E-Cigarette: A New Tobacco Product for Schoolchildren in Paris

doi:10.4236/ojrd.2013.31004

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Open Journal of Respiratory Diseases, 2013, 3, 21-24

http://dx.doi.org/10.4236/ojrd.2013.31004 Published Online February 2013 (http://www.scirp.org/journal/ojrd)

E-Cigarette: A New Tobacco Product for

Schoolchildren in Paris

Bertrand Dautzenberg1,2,3,4, Pierre Birkui1, Maryvonne Noël5,

Johanna Dorsett2, Monique Osman1,2, Marie-Dominique Dautzenberg2,6,7

1Paris Sans Tabac (PST), Paris, France

2Office Français de Prévention du Tabagisme (OFT), Paris, France

3Groupe Hospitalier Pitié-Salpêtrière (APHP), Paris, France

4Université Pierre et Marie Curie, Paris, France

5Rectorat de l’Académie de Paris, Paris, France

6Hôpital Necker Enfants-Malades, Paris, France

7Université René Descartes, Paris, France

Email: [email protected]

Received January 13, 2013; revised February 3, 2013; accepted February 10, 2013

ABSTRACT

Objectives: To explore if the dramatic decrease in price of e-cigarette has transformed this new product into a product

used for tobacco initiation among a teenage population. Methods: The authors added a question in 2012 on e-cigarette

in the yearly survey on tobacco consumption in Paris schoolchildren. The study is conducted on a randomly selected

sample from 2% of classes since 1991. Results: 277 (8.1%) of the 3409 schoolchildren studied (including 575 non re-

sponders to this question) reported having had an experience with e-cigarette. Experimentation rate is 6.4% among the

12 - 14-year-old, 11.8% among the 15 - 16-year-old and 9% among the 17-year-old schoolchildren. Among the 12 - 14-

year-old schoolchildren, 64.4% of e-cigarette experimentation was by non-smokers. Of the 17-year-old teenagers who

had used e-cigarettes, 12.4% were non-smokers. For the whole population, 33.2% of those having tried e-cigarette are

non-smoker, 22.7% occasional smoker, 3.6% ex-smoker and 40.4% daily smoker. Those who experiment cannabis, shi-

sha or binge-drinking are more frequently users of e-cigarette. In the smoker group, there is an inverse trend of rela-

tionship between the readiness to quit tobacco and the rate of use of e-cigarette. Conclusion: For teenager’s, e-cigare-

ttes have become not a product to aid quit tobacco but a product for experimentation and initiation of cigarette use.

Regulation is urgently needed to control the emergent use of this new tobacco product by children.

Keywords: E-Cigarettes; Teenagers; Tobacco Initiation; Epidemiologic Study

1. Introduction

The principle of the e-cigarette was born to an idea by

Herbert A. Gilbert, who on 1965 patented a device that

shares the main characteristics of e-cigarettes [1]. The

history of e-cigarette then restarted at the beginning of

XXI century. The invention of e-cigarettes is attributed to

Hon Lik, Chinese pharmacist [2]. The first prototype of

electronic cigarette uses a lithium battery to produce en-

ergy to vaporize glycerol and a nicotine solution through

a piezoelectric device. The beginning of each puff is con-

trolled by an on demand valve. The ultrasonic production

of aerosol has since been replaced by a heating element

in commercialised e-cigarettes. The device was first in-

troduced to the Chinese domestic market in May 2004 as

a support for smoking cessation. Then export began in

2005-2006, before an international patent in 2007 [1].

The efficacy of e-cigarettes for tobacco cessation has not

been shown [3]. Many health authorities refuse to say

that this product is beneficial for smoking cessation in

the absence of studies. More recently this product has

been sold for use where smoking is banned [4], but many

site managers of private or public places, such as airlines

companies [5], have taken the initiative to ban indoor e-

cigarette use. Now this product is most often sold as a

new, cool alternative to smoking. E-cigarette is cheap be-

cause they are not taxed as tobacco products and because

recently new disposable e-cigarettes has been marketed.

This cheap product potentially provides a gateway for to-

bacco use in teenagers due to a price decrease from 60 -

100 € to less than 6 - 10 €. This present study was con-

ducted to see whether the concern that e-cigarettes has

become a new product for tobacco initiation use in tee-

nagers is justified or not. We had introduced a question

about the e-cigarette in the yearly cross-sectional survey

conducted by Paris Sans Tabac [6].

