International Journal of

Environmental Research
and Public Health

Review
Use of Electronic Cigarettes in European Populations:
A Narrative Review
A. Kapan 1, * , S. Stefanac 1,2 , I. Sandner 1 , S. Haider 1 , I. Grabovac 1 and T.E. Dorner 1
1 Department of Social and Preventive Medicine, Centre of Public Health, Medical University of Vienna,
Vienna 1090, Austria; [email protected] (S.S.); [email protected] (I.S.);
[email protected] (S.H.); [email protected] (I.G.);
[email protected] (T.E.D.)
2 Institute of Outcomes Research, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical
University of Vienna, Vienna 1090, Austria
* Correspondence: [email protected]




Received: 21 January 2020; Accepted: 12 March 2020; Published: 17 March 2020


Abstract: The increasing popularity of electronic cigarettes in past decades has aroused public health
concern. This study aims to review the literature on the prevalence of e-cigarette use among the
general adult and young populations in Europe. We searched Medline and Google Scholar from
September 2019, and included “prevalence of e-cigarettes”, “electronic cigarettes” or “e-cigarettes”,
and “electronic nicotine delivery system” or “vaping”. The prevalence of current e-cigarette use
ranged from 0.2% to 27%, ever-use ranged from 5.5% to 56.6% and daily use ranged from 1% to 2.9%.
Current smokers of conventional cigarettes showed the highest prevalence for the use of e-cigarettes,
ranging from 20.4% to 83.1%, followed by ex-smokers, with ranges from 7% to 15%. The following
socio-demographic factors were associated with a higher chance of using e-cigarettes: male sex and
younger age groups; results for economic status were inconclusive. In European countries, there
is a higher prevalence of e-cigarette use among males, adolescents and young adults, smokers of
conventional cigarettes, and former smokers.

Keywords: prevalence; e-cigarettes; current and ever-use; trend

1. Introduction
Electronic nicotine delivery systems (ENDS) are marketed under a variety of names, most
commonly-referred to as “electronic cigarettes (e-cigarettes),” but also as “e-cigs”, “vapes”, “vape
pens”, and “mods”. These different types of electronic nicotine delivery systems are designed to be
either less harmful than regular cigarettes or used as nicotine replacement therapy (NRT) [1]. The
electronic nicotine device generally consists of a power source, usually a battery, and a heating element
that creates an aerosol that is inhaled by the user after the e-liquid (the solution inside a device) has
been heated to a temperature of above 350 ◦ C [2,3].
There is currently active debate about benefits and harms of e-cigarettes at the individual and
population level. First, there is uncertainty and debate about the degree to which e-cigarettes help
existing smokers to quit. The latest Cochrane Database Systematic Review and meta-analysis found that
participants using nicotine-containing e-cigarettes are approximately two-and-a-half times more likely
to have abstained from smoking for at least 6 months, compared to those using placebo e-cigarettes.
However, the authors have also noted an overall lack of studies and found that the available studies
were of low quality and had generally small sample sizes [4]. A limited number of randomized clinical
trials evaluating e-cigarette use for smoking cessation have been published [5–7], and the results
are conflicting. The latest study mentioned above showed that e-cigarettes were more effective than

Int. J. Environ. Res. Public Health 2020, 17, 1971; doi:10.3390/ijerph17061971 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 1971 2 of 22

NRT [7]. However, it is important to note that this study also differs from an earlier trial [5] in that
participants demonstrated motivation to quit a priori. Moreover, given the constant emergence of
new studies, our as-of-yet unpublished meta-analysis found that e-cigarettes with nicotine showed a
tendency to be effective in smoking cessation, as compared to placebo e-cigarettes without nicotine.
However, the level of evidence was moderate to low, and the analysis results were not significant [8].
Further, little common ground is found among health organizations regarding the question of
e-cigarette use in smoking cessation. For example, Public Health England supports e-cigarette use
for smoking cessation [9], whereas US health agencies concluded there is insufficient evidence to
recommend e-cigarettes use for cessation [10,11]. The National Academies of Sciences raised concerns
due to unanswered questions regarding long-term health effects in users, as reports suggest that
e-cigarettes may damage various organ systems [12]. Moreover, the Centers for Disease Control and
Prevention (CDC) has declared an ongoing epidemic of e-cigarette or vaping use associated with lung
injury (EVALI) throughout the United States [13,14]. As of 7 January 2020, vaping-related lung injuries
have caused 57 confirmed deaths in 27 states and the District of Columbia. Data show that vitamin E
acetate, an additive in some tetrahydrocannabinol- (THC) containing e-cigarettes, is strongly linked to
the EVALI outbreak, while vitamin E acetate has not been found in the lung fluid of people that do
not have EVALI. For this reason, the CDC recommends that people not use e-cigarette products that
contain THC [15].
While vaping e-cigarettes may represent a form of harm reduction for adult smokers, there
are concerns about potential harm for adolescents, including the risk that ENDS use may act as a
gateway to smoking cigarettes among young people [16]. As a meta-analysis from 2016 shows, among
never-smoking adolescents and young adults, e-cigarette use was associated with increased smoking
intention, as compared to peers who did not use e-cigarettes [17].
In order to estimate the impact of e-cigarettes (both positive and negative), it is important
to understand the prevalence of e-cigarette use in the general population. Several studies on the
prevalence of e-cigarette use have been already published [18–21]. However, these are mostly based in
the United States of America, with few focusing on the European continent. This may be problematic as
cultural and public health differences may prohibit generalizations of US-based results on the European
context. Furthermore, with the growing availability of e-cigarettes, an update of the prevalence is
important [22]. In light of such a rise in scientific interest and the number of publications, we aim to
carry out a narrative review of the available literature on e-cigarette use in European population.

2. Materials and Methods

In order to perform a narrative review of available literature on prevalence of e-cigarette use,
we conducted a literature review in September 2019 in Medline and Google Scholar using the terms
“prevalence of electronic cigarettes use”, “e-cigarettes use”, “electronic nicotine delivery system”,
“vaping”, and “frequency of e-cigarette use”. The reference lists of articles that were found were
additionally screened for potential articles.
The retrieved articles were screened for content and were selected if (1) they were written
in English, if (2) the data provided population-based estimates of e-cigarette use in adults and/or
adolescents from one-or more countries of the WHO European region, and (3) if the article was
published in a peer-reviewed journal (4) between 2011 and 2019. Full text articles were obtained only if
the abstracts included data about the prevalence of e-cigarettes with a cross-sectional or a longitudinal
design. Collectively, we summarized the results describing the themes relevant to prevalence and
factors of e-cigarette use. If more studies on the same prevalence data were given, data were shown
in ranges (minimum to maximum as percentage); otherwise the prevalence values were shown as
single percentages.
Int. J. Environ. Res. Public Health 2020, 17, 1971 3 of 22

3. Results
Overall, 22 studies were included in the review (Table 1). Of these, 4 of them included data from
multiple countries [22–25], and 18 studies presented data from single countries [26–43]. All included
studies were either cross-sectional studies, or cross-sectional baseline findings of longitudinal studies.
The sample sizes ranged from 726 to 27901 subjects.
Int. J. Environ. Res. Public Health 2020, 17, 1971 4 of 22

Table 1. Prevalence of e-cigarette use among the general population.

