Abstract:

Given the uncertainties regarding electronic cigarettes’ (e-cigs) impact on health, in 2009 Brazil prohibited sales, importation or advertisements of these products until manufacturers are able to show they are safe and/or effective in smoking cessation. This study sought to analyze: (1) awareness of electronic cigarettes, ever-use and recent use; (2) perception of harmfulness of electronic cigarettes when compared with conventional cigarettes; and (3) correlates of awareness and perception of harmfulness. This is a cross-sectional study among Brazilian smokers (≥ 18 years) using the Wave 2 replenishment sample of the Brazilian International Tobacco Control Policy Evaluation Survey. Participants were recruited in three cities through a random-digit dialing sampling frame between October 2012 and February 2012. Among the 721 respondents, 37.4% (n = 249) of current smokers were aware of e-cigs, 9.3% (n = 48) reported having ever tried or used e-cigs and 4.6% (n = 24) reported having used them in the previous six months. Among those who were aware of e-cigs, 44.4% (n = 103) believed they were less harmful than regular cigarettes (low perception of harmfulness). “Low perception of harmfulness” was associated with a higher educational level and with having recently tried/used e-cigs. Despite restrictions to e-cigs in Brazil, 4.6% of sample smokers reported having recently used them. Health surveillance programs in Brazil and other countries should include questions on use and perceptions of e-cigs considering their respective regulatory environments.