B. DAUTZENBERG ET AL.

2. Methods

A cross-sectional survey is conducted yearly with a one

page questionnaire by Paris Sans Tabac on 2% of stu-

dents randomly selected by class provided a representa-

tive sample of the 188,000 schoolchildren of Paris. Ano-

nymous questionnaires were distributed and collected

with the help of Paris School authorities. The study pro-

vides yearly data on smoking among Parisian schoolchil-

dren with the same methodology since 1991. A question

about e-cigarettes was added in 2012, like one we had

added a question about shisha ten years ago. This ques-

tion is “have you ever used an e-cigarette?”

The non-independence between smoking status and ex-

perimentation of e-cigarette has been assessed by Chi-2

test. The relative risk (RR) with 95% confidence interval

was used to compare experimentation of e-cigarette ac-

cording to the other use of substances.

3. Results

A total of 3409 schoolchildren from 12 to 19 years old

were questioned during the first quarter of 2012. 49.5%

were girls. The mean age of this population is 15.3-years.

In this population the percentage of occasional tobacco

smoker’s increases from 6% to 12% between 12 and 14-

year-old, then remains close to 12%. The rate of daily ciga-

rette smoking increases from 5% for 13-year-old school-

children to 25% for 18-year-old schoolchildren.

A total of 277 teenagers from the study report to have

used e-cigarettes, 2557 never used and 575 provide no

answer to this question (83.2% answer rate). Among the

schoolchildren who have ever used e-cigarettes, 47 report

to have never used regular cigarettes (18.6% of ever

e-cigarette users).

The percentage of teenagers reporting experimentation

of e-cigarettes is 6.4% for 12 - 14-year-old schoolchil-

dren, 11.8% among 15 - 16-year-olds, 19% among 17-

year-old and drops down to 9.3% for the 18 - 19-year-

old schoolchildren. Until the age of 17 years, more girls

have experienced e-cigarettes than boys, with a maxi-

mum experimentation rate at age 17 for girls (23.2%)

(Figure 1).

The experimentation rate of e-cigarette changes accor-

ding to smoking status (Chi-2 test, P < 0.05): 4.4% of

non-smokers, 16.4% of occasional smokers, 19.6% of ex-

smokers and 33.4% of regular smokers have tried using

e-cigarettes. But as smoking regular cigarettes is low in

12 - 14 year old schoolchildren, 64.4% of those who tried

e-cigarette in these young teenagers are not regular ciga-

rette smokers.

Among the 421 daily smoking teenagers, 112 had tried

e-cigarettes (26.7%). The rate of e-cigarette users tend to

be lower for those who plan to quit now (26%), or in the

next 6-month period (25%), compare for those who plan

Figure 1. Percentage prevalence of the teenagers, separately

among girls and boys and age of those who had experiment-

ed on e-cigarettes assessed through the question: “have you

ever used an e-cigarette?” of the PST 2012 survey on 3409

Parisian schoolchildren.

to quit tobacco later (37%) or don’t plan to quit smoking

at all (33%) An inverse relationship trend exists between

ever use of e-cigarette and intent to quit regular smoking.

(RR 1.58; IC 95%: 0.89 - 2.80).

Experimentation of e-cigarette is more frequent among

a 12 - 15-year-old teenage population who have ever

used shisha (RR = 6.75; IC 95%: 4.84 - 9.41) and much

more frequent in the 16 - 19-year-old population who

have ever used shisha (RR = 14.81; IC 95%: 7.54 -

29.06).

Experimentation of e-cigarettes is more frequent in the

12 - 15-year-old teenage population who had ever used

cannabis (RR = 5.52; IC 95%: 4.15 - 7.35) and as the 16

- 19 year old population (RR = 9.09; IC 95%: 6.12 -

13.50).

Experimentation of e-cigarette is more frequent in 12 -

15-year-old teenagers who had experimented more than 4

times with more than 3 alcohol glasses the same day (RR

= 8.60; (IC 95%: 5.71 - 12.96) as in the 16 - 19 year old

population (RR = 3.44; IC 95%: 2.94 - 4.03).

4. Discussion

This is one of the first studies to our knowledge which

reports data on use of e-cigarettes in European teenagers.