Citation Data Source Country Sample Characteristics Findings

• Respondents who have at least tried e-cigarettes: 15%,

• Respondents who have tried them once or twice but do not use them currently: 9% overall,
• Respondents who currently use e-cigarettes or similar electronic devices: 2%,
• 67% of current users used e-cigarettes daily, 20% reported weekly use, 7% monthly and 6% stated
using e-cigarettes less than monthly;
• Respondents who are daily e-cigarette users: 1%,
• Respondents who used to use them but do not use them anymore: 4%,
• Current conventional smokers:

- who currently use e-cigarettes or similar devices: 4% in EU28

- who used to use e-cigarettes but no longer do so: 10% in EU28
- who tried e-cigarettes once or twice: 23% in EU28,
• Ex-smokers:

- who currently use e-cigarettes or similar devices: 4% in EU28

- who used to use e-cigarettes but no longer do so: 4% in EU28
27901 respondents from - who tried e-cigarettes once or twice: 7% in EU28,
European Commission, Special 28 Member States of the
2017 Eurobarometer survey different social and
Eurobarometer 2017 [22] European Union • Never-smokers:
demographic groups

- who currently use e-cigarettes or similar devices: 0% in EU28

- who used to use e-cigarettes but no longer do so: 1% in EU28
- who tried e-cigarettes once or twice: 2% in EU28,
• Among respondents who have at least tried e-cigarettes socio-demographic differences show highest
prevalence among:

- men (17%) compared to women (12%)

- those aged 15–24 (25%) followed by 25–39 (21%), 40–54 (15%) and 55+ (6%)
- participants that were still studying (19%) followed by those who left full time education at
the age of 16–19 (16%) age 20+ (14%) and age 15 and before (8%)
- manual workers (29%), the unemployed (25%, students (19%), and the self-employed (18%)
followed by other white collars (16%), managers (12%), household persons (8%) and the
retired (6%)
- those who stated having difficulties paying bills “most of the time” (23%) compared to those
who stated having such problems “from time to time” (18%) or “never/almost never” (12%),
Int. J. Environ. Res. Public Health 2020, 17, 1971 5 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of ever e-cigarette use 2014: 11.6%; 2017: 14.6%,

• Statistically significant increases (from 2014 to 2017) in ever-use were found in 15 EU member states,
highest in Belgium (OR = 3.45),
• Ever-use was more likely among:

- men (OR = 1.25) than among women

- younger people aged 15–24 (OR = 8.23) compared to aged 25–39 (OR = 3.71) and 40–54 years
old (OR= 2.10),
- people with more years in education (OR = 1.59 for those completing education at age ≥ 20
2014: 27801 respondents years compared with ≤ 15 years),
2017: 27901 respondents as - former (OR = 7.49) and current tobacco smokers (OR = 22.88) compared to never-smokers,
representative samples of the • Among current cigarette smokers, heavy smokers were more likely to have ever used e-cigarettes
2014 and 2017 Adult Special
28 Member States of the population aged ≥ 15 years in than light smokers (OR = 26.59),
Laverty et al. 2016 [23] Eurobarometer for
European Union each of the 28 EU member states • Current e-cigarette use:
Tobacco Survey
and across the EU in terms of
age, gender and area of - 2014: highest prevalence was in France and the United Kingdom (3.6%) lowest prevalence in
residence. Malta (0%),
- 2017: highest prevalence again in the United Kingdom (4.7%) and France (3.7%) and lowest in
Bulgaria (0.2%),
• Overall current e-cigarette use 2014: 1.5%; 2017: 1.8%, 86.7% of current e-cigarette users reported
current use,
• Among ever e-cigarette users younger people were less likely to have become ever current users (p
for trend across age groups < 0.001),
• Ever-use (OR = 1.46) as well as current use (OR = 1.32) of e-cigarettes were more common in 2017
than in 2014,

• Prevalence of e-cigarette ever-use 2012: 7.2%; 2014: 11.6%,

• EU-wide coefficient of variation in e-cigarette ever-use: 42.1% in 2012 and 33.4% in 2014,
• Ever e-cigarette use in 2014 varied from 5.7% in Portugal to 21.3% in France,
• Several member states showed increased odds of ever e-cigarette use such as Malta (aOR = 5.46),
• Reports of trying e-cigarettes in 2014 were more common than in 2012 (aOR = 1.90),
2012: 26751 respondents • Highest prevalence of having ever tried e-cigarettes was found among:
2014: 26792 respondents as
representative Samples of the - current smokers: aOR = 23.36 compared to never-smokers
2012 and 2014 Adult Special 27 Member States of the
Filippidis et al. 2017 [24] Eurobarometer for Tobacco European Union (excluding
population aged ≥15 years in - former smokers: aOR = 6.54 compared to never-smokers
Survey Croatia)
each of the 27 EU member states - younger people aged 18–24: aOR = 5.75 compared to those aged 55 years and older
(excluding Croatia) and across - those living in urban areas: aOR = 1.21 compared to those living in rural areas,
the EU in terms of age, gender - respondents who completed their education at age 20 or older: aOR = 1.65 compared to those
and area of residence. who completed education at age 15 or younger,
• Proportion of current users among ever-users 2014: 15.3%, varying from 1.7% in Slovenia to 28.9% in
Portugal (Austria: 14.7%),
• Those who tried an e-cigarette to quit smoking had the highest likelihood to be current users
(aOR = 2.82),
Int. J. Environ. Res. Public Health 2020, 17, 1971 6 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Overall e-cigarette ever-use: 43.7%,

• Highest prevalence of ever-use was found among students in Lithuania (56.6%) and lowest
prevalence among students in Russia (33.4%),
• Compared to Belarus, students in Lithuania (OR = 1.97) and Poland (OR = 1.44) were more likely to
try using e-cigarettes, whereas students in Russia (OR = 0.79) were less likely to try using e-cigarettes,
Survey performed between • Mean age of e-cigarette usage initiation: 18.2 ± 2.2 years (approximately 2 years later than initiation
2017 and 2018, as a part of of conventional smoking),
the international multi-center Belarus, Lithuania, Poland, 14,352 university students aged • Current e-cigarette use: 1.1%,
Brozek et al. 2019 [25] • Compared to Belarus, students in all other countries were more likely to currently use e-cigarettes,
cross-sectional study, Young Russia and Slovakia 18–34 years
People E-Smoking Study with odds ratios varying from 1.74 (Slovakia) to 2.37 (Lithuania),
(YUPESS) • Current dual use of traditional cigarettes and e-cigarettes: 1.8%,
• Compared to Belarus, students in Poland were less likely (OR = 0.93) whereas students in all other
countries were more likely to be dual users with odds ratios varying from 1.07 (Slovakia) to 1.7
(Russia),
• Females were less likely to be ever-users (OR = 0.62), current users (OR = 0.34) or dual users
(OR = 0.33) compared to males,