Keywords:
Electronic Cigarettes; Nicotine; Tobacco Products

Introduction

Use of electronic nicotine delivery systems (ENDS), of which e-cigarettes (e-cigs) are the most popular, is increasing rapidly in some countries ¹1. Wells Fargo Securities. Equity research. tobacco talk survey-e-cigarettes a promising opportunity. http://stevevape.com/wp-content/uploads/2012/05/E-Cigs-A-Promising-Opportunity.pdf (acessado em 17/Mai/2012).
http://stevevape.com/wp-content/uploads/... . The tobacco control community is fiercely divided on issues of e-cigs safety, efficacy for smoking cessation ²2. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev 2014; 12:CD010216.^,33. McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. Do e-cigarettes help smokers to quit? Findings from the ITC cohorts in the UK and US surveys (2010-2013). ?http://www.akleg.gov/basis/get_documents.asp?session=30&docid=12159 (acessado em 11/Ago/2015).
?http://www.akleg.gov/basis/get_document... whether e-cigs promote youth uptake of cigarette smoking ⁴4. Centers for Disease Control and Prevention. E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012. http://www.cdc.gov/media/releases/2013/p0905-ecigarette-use.html (acessado em 05/Set/2013).
http://www.cdc.gov/media/releases/2013/p... ^,55. Ministry of Social Affairs and Health. Smoking and alcohol consumption among adolescents have decreased, while interest in electronic cigarettes increases. Release 26.6.2013. http://valtioneuvosto.fi/ajankohtaista/tiedotteet/tiedote/en.jsp?oid=389516 (acessado em 28/Set/2013).
http://valtioneuvosto.fi/ajankohtaista/t... , and how these devices should be regulated ⁶6. E-cigarettes: a moral quandary. Lancet 2013; 382:914.^,77. The Lancet Respiratory Medicine. Safety dominates the debate on electronic cigarettes. Lancet Respir Med 2014; 2:429.^,88. Satchell G. Electronic cigarettes - miracle or menace? BBC News UK 2013. http://www.bbc.co.uk/news/uk-21406540 (acessado em 15/Nov/2013).
http://www.bbc.co.uk/news/uk-21406540... ^,99. Letter from 53 scientists to WHO Director-General Margaret Chan generates biggest ever global media coverage on e-cigarettes. Nicotine Science & Policy 2014. http://nicotinepolicy.net/en/n-s-p/1853-letter-from-53-scientists-to-who-dg (acessado em 15/Jun/2014).
http://nicotinepolicy.net/en/n-s-p/1853-... ^,1010. 129 public health and medical authorities from 31 countries write WHO DG Chan urging evidence-based approach to ecigs. Nicotine Science & Policy 2014. http://nicotinepolicy.net/ (acessado em 15/Jul/2014).
http://nicotinepolicy.net/... . Despite this lack of evidence, many countries around the world have banned e-cigs ¹¹11. Institute for Global Tobacco Control. Country laws regulation e-cigarettes: a policy scan. Baltimore: Johns Hopkins Bloomberg School of Public Health; 2015.; and, in the absence of long-term quality data upon which an evidence-based recommendation could be made, the WHO Framework Convention on Tobacco Control (WHO-FCTC) recommended that regulations should: “impede ENDS promotion and prevent uptake by non-smokers, pregnant women, and youth; minimize potential health risks to ENDS users and non-users; prohibit unproven health claims from being made about ENDS; and protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry” ¹²12. WHO Framework Convention on Tobacco Control. Electronic nicotine delivery systems and electronic non-nicotine delivery systems. http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6(9)-en.pdf (acessado em 10/Dez/2014).
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In 2009 the Brazilian Health Regulatory Authority Agency (Anvisa) ¹³13. Agência Nacional de Vigilância Sanitária. Resolução RDC nº 46, de 28 de agosto de 2009. Proíbe a comercialização, importação e propaganda de quaiquer dispositivo eletrônico para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União 2009; 31 ago. published a resolution which made it illegal to sell, import, or advertise ENDS “unless the manufacturer provides scientific evidence on the safety of the device as a substitute for conventional tobacco products and/or effectiveness as a cessation aid”. The resolution covers different kinds of ENDS, liquid cartridges, and accessories regardless of their nicotine content ¹³13. Agência Nacional de Vigilância Sanitária. Resolução RDC nº 46, de 28 de agosto de 2009. Proíbe a comercialização, importação e propaganda de quaiquer dispositivo eletrônico para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União 2009; 31 ago.. To date, there have been no applications made to Anvisa under the resolution. Thus, since 2009, e-cig’s sale have been illegal in Brazil. However, there is evidence that e-cigs are being sold illegally online ¹⁴14. de Almeida LM. Posicionamento da categoria dos cigararos eletrônicos em sites de venda no Brasil [Monografia]. Rio de Janeiro: Instituto Coppead de Administração, Universidade Federal do Rio de Janeiro; 2013. and by street vendors ¹⁵15. Galvão VQ. Cigarros eletrônicos contêm agente cancerígeno, diz FDA. Anunciado como auxiliar para quem quer largar o fumo, produto é ilegal no Brasil e vendido na internet e nos comércios populares. Folha de S. Paulo 2009. http://www1.folha.uol.com.br/fsp/saude/sd2307200901.htm (acessado em 10/Nov/2014).
http://www1.folha.uol.com.br/fsp/saude/s... ^,1616. Edição do Brasil. Cigarro eletrônico é cada vez mais utilizado pela falta de fiscalização. http://www.jornaledicaodobrasil.com.br/site/cigarro-eletronico-e-cada-vez-mais-utilizado-pela-falta-de-fiscalizacao/#sthash.DPVowuvH.dpuf (acessado em 13/Mai/2014).
http://www.jornaledicaodobrasil.com.br/s... ^,1717. Bom Dia Brasil. Flagrantes mostram venda ilegal de cigarro eletrônico no Centro do Rio. http://g1.globo.com/bom-dia-brasil/noticia/2014/04/flagrantes-mostram-venda-ilegal-de-cigarro-eletronico-no-centro-do-rio.html (acessado em 12/Nov/2014).
http://g1.globo.com/bom-dia-brasil/notic... ^,1818. Pesquisa diz que cigarro eletrônico ajuda a fumante a deixar de fumar. http://g1.globo.com/ciencia-e-saude/noticia/2011/02/pesquisa-diz-que-cigarro-eletronico-ajuda-parar-de-fumar.html (acessado em 12/Nov/2014).
http://g1.globo.com/ciencia-e-saude/noti... ^,1919. Carta Capital. O controverso cigarro eletrônico. http://www.cartacapital.com.br/revista/780/o-controverso-cigarro-eletronico-633.html (acessado em 09/Ago/2015).
http://www.cartacapital.com.br/revista/7... .