In our study, e-cigarettes appeared recently on the French

market and rapidly became a familiar product to young

Parisian schoolchildren. This 12 - 15-year-old teenager’s

school population produces a good picture of the general

population of Paris. For the 16 - 19-year-old teenagers,

the sample is representative of Paris school population,

but not of the general population because some teenagers

leave school then they are 16-year-old and many 16 -

19-year-old teenagers from suburbs of Paris come in Pa-

ris to follow the last years of school. The rate of cannabis

use or experimentation of binge-drinking among teena-

gers is quite different according to gender, but the expe-

rimentation of e-cigarette is quite equally distributed in

both genders. Users are mostly 14 - 17-year-old (10.6 %

in girls vs. 9.1% in boys (NS)). The older teenagers (18 -

19-year-old) had a lower rate of ever use of e-cigarette,

B. DAUTZENBERG ET AL. 23

probably because they were not exposed to e-cigarette

before initiation of regular-cigarette-smoking habit, at a

time where disposable e-cigarette were not available. The

experiment tobacco cigarette or shisha is mainly 14 - 17-

year-old teenagers in the PST studies. Our data are com-

patible with the same age of experimentation for e-ciga-

rette.

In our study there is a clear link between experimenta-

tion of cannabis, shisha or binge-drinking and the expe-

rimentation of e-cigarette among a population of teena-

gers. There is also a strong link with the tobacco smoking

status, but there is no positive link in our teenage smok-

ers between ever use of e-cigarette and the intent to quit

tobacco. In our study the trend was inversed. E-ciga-

rette is used by teenagers in Paris to experiment new sen-

sations, not to decrease tobacco use. E-cigarette is clearly

a product of initiation to cigarette, not a product for to-

bacco cessation in this teenager population.

Four studies are available on the use of e-cigarettes

from Medline research in November 2012.

A consumer-based mail-in survey [7] was completed

in the US by 10 587 adults (≥18-year-old) in 2009 and

10,328 adults in 2010. Ever use more than quadrupled

from 2009 (0.6%) to 2010 (2.7%). Use of e-cigarette was

most common among women and those with lower edu-

cation. Current tobacco users, as in our study, were most

likely to try e-cigarettes. However, current smokers who

had tried e-cigarettes did not say they planned to quit

smoking more often than smokers who had never tried

them, as in our study in teenagers.

A study among US adults report data from 2 surveys

conducted in 2010 [8]: a national online study (n = 2

649) and the Legacy Longitudinal Smoker Cohort (n =

3658) who report another online survey. The use of e-ci-

garette was higher among current smokers (11.4%, 95%

CI: 9.3 - 14.0) than in former smokers (2.0%, 95% CI:

1.0 - 3.8) or in never-smokers (0.8%, 95% CI: 0.35 -

1.7).

A study conducted in Korea used the data from the

2008 Health Promotion Fund Project [9] those who had

tried e-cigarettes among adolescents in five schools in

Korea. Overall, 444 (10.2%) students responded as hav-

ing seen or heard of e-cigarettes. Only twenty-two stu-

dents who had seen this product reported as having used

an e-cigarette (0.5% of the student study population).

The contact routes of information on e-cigarettes were

the Internet (249, 46.4%), friends (150, 27.9%), televi-

sion (59, 11.0%), books (50, 9.3%), and others (29,

5.4%). This data had been conducted before the availa-

bility of disposable e-cigarettes.

More recently in Poland a large survey conducted in

high schools en 2011 [10] reported that 23.5% of stu-

dents aged 15 to 19 had ever use e-cigarettes and that

8.2% had done so within the previous 30 days. It is in the

same range but higher than reported among Parisian stu-

dents in our study. As in our study, in Poland a signifi-

cant number of never smoker’s students reported ever

used of e-cigarettes (3.2%).

Compared to publish studies, our 2012 study reports in

teenagers an experimentation ten times higher than the

experimentation rate of Korean students in 2008, two

times higher than in the US adult population in 2010, but

lower than the polish study. The use of e-cigarettes in

non-regular cigarette smokers and the general consump-

tion in our teenager study are high. In adults, a US study

shows no link with intent to stop tobacco. In our teenager

study there is an inverse correlation: daily smoking te-

enagers who plan to quit soon are less often ever users of

e-cigarettes.