• Overall prevalence of e-cigarette ever-use: 11.8% of which 70% had only tried out e-cigarettes,
• Prevalence of ever-use among:

- smokers: 32.7%; never-smokers: 2.3%

- ex-smokers who had quit smoking after 2010: 24.5%; ex-smokers who had quit smoking
before 2010: 1.8%
- men: 15%; women: 8%,
• Overall prevalence of current regular use of e-cigarettes: 1.4%,
• Current regular use among:

- current smokers: 4.3%, never-smokers: 0.1%, ex-smokers who had quit smoking after 2010:
5.6%,
2016 computer-assisted • Overall Prevalence of former regular use: 2.2%,
4002 randomly-chosen persons, • Former regular use among:
Eichler et al. 2016 [26] telephone interviews using a Germany
aged 14 and older
figure questionnaire
- current smokers: 6.0%, never-smokers: 0.3%, ex-smokers who had quit smoking after 2010:
8.3%,
• Special groups:

- Age group 20–39: most frequently represented group (2.4% current regular use, 4.4% former
regular use and 16.1% have-tried),
- Blue collar workers: above average use (4.6% for current regular use, 6.4% for former regular
use and 14.2% for have-tried),
- School students: above average in terms of “have-tried” (10.4%) and “former regular use”
(5.9%) but low regarding “current use” (0.7%),
• The most common frequency of e-cigarette use: among current and former users as well as smokers,
smokers who quit in 2010 or later and those aged 20–59,
Int. J. Environ. Res. Public Health 2020, 17, 1971 7 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of e-cigarette ever-use: 25.7%,

• Among these: 23.4% were current vapers, 60% of daily and 47.6% of occasional cigarette smokers
reported lifetime use of e-cigarettes, whereas only 12.3% of ex-smokers and 5.6% of never-smokers
did so,
• Prevalence of lifetime e-cigarette use was highest at age 15–24 years (48.8% of males and 40.7% of
females),
• E-cigarette lifetime-use was lower in females (22.7%) compared to males (28.7%),
• Prevalence of e-cigarette current use: 6%,
• Among these: about half were daily vapers (75% of daily users were smokers and 23.1% were former
smokers),
Representative random sample
2014 Health - 83.1% were smokers, 74.7% were daily smokers and 15% were former smokers (more than
Andler et al. 2016 [27] France of 15635 individuals of the
Barometer Survey 98% of current e-cigarette users were or had been conventional cigarette smokers),
French population aged 15–75
- farm workers, craftsmen, retailers, and business owners who smoked conventional cigarettes
were less likely to use e-cigarettes, compared to those with lower incomes and
the unemployed,
• Prevalence of current e-cigarette use was highest at age 25–34 years (9.6% of males and 6.6% of
females),
• E-cigarette current use was lower among females (5.2%) compared to males (6.8%),
• Prevalence of daily vapers: 2.9%,
• Fewer females (2.3%) than males (3.5%) were daily vapers,
• Prevalence of vaping ex-smokers: 0.9%,
• Average duration of e-cigarette use: 4 months,

• Total prevalence of e-cigarette ever-use was found to be 9.6%, while for current e-cigarette use, it was
2%,
• Prevalence for current e-cigarette use was highest among former daily (3.9%) and current tobacco
smokers (3.3%–3.4%),
• Sex, age, residential area, occupation, and smoking status were significantly associated with ever-use
of e-cigarettes, while education was not
• Highest prevalence of e-cigarette ever-use was stated among:

- females (9.7%): they were 25% more likely than men to be ever e-cigarette smokers
2014 National Survey on the A representative sample of 5385 - those aged 25–34 (13.7%)
Kilibarda et al. 2017 [28] Serbia - those living in urban areas (11.4%), they were 53% more likely than those living in rural areas,
Lifestyle of Citizens of Serbia Serbians aged 18–64 years
• Prevalence of lifetime e-cigarette use was highest among current daily smokers (20.2%), with smokers
generally being three times more likely than non-smokers to have ever used e-cigarettes,
• It was found that sex, age, occupation, and current smoking status were significantly associated with
current e-cigarette use. Highest prevalence was stated among:

- females (2.3%) compared to men (1.6%), those aged 25–44 (3%; 95% CI 2.0–4.0) compared to
those aged 55–64 (1.1%; 95% CI 0.6–1.7)
- intellectual (3.4%), compared to businessman (2.7%), non-active (1.7%), and student (0.9%),
- current smokers (3.3%–3.4%),
Int. J. Environ. Res. Public Health 2020, 17, 1971 8 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Overall prevalence of e-cigarette ever-use: 12%; Ever e-cigarette use was significantly associated with

- daily tobacco use (OR = 19.6) current snus users (OR = 14.2)
- age 15–24 years (OR = 10) age 25–34 (O R= 6.6) age 35–44 (OR = 2.2)
- male (OR = 2.1) females (OR = 1)
- being a student (OR = 2.8 ) unemployed (OR = 1.7)
- 50% of ever-users stated always using nicotine-containing e-liquids
- 40% of daily smokers and half of those currently using snus had at least tried e-cigarettes
- 16% of ever-users reported not knowing whether the e-cigarette they had used contained
nicotine or not,
3485 respondents out of a • Overall prevalence of e-cigarette current use: 2%; Current e-cigarette was significantly associated with
2014 population-based drug
Ruokolainen et al. 2017 [29] Finland representative random sample
survey
(N = 7000) of Finns aged 15–69 - daily tobacco use (OR = 60.6) occasional (OR = 37.8) current snus users (OR = 12.6)
- age 15–24 years (OR = 12) age 25–34 (OR = 11.6) age 35–44 (OR = 5.1)
- male (OR = 2.3) compared to females (OR = 1)
- being unemployed a student (OR = 3.9) student (OR = 2)
- 77% of current users stated always using nicotine-containing e-liquids, 14% sometimes and
9% never using liquids, respectively,
• Daily or almost daily use was most common among current snus users (4.3%) and the unemployed
(2.7%),
• Concerning current e-cigarette users, the smallest percentage of respondents that stated always using
nicotine was found among 15–24-year-olds (47%) and the highest among 25–34-year-olds (65%),

