current use of e-cigarettes among adult never-smokers appears to be consistently less common than among smokers, with reported overall prevalence of less than 1% in the UK,4 Australia,1 New Zealand,17 Canada,18 and the US.19 

In 2016 in the US, 15.4% of adults had ever used an e-cigarette, and 3.2% currently used e-cigarettes;19 3.8% of men and 2.6% of women reported being a current user.20 Adults aged 18–24 years were the most likely to have ever used an e-cigarette (23.5%) and to currently use e-cigarettes (4.5%); the percentages declined steadily with age. Across all age groups, fewer than one quarter of adults who had ever used an e-cigarette reported current use.19 Between 2014 and 2018 the percentage of US adults that had ever used a cigarette increased from 13.0% to 15.7 % 21 In 2015, among current e-cigarette users (3.5%), 58.8% also were current smokers, 29.8% were ex- smokers, and 11.4% were never smokers. Among current e-cigarette users aged 45 or over, almost all (98.7%) were either current or ex-smokers, and 1.3% had never been smokers. In contrast, among current e-cigarette users aged 18–24 years, 40.0% had never been cigarette smokers.2 Another study found that in 2016, 1.4% of never smokers reported vaping, and of these users, about 60% were young adults aged 18 to 24.22 Unlike older age groups, where prevalence remained steady, the percentage of current e-cigarette users increased from 5.1% of 18­­–24-year-olds in 2014 to 7.6% in 2018.23, 24  Among current e-cigarette users in 2012-13, one survey found that use was most commonly infrequent (fewer than 4 days per month;38.1%) while 29% reported daily use.25 Within the US, current e-cigarette use by state was highest in Oklahoma (6.7%) and lowest in DC (2.4%) as of 2016.26

Despite the sale and advertisement of e-cigarettes being banned in Mexico, a nationally representative survey conducted in 2016 found 1.1% of teenagers, 0.3% of adult non-smokers and 4.5% of adult smokers were current users.27 In Brazil in 2015, 0.46% of the population were e-cigarette users.28

In 2015, 13.2% of Canadians aged 15 and over reported having ever tried an e-cigarette; 3.2% had used one in the past 30 days, and 1.0% reported daily use. Use of e-cigarettes increased significantly between 2013 and 2015 (from 8.5% to 13.2%), and prevalence was greater among smokers: 51.0% of current smokers had ever used e-cigarettes in 2015, compared to 7.6% of non-smokers (including ex- and never-smokers); past-month use was 15.5% among current smokers and 1.4% among non-smokers.18

In the UK in 2019, it was estimated that 7.1% of adults were currently using e-cigarettes, compared with 1.7% in 2012. Of these, just over half (54.1%) were ex-smokers, while 39.8% reported dual use (using both conventional and e-cigarettes).4, 29 Adults aged 35–44 years were most likely to be current users (9.5%), followed by 45–54-year-olds (9.3%), 25–34 year-olds (7.8%), 18–24-year-olds (4.3%) and over-55-year-olds (5.6%).30 In the EU, the prevalence of ever-use of e-cigarettes increased from 7.2% in 2012 to 11.6% in 201431 to 14.6% in 2017.32 In 2017, 1.8% of adults were current regular e-cigarette users; the UK (4.7%) and France (3.7%) had the highest prevalence, while Italy (0.2%) and Bulgaria (0.2%) had the lowest. Almost two in five (37.9%) current smokers reported having tried e-cigarettes, which was higher than for ex-smokers (15.7%) and never smokers (2.7%).33 In Poland, a 2019 study found 4.0% of participants had used e-cigarettes and 1.4% were current e-cigarette users.34 In Germany in 2015, 2.9% of 18–64-year-olds reported having used e-cigarettes in the past month.35

In New Zealand in 2016, ever use and current use of e-cigarettes were estimated to be 17% and 2% respectively. 36 In 2014, prevalence was highest among current smokers (49.9% ever-use and 4.0% current use), followed by ex-smokers (8.4% ever-use and 0.1% current use) and never smokers (3.4% ever-use and 0.1% current use).37

In Malaysia in 2016, ever-use and current use of e-cigarettes were 11.9% and 3.2% respectively. Prevalence was highest among current smokers (34.3% ever-use, 10% current use), followed by ex-smokers (15.4% ever-use, 4.3% current use) and never smokers (3.1% ever-use and 0.6% current use). 38 E-cigarette use is more common in smokers who are young (18–44-year-old), male, single, students and living in urban areas.39, 40