E-cigarette ever use is in high expansion in teenagers.

The majority of experimentation of e-cigarette in 12 - 14-

year-old occurs in non-smokers. E-cigarette ever use in

smokers who plan to quit soon was less than in those

who don’t plan to quit. E-cigarette is used as other new

tobacco products. To prevent this initiation and this use

as an initiation tobacco product, we recommend regulat-

ing e-cigarettes as it is done for other tobacco products

(or medicine), to prohibit any promotion and sale in

shops or on the Internet to teenagers under 18 years old.

The new project of EU directive on tobacco product [11]

opens a room with article 18 for regulation of product

other than tobacco who deliver nicotine. The prevention

of use of e-cigarette by teenagers is need in this new

regulation.

5. Acknowledgements

This work was conducted with help of Paris school au-

thorities (Rectorat de l’Académie de Paris); PST is sup-

ported by the Paris section of National Insurance (CPAM)

and OFT receives a support of the French Ministry of

health (DGS) to assess e-cigarettes.

REFERENCES

[1] http://www.google.com/patents?id=RjlUAAAAEBAJ&pr

itsec=abstract&zoom=4&source=gbs_overview_r&cad=0

#v=onepage&q&f=false

[2] Kcancer, “2010 Kcancer Hero Mr Hon Lik,” 2010.

http://www.prlog.org/10588774-hon-lik-2010-kcancer-he

ro-nominee.html

[3] R. Polosa, P. Caponnetto, J. B. Morjaria, G. Papale, D.

Campagna and C. Russo, “Effect of an Electronic Nico-

tine Delivery Device (E-Cigarette) on Smoking Reduction

and Cessation: A Prospective 6-Month Pilot Study,” BMC

Public Health, Vol. 11. No. 786, 2011, pp. 1-12.

[4] M. Laugesen, “Nicotine Electronic Cigarette Sales Are

Permitted under the Smokefree Environments Act,” The

New Zealand Medical Journal, Vol. 123, No. 1308, 2010,

pp. 103-105.

B. DAUTZENBERG ET AL.

[5] International Air Transport Association, “Electronic Ciga-

rettes” 2012.

https://www.iata.org/whatwedo/safety/Documents/guidan

ce-electronic-cigarettes.pdf

[6] B. Dautzenberg, P. Birkui, J. Rubal, L. R. França and M.

P. Duflot, “Decrease in Smoking by Parisians Students

after the Launch and Implementation of a National Can-

cer Prevention Plan,” Santé Publique, Vol. 17, No 4,

2005, pp. 519-530. doi:10.3917/spub.054.0519

[7] A. K. Regan, G. Promoff, S. R. Dube and R. Arrazola,

“Electronic Nicotine Delivery Systems: Adult Use and

Awareness of the ‘E-Cigarette’ in the USA,” Tobacco Con-

trol, Vol. 22, No. 1, 2013, pp. 19-23.

doi:10.1136/tobaccocontrol-2011-050044

[8] J. L. Pearson, A. Richardson, R. S. Niaura, D. M. Vallone

and D. B. Abrams, “E-Cigarette Awareness, Use, and Harm

Perceptions in US Adults,” American Journal of Public

Health, Vol. 102, No. 9, 2012, pp. 1758-1766.

doi:10.2105/AJPH.2011.300526

[9] J. H. Cho, E. Shin and S. S. Moon, “Electronic-Cigarette

Smoking Experience among Adolescents,” Journal of Ado-

lescent Health, Vol. 49, No. 5, 2011, pp. 542-546.

doi:10.1016/j.jadohealth.2011.08.001

[10] M. L. Goniewicz and W. Zielmska-Danch, “Electronic

Cigarette Use among Teenagers and Young Adults in Po-

land,” Pediatrics, Vol. 130, No. 4, 2012, pp. 879-885.

doi:10.1542/peds.2011-3448

[11] Commission Européenne, “Proposition de Directive du

Parlement Européen et du Conseil Relative au Rappro-

chement des Dispositions Législatives, Réglementaires et

Administratives des États Membres en Matière de Fa-

brication, de Présentation et de Vente du Tabac et de Ses

Produits,” 2012.

http://ec.europa.eu/health/tobacco/docs/com_2012_788_fr

.pdf