• Prevalence of ever-use: 6.8%,

• E-cigarette ever-use 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,
• Participants with an intermediate level of education were more likely to have ever used e-cigarettes
(prevalence 10.2%, OR = 1.91), compared to those with the education levels was low or high,
• In terms of smoking status, current smokers showed the highest prevalence of ever-use of e-cigarettes
(20.4%) compared to ex-smokers (7%) and never-smokers (2.6%),
3000 individuals aged ≥15 years, • Prevalence current use: 1.2%,
representative for the general • Regular use among men (1.5%) and women (0.9%),
Gallus et al. 2014 [30] 2013 survey on smoking Italy • Regular use among different levels of education was comparable to each other (low 1.0%,
Italian population aged 15 years
and over. intermediate 1.6%, high 0.5%),
• According to age, current use of e-cigarettes was most frequent in those aged 15–24 (2.4%),
continuously decreasing with increasing age until 0.3% among those aged ≥ 65,
• In terms of smoking status, current smokers showed the highest prevalence for current use of
e-cigarettes (3.7%) compared to ex-smokers (2.8%) and never-smokers (0.1%),
• Among current users, 95.5% used e-cigarettes with nicotine and the remaining 4.5% used e-cigarettes
with vapor and flavors only,
• Frequency of use among current users varied from 1 to 70 e-cigarettes per day (mean: 10 overall),
Int. J. Environ. Res. Public Health 2020, 17, 1971 9 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Current e-cigarette use among all adults: 5.5%,

- respondents from the lowest of 5 social grades were twice as likely to use e-cigarettes
compared with those from the highest grade,
- past-year smokers: 21.3%,
Monthly repeat household The Smoking Toolkit Study - respondents from the 3 lowest social grades had significantly lower odds of e-cigarette use
survey between January 2014 involved 1700–1800 adults aged compared with those from the highest grade,
Kock et al. 2019 [31] England - smokers during a quit attempt: 34.6%,
and December 2017 16+ living in households in
(Smoking Toolkit Study) England - no significant associations across the overall period between social grades and prevalence of
e-cigarette use among smokers attempting to quit,
- long term ex-smokers: 5.9%,
- respondents from the second and third lowest social grades were twice as likely to use
e-cigarettes compared with respondents from the highest grade,
- the trend of ex-smokers using e-cigarettes increased from 2014 to 2017 across all social grades,

• Prevalence of ever e-cigarette use: 7.4%,

• Among these: 47.1% were currently non-cigarette users,
• E-cigarette use was significantly associated with younger age groups: those aged 18–24 used more
Survey in public street 1176 adults of any age in six
e-cigarettes (14.2%) than those aged 55 years and over (1.3%),
Jawad et al. 2015 [32] settings conducted between Southeast London (England) southeast, ethnically diverse
March 2013 and March 2014 London boroughs - non-white ethnicities: 14.9%, compared to 5.6% among those of white ethnicity,
- use of waterpipe tobacco: 20.6% of waterpipe tobacco smokers used e-cigarettes compared to
1.5% of non-waterpipe tobacco smokers,

• Prevalence of e-cigarette ever-use: 6.5%,

• Among these, 75% were smokers, 22.9% were former smokers and 2.1% were never-smokers,
• 62.5% of ever-users, used e-cigarettes containing nicotine,
• Highest prevalence of ever-use was found among:
Survey conducted between
May 2013 and February 2014 - men: 8% compared to women (5.3%, OR = 0.69)
A representative sample of the
in the course of the - younger people ≤ 44 years old
Martinez-Sanchez et al. 2014 [33] Barcelona (Spain) adult (≥16 years old) population
longitudinal study, The
of Barcelona (n = 736) - people with intermediate education level: 9.8% (OR = 1.42 compared to low education level),
Determinants of Cotinine - current smokers: 21.1% (OR = 54.57 compared to never-smokers)
phase 3 project - current smokers with a high cigarette dependence score: 46.4% (OR = 3.96 compared to
low-medium cigarette dependence score),
• Overall 1.6% were current e-cigarette users, 2.2% past users and 2.7% had only experimented
with e-cigarettes,
Int. J. Environ. Res. Public Health 2020, 17, 1971 10 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of e-cigarette ever-use: among all students aged 15–24: 20.9%, among high school
students aged 15–19: 23.5%, among university students aged 20–24: 19.0%, among never-smoking
students: 3.2%,
• Prevalence of e-cigarette use within the previous 30 days:

- among all students aged 15–24: 6.9%, among high school students aged 15–19: 8.2%, among
university students aged 20–24: 5.9%,
• Associated with ever-use of e-cigarettes in terms of predicted probabilities was:

20240 students enrolled at 176 - ever-use of cigarettes: 38% vs. 8.8% of those who had never smoked; gender: male 26.9% vs.
A survey among high school 13.9% of girls,
nationally-representative Polish
and university students
high schools and universities, - having a parent or partner who smokes: 23.6% vs. 16.1% of those without smoking parents
Goniewicz et al. 2012 [34] conducted between Poland
aged 15–24 years, of which or partners,
September 2010 and June
13250 responded to questions - living in an urban area,
2011
about e-cigarettes
• Associated with current use of e-cigarettes in terms of predicted probabilities was:

- current smoking: 11.3% vs. 0.8% of those not currently smoking,

- having a parent or partner who smokes: 6.8% vs. 1.5% of those without smoking parents
or partners,
• Highest risk of ever (> 50%) and current e-cigarette use (> 25%) was identified for cigarette smoking
boys, regardless of their age and place of living and who had a parent or partner who also smoked,
• Lowest risk of ever (< 4%) and current e-cigarette use (< 1%) was identified for nonsmoking girls,
regardless of their age, who lived in rural areas and had nonsmoking parents and partners,

• Prevalence of e-cigarette ever-use among all participants: 22%,

- never tobacco users: 10%, ever tobacco users: 33% (OR = 6.7 compared to never tobacco
smokers),
- current tobacco users: 26% (OR = 9.8 compared to never tobacco smokers),
- boys: 22% (OR = 1.3) vs. 22% among girls,
- those whose parents smoked tobacco: 25% (OR = 1.4) vs. 19% among those whose parents
were non-smokers,
- those most or all of whose friends smoked tobacco: 27% (OR = 2.3) vs. 13% among those none
The survey adapted from the 3552 secondary and high school of whose friends were smoking,
Global Youth Tobacco Survey students aged 13–19 years from - those who indicated alcohol consumption: 5% among moderate alcohol consumers–32%
Piotrkowski District
Kaleta et al. 2016 [35] was conducted between Piotrkowski District (2645 among binge drinkers vs. 9% among non-drinkers (OR = 5.3),
(Poland)
November 2014 and May secondary school students and
- those who indicated that e-cigarettes were less harmful than current cigarettes: 21%
2015 907 high school students)
(OR = 1.8) vs. 19% among those who indicated no difference in harmful effects between
e-cigarettes and current cigarettes,
- those who indicated that e-cigarettes were more harmful than current cigarettes: 44%
(OR = 2.7) vs. 19% among those who indicated no difference in harmful effects between
e-cigarettes and current cigarettes,
- those whose mothers had the highest education level: 16% (OR = 0.5) vs. 24% among those
whose mothers had the lowest education level,
- those whose fathers had medium education level: 23% (OR = 1.5) vs. 21% among those
whose fathers had the lowest education level,
Int. J. Environ. Res. Public Health 2020, 17, 1971 11 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of current e-cigarette use in the past month among all participants: 27%,