In Korea, between 2013 and 2016, ever use and current use of e-cigarettes were 7.7% and 2.0% respectively. Prevalence was highest among current smokers (28.8% ever use, 8% current use), followed by ex-smokers (7.3% ever use, 1.5% current use) and never smokers (0.4% ever use and 0.1% current use). E-cigarette use was also more common in younger age groups, males and lower socioeconomic groups.41

In China, a series of city-wide surveys in 2013--14 found 2.9% of respondents had used e-cigarettes and 0.8% were current users, most of whom were tobacco smokers (93.0%).42 Another study of young adults (19–29 years) in China found 24.5% were e-cigarette users, though only 2.3% were frequent users.43

Results from the 2016 ITC survey of Australia, England, US and Canada showed that  participants with alcohol problems and depression were more likely to be e-cigarette users.44 Other predictors of e-cigarette use include lifetime mental health conditions and psychological distress.45 46 Another study showed e-cigarette users had on average higher state-trait anxiety as well as more open and neurotic personality traits compared to a non-user sample.47 A study of young adults in the US found marijuana and alcohol use, both dually and exclusively, increased likelihood of current e-cigarette use.48 E-cigarette users are more likely than non-users to engage in high risk behaviour such as the use of non- prescribed pain-killers, sedatives, tranquilizers and Ritalin.49 Another study of young adults found childhood maltreatment was associated with e-cigarette use.50 A  large US study in 2014-16 found that while smoking is associated with lower socioeconomic status, e-cigarette use showed no association with income or education level.51 Another study in the US found that white smokers with higher-incomes were more likely to exclusively use e-cigarettes than African American, Hispanic and low-income smokers, who tended to view tobacco smoking as less harmful and more socially acceptable.52 A survey of young adults in France found that lifetime e-cigarette use was associated with low socioeconomic status, smoking, positive perception of e-cigarettes, asthma, and overweight/obesity, while current use was only associated with smoking and positive perceptions.53 In Germany in 2015, users were more likely young, male and tobacco smokers.54

18B.3.3 International trends in use among teenagers

Awareness of and experimentation by children and adolescents are growing in some countries, and it is of note that experimentation with e-cigarettes may be more common among non-smoking youth than among non-smoking adults. A review of e-cigarette use among adolescents found that use was more likely among those who were male, older, had a higher amount of pocket money, and had more tobacco smoking-related characteristics, such as regular and heavier smoking, and having peers who smoke.55 Another study found adolescents who experience depressive symptoms are more likely to use e-cigarettes and even more so if they have a parents with depression.56 In Korea and Canada studies found use of e-cigarettes was associated with illicit drugs and alcohol use.57, 58

Multiple studies have found the majority of teenage e-cigarette users use flavoured e-liquids/refills, fruit flavours being the most common.59-61 In the US, past month flavoured e-cigarette use was highest in teenage e-cigarette users (97%), followed by young adult users (96.8%) and adult users (81.2%).62

National data from the US show that in 2019, e-cigarettes were the most commonly used tobacco product among high school (27.5%) and middle school (10.5%) students. In 2019, 21% of e-cigarette users in high school and 9% of users in middle school reported using e-cigarettes daily. There was a nonlinear increase in e-cigarette use between 2011 and 2019 among middle school (0.6% to 10.5%) and high school students (1.5% to 27.5%). 63-67 Decreases in cigarette and cigar use during 2011–2016 were offset by increases in hookah and e-cigarette use, resulting in no significant change in any tobacco use; in 2016, 20.2% of high school students and 7.2% of middle school students reported current use of any tobacco product.68 Though in 2019 overall tobacco use rose to 31.2% of high school students and 12.5% of middle school students due to the increase in e-cigarette use.63 An analysis of trends from 2011 to 2015 found that in all years, e-cigarette use was associated with use of cigarettes and other tobacco products; however, over time, past month e-cigarette users increasingly comprised those who had never used other tobacco products (from 0.1% in 2011 to 1.8% in 2015 for girls and 0.2% to 2.9% for boys).69