Given the presence of e-cigs in Brazil, it is important to measure the e-cig use and perceptions among Brazilian smokers. The objectives of this study were to examine the following key measures among a probability sample of smokers in three major Brazilian cities: (1) e-cigs awareness, ever-use, and recent use (≤ 6 months), (2) perceptions of the harmfulness (POH) of e-cigs compared to regular cigarettes, and (3) correlates of awareness and POH.

Methods

Study design and procedures

A cross-sectional analysis was conducted using the Wave 2 replenishment-only smoker sample of the Brazilian International Tobacco Control Policy Evaluation Survey (ITC Brazil). Details of the methodology are reported elsewhere ²⁰20. Fong GT, Cummings KM, Borland R, Hasting G, Hyland A, Giovino GA, et al. The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project. Tob Control 2006; 15 Suppl 3:iii3-iii11.^,2121. International Tobacco Control. Policy evaluation project. Brazil wave 1 and wave 2 technical report. http://www.itcproject.org/files/ITC_BR1-2_Technical_Report_Final_27Feb2014.pdf (acessado em 05/Jun/2015).
http://www.itcproject.org/files/ITC_BR1-... . At Wave 2 new respondents were recruited via a random-digit dialing sampling frame in three cities (Rio de Janeiro, São Paulo, and Porto Alegre) to replace respondents from Wave 1 who were lost to follow up. The interviews were administered in Portuguese by telephone between October 2012 and February 2013.

Study sample

The Wave 2 replenishment smoker sample was a probability-based representative sample of 727 adults (≥ 18 years) who currently smoked cigarettes at least once a month and had smoked at least 100 cigarettes; six were excluded because they did not answer the question about awareness of e-cig. The response and cooperation rates were 22.8% and 98.9%, respectively.

For this report, we analyzed only the replenishment smoker sample because of differences in how “recent e-cigs use” was assessed in the replenishment survey vs. the contact survey (those who had participated in the previous survey wave). In addition, the demographic profiles of the two samples were very different (Table 1). These differences negated the possibility of combining the two samples. We chose to conduct analyses for this paper on the replenishment sample because it consisted of probability samples of each of the three cities, and, thus, inferences could be drawn about the population of smokers in each of the three cities.

Measures

Demographic variables included: sex, age, education (elementary school or less, incomplete high school, high school) and monthly household income that was classified as low (< 3 minimum wages, meaning less than BRL 1,866, equivalent to < USD 894), moderate (3-9 minimum wages, meaning an income between BRL 1,866 and BRL 5,598, equivalent to an income between USD 894 and USD 2,683), or high (10 or more minimum wages, meaning an income of BRL 5,598 or higher, equivalent to USD 2,683 or higher).

The smoking-related variables included: smoking frequency (1 = non-daily smoker, 2 = daily “light to moderate” smoker, 3 = daily ‘heavy’ smoker) where daily smokers were those who smoked regular cigarettes at least once a day; Heaviness of Smoking Index (HSI) ²²22. Heatherton TF, Kozlowski LT, Frecker RC, Rickert W, Robinson J. Measuring the heaviness of smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day. Br J Addict 1989; 84:791-9.^,2323. Chabrol H, Niezborala M, Chastan E, de Leon J. Comparison of the Heavy Smoking Index and of the Fagerstrom Test for Nicotine Dependence in a sample of 749 cigarette smokers. Addict Behav 2005; 30:1474-7., a scale for measuring nicotine dependence level consisting of two items (the number of cigarettes smoked per day and time to first cigarette of the day), was derived for daily smokers only, with an overall score ranging between 0-6 (HSI ≤ 3 = light to moderate smoking, and HSI 4-6 = high to very high smoking); and intentions to quit smoking (within 6 months vs. longer/not at all).