- never tobacco users: 6%, ever tobacco users: 27% (OR = 7.5 compared to never tobacco
smokers),
- current tobacco users: 58% (OR = 32.5 compared to never tobacco smokers),
- boys: 32% (OR = 1.7) vs. 21% among girls,
- those whose parents smoked tobacco: 33% (OR = 1.4) vs. 23% among those whose parents
were non-smokers,
- those whose most or all of whose friends smoked tobacco: 48% (OR = 4.5) vs. 13% among
those none of whose friends were smoking,
- those who indicated alcohol consumption: 5% among moderate alcohol consumers – 41%
among binge drinkers vs. 12% among non-drinkers (OR = 4.3),
- those who indicated that e-cigarettes were less harmful than current cigarettes: 28%
(OR = 2.1) vs. 29% among those who indicated no difference in harmful effects between
e-cigarettes and current cigarettes,
The survey adapted from the 3552 secondary and high school
- those who indicated that e-cigarettes were more harmful than current cigarettes: 15%
Global Youth Tobacco Survey students aged 13–19 years from
Piotrkowski District (OR = 0.3) vs. 29% among those who indicated no difference in harmful effects between
Kaleta et al. 2016 [35] was conducted between Piotrkowski District (2645
(Poland) e-cigarettes and current cigarettes,
November 2014 and May secondary school students and
2015 907 high school students) - those whose mothers had the highest education level: 13% (OR = 0.5) vs. 32% among those
whose mothers had the lowest education level,
- those whose fathers had the highest education level: 17% (OR = 0.6) vs. 33% among those
whose fathers had the lowest education level,
• Predictors of continued e-cigarette use were:

- male gender: OR = 1.4 compared to female gender

- current tobacco smoking: OR = 3.0 compared never tobacco smoking
- lack of knowledge about a ban on smoking in the school: OR = 1.4 compared to a ban on
smoking in the school,
• Factors that protected from current e-cigarette use were:

- higher parental education: OR = 0.5 compared to a low parental education,

- perception of e-cigarettes as more harmful than tobacco cigarettes: OR = 0.2 compared to the
perception of e-cigarettes being as harmful as tobacco cigarettes,
Int. J. Environ. Res. Public Health 2020, 17, 1971 12 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of e-cigarette ever-use in year 6 primary school children: 5.8%,

• Among these, 3.7% reported using them just once, E-cigarette use was more prevalent among boys
(7.2% vs. 4.6%),
• Secondary school students: 12.3%;
• Prevalence of e-cigarette ever-use among ‘never-smokers’: 5.3% at age 10–11 (Year 6), dropping to 2%
in Year 7, before rising throughout secondary school to 8% by age 15–16 (Year 11),
• Most children in school years 6, 7 and 8 who reported ever-use of e-cigarettes have never smoked
tobacco. Approximately half of Year 9 students have tried tobacco and among students in school
CHETS Wales 2: 1601 school years 10–11, a major proportion has tried tobacco,
Two data sets:2014 Child
children in Year 6 (aged 10–11) • 42.8% of those who had used e-cigarettes on a few occasions stated that they had never
Exposure to Tobacco Smoke
within a nationally smoked tobacco,
(CHETS) survey (‘CHETS
representative sample of 75 • Almost half of those who had tried smoking have tried an e-cigarette compared to only 4.8% of those
Moore et al. 2015 [36] Wales 2’) and 2014 Welsh Wales
primary schools and HBSC: who have never tried tobacco, The percentage of e-cigarette ever-users reporting to be current
Health Behaviour in
9055 school students aged 11–16 smokers increased from 10% at age 10–11 to 40% by age 15–16,
School-aged Children (HBSC)
in a nationally representative
Survey (‘HBSC Wales’) • Compared to never-smokers, the odds for e-cigarette use were more than 16 times greater for children
sample of 82 secondary schools
aged 10–11 years old who had ever smoked tobacco and more than 17 times greater for
current smokers,
• Prevalence of current e-cigarette use in secondary school students: 1.5%,
• Regular use was more likely among those who had smoked tobacco: 80% of current e-cigarette users
reported having also smoked tobacco (RR= 66.30) but 72.1% of young people who had used an
e-cigarette a few times and 43.2% of current e-cigarette users were not current smokers,
• Associations with current e-cigarette use were found for smoking weekly: RR = 121.15, smoking
daily: RR = 115.38, lifetime cannabis use: RR = 53.03,

• Prevalence of e-cigarette ever-use: 17.4%;

• Among these:

- 8.3% were never-smokers

- 12.6% had experimented only once or twice
- 2% had used e-cigarettes more than 20 times
- 65.7% stated use of nicotine e-liquids (among these, 2.9% were never-smokers), 23.5% used
liquids without nicotine and 10.9% did not know whether the liquid had contained nicotine
or not,
• Highest prevalence of e-cigarette ever-use was found among:

A nationally representative - older adolescents for both sexes: 18.4% of 18-year-old girls had tried e-cigarettes once or twice
sample of 9398 individuals aged compared to 0.3% of 12-year-old girls,
2013 nationwide Adolescent
Kinnunen et al. 2015 [37] Finland 12, 14, 16 and 18 years, of which - boys: 20.5% of 18-year-old boys had tried e-cigarettes once or twice compared to 18.4% of
Health and Lifestyle Survey
3535 responded to the 18-year-old girls,
questionnaire
• Factors that protected from e-cigarette use were:

- parents´ high level of education; being in employment; intact family,

• Associated with e-cigarette experimentation was:

- daily smoking: OR = 41.35 compared to never smoking,

- snus use: OR = 2.96 compared to never snus use,
- waterpipe use: OR =2.21 compared to never waterpipe use,
- children´s vocational education: OR = 2.06 compared to general education,
- poor school performance: OR = 1.92 compared to school performance much or slightly better
than class average,
Int. J. Environ. Res. Public Health 2020, 17, 1971 13 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of ever-use of

- e-cigarettes with nicotine: 13.7% (Cohort I), 12.3% (Cohort II)

- e-cigarettes without nicotine: 29.4% (Cohort I), 27.6% (Cohort II)
• In the group of current users the highest frequency of use was detected among those who used
nicotine-containing e-cigarettes (11.1 in Cohort and 9.3 in Cohort II)) compared to those using
e-cigarettes without nicotine (7.9 in Cohort I and 4.8 in Cohort II),
Cohort I: 6819 adolescents from
The survey among cohort I • Compared to never using cigarettes, ever having used a conventional cigarette was associated with
19 secondary schools across the
was conducted in 2014–2015 ever-use of e-cigarettes with nicotine: OR = 20.04 (Cohort I), OR = 19.70 (Cohort II),
Netherlands, aged 11–17 years;
Treur et al. 2018 [38] and the survey among cohort Netherlands • Compared to never using cigarettes, ever having used a conventional cigarette was associated with
Cohort II: 2758 adolescents from
II was conducted in ever-use of e-cigarettes without nicotine: OR = 13.17 (Cohort I), OR = 7.31 (Cohort II),
14 educational institutes in the
2016–2017 • Highest prevalence of ever-use was found among:
Netherlands, aged 14–21 years
- those aged 16–17: OR = 1.9 (Cohort I) for ever-use of e-cigarettes with nicotine compared
to 11–13-year-olds,
• E-cigarette ever-use was less likely among girls compared to boys;