In the US, use of JUUL branded e-cigarettes (see Section 18B.1) is particularly high among adolescents. In 2018 an estimated 7.6% of 15–17-year-olds and 1.5% of 13–14-year-olds had ever-used a JUUL e-cigarette.70 In 2019, among current e-cigarette users, an estimated 59.1% of US high school students and 54.1% of middle school students reported JUUL as their usual e-cigarette brand in the past 30 days.63 A two wave study found a pattern of graduation in the type of e-cigarettes system used.  Most adolescents who used non-rechargeable or refillable in the first wave, progressed to using rechargeable and refillable e-cigarette systems by the second  wave.71

In Canada in 2017, 6.3% of 15–19-year-olds reported having used an e-cigarette in the past 30 days, unchanged from 6.3% in 2015 and greater than the 2.6% in 2013. In 2016-17, 5.4% of Canadian students in grades 7–9 reported having used an e-cigarette in the past 30 days, compared to 3.9% in 2014-15.72 Data from various surveys of 11–16-year-olds across the UK show that for 2015-16, ever-use of e-cigarettes ranged from 7% to 18%, and regular (at least weekly) use ranged from 1% to 3%. Among never smokers, ever-use ranged from 4% to 10%, with regular use between 0.1% and 0.5%. Among regular smokers, ever-use ranged from 67% to 92% and regular use 7% to 38%. One survey indicated an increase in the prevalence of ever use of e-cigarettes from 7% (2016) to 11% (2017), but the prevalence of regular remained stable at 1%.73 In 2019 in Great Britain, 2% of 11–18-year-olds reported using e-cigarettes at least weekly, 3% reported using them once a month or less, and 10% had tried them just once or twice. Use increased with age; 8.5%% of 11–15-year-olds and 26.7% of 16–18-year-olds reported having tried an e-cigarette, and at least weekly use increased from 1.1% for 11–15-year-olds to 2.5% of 16–18-year-olds. Six per cent of never smokers reported ever use of e-cigarettes, compared with 46% of former smokers and 76% of current smokers.74, 75 Relative to the US and Canada, little increase has been seen between 2017 and 2018 in England.76

In New Zealand, ever-use of e-cigarettes among teenagers is steadily increasing from 33.3% in 2018 to 37.3% in 2019 and daily use has increased from 1.8% in 2018 to 3.1% in 2019.77, 78 A study in Switzerland found that in 2012, 43% of adolescents had ever tried e-cigarettes, with 19% of them being experimenters and 24% users (i.e., used several times or regularly).79 Awareness and ever-use of e-cigarettes increased significantly among Finnish adolescents from 2013 to 2015; ever-use increased from 17.4% to 25%.80 In Poland, ever-use and current use of e-cigarettes in teenagers aged 15–19 increased from 16% and 5.5% respectively in 2010–11, to 62% and 30% in 2013–14. Current use of e-cigarettes (use in past 30 days) in teenagers aged 15–19 increased from 5.5% in 2010–11 to 29.9% in 2013–14.81 Ever use among 15-year-olds in Greece in 2014 was 16.6%, and most of this was experimentation (0.5% reported current e-cigarette use).82 In Serbia, 6.2% of 13–15-year-olds had recently used e-cigarettes according to a 2017 survey.83 In Italy the estimated percentage of 13–15-year-olds using e-cigarettes has increased from 7.4% in 2014 to 17.5% in 2018 while the prevalence of tobacco cigarette use has remained about 20%.84 In 13 Eastern European urban areas, one-third of adolescents had used e-cigarettes, and one in five had used e-cigarettes three or more times; 2.6% of never cigarette smokers had used e-cigarettes at least three times.85  In 2017, 52% of French 17-year-olds had tried e-cigarettes, and 8% of those who had recently used  e-cigarettes had never tried tobacco cigarettes.86 Over onequarter (28.6%) of Russian adolescents reported having ever used an e-cigarette in 2015, and 2.2% reported past-month use. Ever smokers were substantially more likely to have tried e-cigarettes.87

A survey of middle school students in China in 2013–14 found that prevalence of e-cigarette use was 1.2% and prevalence of e-cigarette awareness was 45.0%.88 A 2017 study of middle and high school students the Zhejiang province, found 2.15% had used e-cigarettes in the past month.89 In South Korea in 2015, the prevalence of e-cigarette ever and current (past 30 days) use among adolescents was 10.1% and 3.9%, respectively.90 In Malaysia, a 2019 study of adolescents found 9% had used e-cigarettes in the past month. 91In Indonesia, a 2018 study of high-school students found 32.2% had used e-cigarettes and 11.8% were current e-cigarette users.92

 

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References

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