Respondents answered questions about e-cigs:

Awareness: “Have you ever heard of electronic cigarettes or e-cigs?” (Responses: yes or no);

Those who answered yes to the awareness question were asked:

Ever-trial: “Have you ever tried an electronic cigarette?” (Responses: yes or no);

Recent use: “In the last 6 months, have you used or tried any of the following products: e-cigs?” (yes or no);

POH compared to regular cigarettes: “Do you think e-cigs are more harmful than regular cigarettes, less harmful, or are they equally harmful to health?” This variable was then categorized into “e-cigs are less harmful than regular cigarettes” versus “no difference” or “more harmful than regular cigarettes” or “does not know”.

Statistical analyses

Descriptive statistics were estimated using unweighted data. All other estimates were weighted to reflect the population prevalence of e-cigs awareness, ever-trial, and recent use. Logistic regression models estimated the association between sociodemographic and smoking-related covariates on awareness and POH (“less harmful than regular cigarettes” vs. other responses; limited to those aware of e-cigs). Regression models adjusted for: sex, age (continuous), education, income, city of residence, intention to quit, and smoking frequency. Data were analyzed using Stata 12.0 (StataCorp LP, College Station, USA), accounting for the complex sampling design.

Results

Differences in demographic and smoking-related variables between the Wave 2 recontact and replenishment samples are presented in the Table 1.

Replenishment sample - sociodemographic and smoking profile (Table 2): 67.3% of respondents were female, the average age was 50.8 years, and 37.4% of respondents lived in São Paulo City, Brazil. 44.8% reported having attained high school or further degree, and 47.5% earned a moderate monthly household income; 54.2% were planning to quit beyond 6 months (or not quit at all), and 71.2% of respondents were daily “light-moderate” smokers.

Awareness: 37.4% (249/721; 95%CI: 32.8%-42.3%) of current smokers were aware of e-cigs. Younger, better-educated smokers were more likely to be aware of e-cigs than their counterparts (adjusted p-value = 0.042 and < 0.001, respectively) (Table 2). Ever-use: 9.3% (48/721; 95%CI: 6.5%-13.3%) of smokers reported having ever tried e-cigs. Recent use: 4.6% (24/721; 95%CI: 2.8%-7.4%) of smokers reported having used or tried e-cigs in the last 6 months.

POH compared to regular cigarettes: among smokers who were aware of e-cigs, 44.4%, (n = 103/249; 95%CI: 36.8%-52.3%) believed e-cigs were less harmful than regular cigarettes (i.e., had “low POH”), 20.6% (n = 57/249) thought they were equally harmful, 2.7% (n = 7/249) thought they were more harmful, and 32.4% (n = 82/249) did not know. “Low POH” was associated with being better-educated, having recently used/tried e-cigs, and being a daily “light-moderate” smoker, as compared to daily ‘heavy’ smoker (adjusted p-values = 0.024, < 0.001, and 0.047, respectively) (Table 3).

Discussion

This study examined e-cig awareness and use in Brazil, a country with strict regulatory requirements. Brazilian smokers’ awareness of e-cigs (37.4%) was lower than in other ITC countries without such requirements (Netherlands, 88%; United States, 73%; Republic of Korea, 79%; and United Kingdom, 54%); but ever-use (9%) was not much lower compared to the same countries (18%, 12%, 10%, and 15%, respectively). In contrast, 2009 data from China, a country with no ban, showed lower awareness (31%) and ever-use (2%), likely attributable to Chinese market factors and earlier survey date (2009) ²⁴24. Gravely S, Fong GT, Cummings KM, Yan M, Quah AC, Borland R, et al. Awareness, trial, and current use of electronic cigarettes in 10 countries: findings from the ITC Project. Int J Environ Res Public Health 2014; 11:11691-704.. Between-country comparisons should be interpreted with caution because country-specific factors may have contributed to variability.