- OR = 0.52 (Cohort I), OR = 0.65 (Cohort II) for ever-use of e-cigarettes with nicotine,
- OR = 0.51 (Cohort I), OR = 0.53 (Cohort II) for ever-use of e-cigarettes without nicotine,

• 2013 prevalence of having experienced e-cigarettes among respondents: 17.9% (boys: 19%, girls:
16.8%) compared to 9.8% in 2012,
• Experimentation rate increased with advancing age from 5% (12-year-olds) to 30% (16-year-olds),
• E-cigarette experimentation was highest among daily smokers (63%), followed by occasional smokers
(38.7%), former smokers (37.3%) and non-smokers (7.1%),
• E-cigarette experimentation was significantly associated with

- age: OR = 0.66 for participants older than 15 years compared to those age 15 or younger,
- having ever smoked a cigarette: OR = 4.46 compared to never smoking a cigarette,
- smoking less than 10 cigarettes: OR = 2.28 compared to non-smoking,
A randomly selected,
- smoking 10 cigarettes or more: OR = 5.67 compared to non-smoking,
2013 repeated school-based representative sample of 2% of
Dautzenberg et al. 2015 [39] Paris (France) - best friends being smokers: OR = 1.54 compared to the best friend being non- or ex-smoker,
survey schoolchildren (n = 3279) of the
city of Paris aged 12–19 years - siblings being smokers: OR = 1.88 compared to not having siblings, siblings being non-
or ex-smokers,
- experimentation of shisha: OR = 2.60 compared to never using a shisha,
- cannabis use: OR = 1.90 compared to having never used cannabis,
- having one parent who forbids smoking: OR = 1.84 compared to “No prohibition”,
- having two parents who forbid smoking: OR = 2.32 compared to “No prohibition”,
- the kind of school: OR = 0.66 for children attending private schools compared to children
attending public schools,
• Prevalence of use in the last 30 days: 5.6%,
• Prevalence of use in the last 30 days among e-cigarette experimenters: 32.5%,
Int. J. Environ. Res. Public Health 2020, 17, 1971 14 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Prevalence of e-cigarette experimentation: 54%,

• Among these, 20% had never tried standard cigarettes,
• Experimentation with e-cigarettes was predicted by
1486 participants in their first
Survey conducted in Winter Hauts-de-Seine region year of “lycée”, aged 16 years, of - higher age: OR = 1.30 (compared to younger participants in terms of above and below
Rennie et al. 2016 [40] median age),
of 2014–2015 (France) which 1478 answered questions
concerning e-cigarettes - higher socioeconomic status: OR = 1.10 (compared to lower socioeconomic status),
- maternal smoking of standard cigarettes: OR = 1.63 (compared to maternal nonsmoking),
- paternal smoking of standard cigarettes: OR = 1.93 (compared to paternal nonsmoking),
- male gender: OR = 1.21 (compared to female gender),

• Prevalence of e-cigarette ever-use: 24.0%,

• E-cigarette ever-use was found to be more likely among:

- young men: 26.5% compared to young women (21.5%, OR = 0.73)

- students in designated disadvantaged schools: 32.6% (OR = 1.77) compared to students in
A representative sample of 821 non-disadvantaged schools (20.6%)
2014 survey on e-cigarette young people from 16 - current tobacco smokers: 69.5% (OR = 54.85 compared to non-smokers) compared to
Babineau et al. 2015 [41] use, tobacco use, and socio- Ireland secondary schools in their fifth ever-smokers (30.4%, OR = 11.20 compared to non-smokers) and never-smokers (4.2%)
demographic items year of secondary school, aged - young people born in Eastern Europe: 44.4% compared to 21.9% among those born in Ireland
16–17 and 23.6% to those born elsewhere,
• Prevalence of current e-cigarette use: 3.2%,
• Prevalence of current e-cigarette use among current smokers: 10.6%,
• On-going e-cigarette use was just predicted by male gender with females being less likely than males
to use e-cigarettes on a current basis (OR = 0.38),

• Prevalence of e-cigarette ever-use was 26%;

- e-cigarette with nicotine was 13%; without nicotine was 10%,

- without knowing whether they contained nicotine was 6%,
• Identified risk factors for e-cigarette ever-use were:

- smoking conventional cigarettes (OR = 14.6 compared to never smoking) having tried
2014 survey as part of a study cigarettes (OR = 5.6 compared to never smoking),
665 participants from four
on “School as a setting for - having tried snus (OR = 2.2 compared to never using snus),
municipalities in compulsory
Geidne et al. 2016 [42] ANDT (Alcohol, Narcotics, Sweden
school, grade 9 - using or having used alcohol (OR = 4.4 compared to never using alcohol),
Doping, Tobacco)
(15–16-year-olds) - having smoked a water pipe (OR = 3.2 compared to never smoking a water pipe),
prevention” - not living with both parents (OR = 2.2 compared to always living with both parents),
- having older siblings (OR = 1.7–1.8 compared to not having siblings),
- not enjoying school (OR = 2.7 compared to stating very good/good school satisfaction),
• Having many books at home indicated less use of e-cigarettes (OR = 0.5–0.6 compared to having few
books at home),
• Participants from southern Sweden smoked e-cigarettes more (50% ever-use) than those in the other
two municipalities (17% ever-use in western municipalities),
Int. J. Environ. Res. Public Health 2020, 17, 1971 15 of 22

Table 1. Cont.
Citation Data Source Country Sample Characteristics Findings

• Use of e-cigarettes in the past 12 months among:

- all participants: 4.9%; among these, 12.0% used them daily,

Analysis as part of the Cohort - current smokers: 9.3%; among these, 12.2% used them daily,
Study on Substance Use Risk 5081 young Swiss men enrolled
- former smokers: 1.6%; among these, 13.6% used them daily,
Douptcheva et al. 2013 [43] Factors (C-SURF), with data Switzerland during mandatory visits at
collected between August army recruitment centers - never-smokers: 0.4% (no daily use),
2010 and February 2013 • E-cigarette use among current smokers was significantly associated with secondary education:
OR = 1.5 compared to tertiary or primary education,
• German-speaking region: OR = 1.3 compared to French-speaking region,

Note: CI = confidence interval; OR = odds ratio; aOR = adjusted odds ratio; RR = relative risk ratio; bold indicates the prevalence of e-cigarette ever-use, current, current, or daily use
Int. J. Environ. Res. Public Health 2020, 17, 1971 16 of 22

3.1. Prevalence of Using E-Cigarettes in the General Population

In Table 1, the findings regarding the use of e-cigarettes in the general population are summarized.
The prevalence of current e-cigarette smokers (the definition of current use of e-cigarettes varied among
the surveys, from “vaped at least one e-cigarette in the last 30 days” to “at least one e-cigarette per
day at the moment of the survey”) ranged from 0.2% to 27%, those who reported ever trying ranged
from 5.5% to 56.6%, and between 1% and 2.9% were found to be daily e-cigarette users. There were
differences in age among participants who had tried e-cigarettes. The highest prevalence was found
among those aged 10–24 years (5.5% to 56.6%), followed by those aged 25–39 (13.7% to 25%), 40–65 (5%
to 6.7%), and those aged ≥ 65 years (1.3% to 1.6%). For example, in a sample of 5385 Serbians, there
were about 3 times more current e-cigarette users among 25–44-year-olds than among 55–64-year-olds
(3% vs. 1.1%) [28]. It seems to point to a trend that with increasing age, the use of e-cigarettes decreases.

3.2. Spacial Differences in Using E-Cigarettes within the WHO European Region
European regions showed a varying picture; southern regions showed similarities, with the
reported prevalence of ever-use in Italy and Spain ranging from 5.6% to 6.5%. In northern regions,
however, the prevalence ranged from 12% to 17.4% in Finland, to up to 26% in Sweden. We also
observed differences between western and eastern European regions. Low prevalence was mostly
found in western European countries, with the following prevalence rates: France (17.9% to 54%)
Netherlands (29.4%), Ireland (24%), Germany (11.8%), England (7.4%), Wales (5.8%), and the lowest
prevalence in Switzerland (4.9%). In comparison, highest prevalence was reported among eastern
European countries, with highest being in Lithuania (56.65%), followed by Poland (20.9% to 45%),
Belarus (42.7%), Slovakia (34.4%), Russia (33.4%), and with considerably lower prevalence of ever-use
being reported in Serbia (less than 10%). Thus in general, the results indicate higher prevalence among
eastern WHO European region countries.

3.3. Gender and Ethnic Difference

Men showed higher prevalence rates of e-cigarettes use than women. In included studies, men
showed up to 5 times higher prevalence of e-cigarette use than women. Further, daily use was more
common among men (1.5%) than among women (0.9%). In the study of Jawad et al. (2015), differences
among ethnic groups are reported. When comparing Caucasians with other ethnicities, studies report
more use among other ethnic groups (14.9% versus 5.6%; adjusted OR 1.76, 95% CI 1.13 to 2.73) [32].

3.4. Socio-Economic Differences

Studies from Italy [30] and Spain [33] show that participants with secondary school education
were more likely to have ever used e-cigarettes than those who reported their educational level as being
“low” or “high”. Current use among participants with differing educational levels ranged from 0.5%
in those reporting high educational level, to 1% in those with low, and 1.6% in those with secondary
level. Different results are shown in an English study reporting differences in e-cigarette use, in which
smokers with a higher social grade (based on occupation) also showed higher e-cigarette use than
those with a lower social grade [31]. The use of e-cigarettes in long-term ex-smokers increased over
time among all groups, and was far more common in groups with lower socio-economic status. In the
analyses, respondents were stratified by socio-economic status using the National Readership Survey
classification system for social grade based on the occupation of the main income earner, which has
useful discriminatory power as a target group indicator [31]. In addition, a study from Poland shows
that participants whose parents had a primary-level education indicated current e-cigarette use more
frequently than those whose parents had a tertiary-education level [35].
In terms of employment status and household income, the odds of being an ever e-cigarette user
increased with lower income and unemployment (OR = 2.9), as compared to those with employment
and higher income. Among respondents who had at least tried e-cigarettes, socio-economic differences
Int. J. Environ. Res. Public Health 2020, 17, 1971 17 of 22

showed the highest prevalence among the unemployed (25%), manual workers (29%), students (19%),
and the self-employed (18%), followed by other white-collar workers (16%), managers (12%),
housewives (8%), and retired persons (6%) [22].

3.5. E-Cigarette Use and Smoking Status

Current smokers of conventional cigarettes showed the highest prevalence for ever-use of
e-cigarettes, ranging from 20.4% to 83.1%. This is followed by ex-smokers, with prevalence rates
ranging from 7% to 15%. Using e-cigarettes was rare among non-smokers, with a prevalence ranging
from 2.3% to 5.6% for ever-use. For example, a cross-sectional survey of a French population aged
15–75 years old showed that more than 98% of current e-cigarette users were, or had been, conventional
cigarette smokers [27].
The concern that young people who use e-cigarettes may be more likely to smoke cigarettes in
the future [44] can be partly confirmed by the study of Treur et al. (2018) [38]. Adolescents who ever
used an e-cigarette with nicotine were 11.90 more likely (95% CI 3.36 to 42.11) to smoke a conventional
cigarette 6 months later than those who never used an e-cigarette with nicotine. On the contrary,
the odds of smoking a conventional cigarette 6 months after smoking an e-cigarette without nicotine
were 5.36 (95% CI 2.73 to 10.52) and 5.36 (95% CI 2.78 to 10.31) for water pipe. An additional study
shows that the percentage of e-cigarette ever-users and reported current smokers increased from 6.9%
among 10–11-year-olds to 39.2% among 15–16-year-olds. Current use of e-cigarettes was more likely
among those who had previously smoked tobacco. Eighty percent of current e-cigarette users reported
having also smoked cigarettes, compared to 72.1% of young people who had used an e-cigarette a few
times, and 43.2% of current e-cigarette users were not current smokers [36].

3.6. Type of E-Cigarette Used (Nicotine or Non-Nicotin)

One study reports that 77% of the current e-cigarette users always used nicotine-containing
e-liquids, 14% sometimes, and 9% never used nicotine-containing e-liquids. Fifty percent of ever-users
stated always using nicotine-containing e-liquids [29]. Another study shows that among current users,
95.5% used e-cigarettes with nicotine and the remaining 4.5% used e-cigarettes with vapor and flavors
only [30]. In contrast in Spain, 62.5% of ever-users tended to use e-liquids with nicotine [33].
A different picture can be seen in the younger population. One study shows that 65.7% of
e-cigarette ever-users tended to use nicotine e-liquids (among these, 2.9% were never-smokers), 23.5%
used liquids without nicotine, and 10.9% did not know whether the liquid had contained nicotine or
not [37]. In addition, adolescents in Sweden reported more use of e-cigarettes with nicotine (13%)
compared to e-cigarettes without nicotine (10%) [42]. In a Dutch cohort however, the prevalence of
ever-use of e-cigarettes with nicotine was 13.7% (11 to 17 years) and 12.3% (14 to 21 years), respectively,
whereas the prevalence of e-cigarette use without nicotine was 29.4% (11 to 17 years), and 27.6% (14 to
21 years), respectively. In the group of current users, the mean number of times used in the past month
was highest for e-cigarettes with nicotine, or 11.1 (SD = 14.5) in 11–17-year-olds and 9.3 (SD = 13.9)
in 14–21-year-olds, compared to those using e-cigarettes without nicotine, 7.9 (SD = 12.0) and 4.8
(SD = 9.5), respectively [38].