Among smokers who were aware of e-cigs in Brazil, 44.4% believed they were less harmful compared to regular cigarettes. A United States study in 2012-2013 (no ENDS ban) showed that 51% of smokers believed e-cigs were less harmful compared to regular cigarettes ²⁵25. Tan AS, Bigman CA. E-cigarette awareness and perceived harmfulness: prevalence and associations with smoking-cessation outcomes. J Prev Med 2014; 47:141-9.. Data are difficult to interpret, but it appears that a substantial proportion of smokers in countries both with and without strict regulations believe e-cigs are less harmful than regular cigarettes.

This study was the first to examine correlates of e-cigs awareness and POH in Brazil. Younger and better-educated smokers were more likely to be aware of e-cigs, as in other countries ²⁶26. Adkison SE, O'Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH, et al. Electronic Nicotine Delivery Systems. International Tobacco Control Four-Country Survey. Am J Prev Med 2013; 44:207-15.. In Brazil this group has greater access to the Internet ²⁷27. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Acesso à Internet e posse de telefone móvel celular para uso pessoal, 2011. ftp://ftp.ibge.gov.br/Acesso_a_internet_e_posse_celular/2011/PNAD_Inter_2011.pdf (acessado em 22/Nov/2013).
ftp://ftp.ibge.gov.br/Acesso_a_internet_... and may be more frequently targeted by online ads and novelty promotion ²⁸28. Common Sense Media. Advertising to children and teens: current practices. Research brief 2014. https://www.commonsensemedia.org/research/advertising-to-children-and-teens-current-practices (acessado em 11/Ago/2015).
https://www.commonsensemedia.org/researc... . Respondents with ‘low POH’ were also more likely to be better-educated.

Currently, there is no consensus on the overall population health impact of e-cigs ²⁹29. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation 2014; 129:1972-86.^,3030. Hall W, Gartner C, Forlini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction 2015; 110:1061-7.. The overall population impact of e-cigs will depend on a number of factors, none of which have been established to date, including the extent to which e-cigs affect short-term and long-term health, the impact of e-cigs on quitting attempts and success among smokers, whether or not e-cigs promote smoking among youth, and the extent to which the presence of e-cigs and advertising and marketing of these products may produce renormalization of cigarettes and other smoked tobacco products.

Although Brazil currently prohibits e-cig sale, import, and advertising, there is a clause in the Resolution that will permit them if e-cigs are proven safe/effective for smoking cessation. Long-term high quality studies are necessary to inform evidence-based recommendations that can be adopted by WHO-FCTC Member States.

Limitations

Because the data reported in this study are cross-sectional, we could not evaluate pre-Resolution versus post-Resolution e-cig awareness and perceptions. The survey used a telephone landline sampling frame, and smokers without landlines are more likely to be from lower socioeconomic groups and may respond differently compared to smokers from higher socioeconomic groups. The survey did not distinguish between e-cig experimentation vs. sustained use, and did not assess if users legally used e-cigs while outside of Brazil. Three Brazilian cities were surveyed, and thus results may not be generalizable to the entire country.

Conclusions

Despite strict e-cig regulatory requirements in Brazil, 4.6% of the adult smoker sample reported having used an e-cig at least once in the past 6 months. Of those aware of e-cigs, about 44% believed e-cigs were less harmful than regular cigarettes. Long-term high quality studies are necessary to inform evidence-based recommendations that can be adopted by the WHO-FCTC Member States. National health surveillance programs should include questions about ENDS use and perceptions under their respective regulatory environments.

What this paper adds

This study describes e-cig awareness, perceptions of harmfulness, and correlates of these measures in Brazil, a middle-income country with strong tobacco control policies (for the past 20 years) and with strict e-cig regulations (since 2009). It is the first study to examine the correlates of e-cig perceptions in Brazil.

Acknowledgments

The authors thank Mary McNally from the University of Waterloo for assistance in the review of this manuscript.

References

Publication Dates

History