3.7. Trends in Using E-cigarettes

Time trends in using e-cigarettes can be derived from the Eurobarometer, which was carried out
in 2014 and 2017 with similar methods [22,23]. Data show that 1.5% (95% CI 1.2 to 1.8) of the adult
population in the European Union in 2014 were currently e-cigarette users, compared to 1.8% (95% CI
1.5 to 2.1) in 2017, respectively. Additionally, the prevalence of e-cigarette ever-use increased from 2012
(7.2%) to 2017 (14.6%) [23].
Int. J. Environ. Res. Public Health 2020, 17, 1971 18 of 22

3.8. Reasons for E-cigarette Use

The most frequent reasons for starting the use of e-cigarettes were to stop or reduce tobacco
consumption (61%), because e-cigarettes were seen as less harmful (31%), had lower costs (25%),
and that e-cigarette use is allowed in areas where regular tobacco smoking is not (15%); other reasons
included different flavors (12%), that friends were also taking up e-cigarette smoking (11%), and that
e-cigarettes were perceived as cool or attractive (6%) [22]. A study by Filippidis et al. (2017) of adults
from 27 European countries shows that the main reason for using e-cigarettes among current e-cigarette
users was that they believed e-cigarettes could help them quit smoking, and because they wanted to
circumvent smoking bans [24].
A further study of people aged 14 years or over from Germany found that the main reasons for
e-cigarette use in ever-users were “curiosity” (59%), followed by “quitting tobacco use or nicotine use”
(29.1%), “complement to smoking” (7.8%), and “other reasons” including taste and lower price (2.1%).
Current e-cigarette users most frequently named “quitting tobacco or nicotine use” (52%), followed by
“complement to smoking” (25%), and “curiosity” (12.5%) as their reasons. Among smokers, “quitting
tobacco or nicotine use” (46%), and among young people, “curiosity” (73%) were the main reasons for
e-cigarette use [26].
The reasons for e-cigarette use found by Andler et al. (2016) in a survey of adults from France
were addiction to nicotine (three quarters of e-cigarette users), the consideration of e-cigarettes being
less harmful than conventional cigarettes (named by 60% of dual users and 80% of former smokers who
vaped), e-cigarettes being less expensive (stated by 66% of dual users and 71% of vaping ex-smokers),
and being permitted in places where conventional cigarettes are banned (reason for 28% of dual users
and 20% of vaping ex-smokers). They also found that among dual users, 69.4% wanted to quit smoking
conventional cigarettes, as compared to 54.2% among non-vaping smokers [27].

4. Discussion
The results of our review show that the European population’s lifetime-prevalence of using
e-cigarettes is high, whereas prevalence of current daily smoking of e-cigarettes is quite low. In 2018,
3.2% of US adults reported current e-cigarette use [45], which is similar to our findings in the WHO
European region. However, there are major differences in subpopulations in Europe. Our review shows
much lower prevalence of e-cigarette use among older adults who have never smoked. However, the
prevalence seems to be on the rise. In summary, daily e-cigarette use was much more common among
smokers or former smokers [23]. There was evidence of variation in e-cigarette use by ethnicity and
region. For example, the survey by Jawad et al. (2015) found that there was more e-cigarettes use
among non-Caucasian ethnic minorities [32]. This is in line with a four-country survey (Canada, USA,
United Kingdom, and Australia) from 2013 [46] that found that there was generally higher awareness
of e-cigarette use among the Caucasian ethnicity compared with non-Caucasian ones. There are other
disparities, such as spatial differences in e-cigarette use. People from eastern European countries
used e-cigarettes more often than the European regional average. This may be due to differences in
tobacco control policies and different accessibility to tobacco. For instance, Czech Republic, Slovakia,
and Poland have weak implementation of smoke-free public rooms, especially in the hospitality
industry [47]. Further, in poorer countries, people tend to smoke more; socioeconomic inequality
is apparent in initiation: the risk that young people will start smoking is higher in less privileged
groups [48]. Such disparity calls for possible policy interventions that can help accelerate the reduction
of e-cigarette use in these areas.
Studies show that adolescents who ever used an e-cigarette with nicotine were more likely to smoke
cigarettes in the future [38,44]. A large proportion of current e-cigarette users reported having also
smoked cigarettes, but almost three-quarters of young people who had used an e-cigarette a few times,
and almost half of current e-cigarette users, were not current smokers [36]. Further, among young adults,
experimentation with e-cigarette use increased with advancing age, among daily smokers, best friends
being smokers, and those whose siblings were smokers. [39,42]. Young males were also slightly
Int. J. Environ. Res. Public Health 2020, 17, 1971 19 of 22

more likely to experiment with e-cigarettes than females. The data suggest that peers may influence
experimentation in young populations [37,39,40]. Another reason of e-cigarette experimentation may
also be that sensation-seeking, or the need for new, different, or complex sensations and experiences-and
the willingness to take risks to achieve them-is associated with adolescent substance use [49]. Further,
studies shows that sweet flavors and smells are disproportionately appealing to youth, and are cited
as a primary reason for use among this age group relative to adults [50]. On the basis of the above,
regulation of flavor chemicals in e-cigarette products should be addressed, given that preferences for
specific sweet flavors predicted e-cigarette use exclusively among youth. Overall, these results provide
some support for the hypothesis that e-cigarettes act as a gateway to conventional cigarette smoking,
though other explanations for the association are possible. The findings of high prevalence of use
among adolescents and young adults suggest that e-cigarettes have the potential to expand the nicotine
market in these age groups and may have the effect of renormalising smoking. Further monitoring
and research to investigate these issues is required.

Limitations & Directions for Future Research

One limitation is that only one author conducted the narrative review process. It is possible
that another reviewer may have included additional information. However, our study is based on
published evidence and offers an overview of the use of electronic cigarettes in European populations.
The findings are limited by the quality of the methods of the surveys in the included studies. For
example, some questionnaires were not validated, thus the extent to which they capture true prevalence
is unclear, as is the extent to which this affected the internal validity of the findings. Furthermore,
wording of questions assessing e-cigarettes may have changed, potentially introducing misclassification
bias. A lack of a unified definition of what constitutes “use” of an e-cigarette is also a challenge for
the survey research, while measures should aim to also capture, for example, “current daily use” or
other factors.

5. Conclusions
Overall, the results suggest that e-cigarettes are used predominantly by smokers and former
smokers. There is a higher prevalence of e-cigarette use among males, adolescents, and young adults,
as well as within populations of eastern European countries. For adolescents and young adults,
additional research is recommended to identify whether e-cigarettes encourage or reduce uptake of
smoking and support smoking cessation.

Author Contributions: I.G., S.H. and T.E.D. conceived the original idea. I.S. conducted the literature search.
A.K. and T.E.D. provided strategies for data analysis and interpretation. A.K. and S.S. drafted the manuscript.
All authors provided significant input to the submitted manuscript and approved its submission.
Funding: This research was funded by the Health Insurance Group of Styria (STGKK). The views expressed in
this publication are those of the authors and do not necessarily reflect the views of the funding agency.
Conflicts of Interest: The authors declare no conflict of interest. The funding institution had no role in the
interpretation of the data or in the writing of the manuscript.

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