# ABSTRACT

## Objective

To describe the prevalence of use of electronic nicotine delivery systems (ENDS) and waterpipe in Brazil, by population subgroups, and to evaluate the trend between 2013 and 2019.

## Methods

We used data from the 2019 National Health Survey to estimate the prevalence of lifetime and current use of ENDS and current use of waterpipes by socio-behavioral characteristics. Differences in prevalence over time were calculated using data from the III Brazilian Household Survey on Substance Use-2015 and the National Health Survey-2013.

## Results

For 2019, the prevalence of current use of ENDS was estimated at 0.64% (∼1 million people), of which ∼70% were in the age group of 15–24 years old. The highest prevalence was observed in the Midwest region, but the Southeast region concentrates half of these users. Almost 90% are non-smokers, with high prevalence among those who also use waterpipe and abuse alcohol. There was an increase in ENDS use between 2015 and 2019, particularly among younger people. The prevalence of current waterpipe use in 2019 was estimated at 0.47% (∼800,000 individuals), of which ∼80% were 15–24 years old. There was an increase in the prevalence of current waterpipe use between 2013 and 2019, and among young people the increase was ∼300%.

## Conclusions

In Brazil, ENDS have been used mostly by young people, and by never smokers of manufactured cigarettes. The use of ENDS and waterpipe has been increasing even with the country’s regulatory restrictions, which may compromise the successful history of the tobacco control policy.

Keywords:
Electronic nicotine delivery systems; Smoking water pipes; Tobacco products; Nicotine; Tobacco use disorder

# INTRODUCTION

With the reduction in the number of industrialized cigarette users worldwide11. World Health Organization. WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 [Internet]. Geneva: World Health Organization; 2019 [accessed on May 12, 2021]. Available from: https://www.who.int/teams/health-product-and-policy-standards/access-to-assistive-technology-medical-devices/health-promotion
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, the tobacco industry has invested in the marketing of new products such as electronic nicotine delivery systems (ENDS) — which include electronic cigarettes, heated tobacco cigarettes and electronic waterpipes —, and also in giving greater visibility to more traditional products, such as the waterpipe.

Unlike conventional cigarettes, the release of nicotine in ENDSs does not depend on combustion to produce smoke, but on an electronic mechanism that produces steam, heating a liquid that contains nicotine and additives (electronic cigarettes) or solid tobacco sheets (heated tobacco cigarette). Therefore, they have been portrayed as a less harmful alternative to conventional cigarettes that can even help with smoking cessation22. Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, et al. Estimating the harms of nicotine-containing products using the MCDA approach. Eur Addict Res 2014; 20 (5): 218-25. https://doi.org/10.1159/000360220
https://doi.org/10.1159/000360220...
. As for the traditional waterpipe, many still believe that, although it uses combustion to release smoke, it is less toxic because it is filtered in water33. Instituto Nacional de Câncer José Alencar Gomes da Silva. Narguilé: o que sabemos? [Internet]. Rio de Janeiro: INCA; 2019 [accessed on May 1, 2021]. Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//narguile-o-que-sabemos.pdf
https://www.inca.gov.br/sites/ufu.sti.in...
.

The difficulties of regulating the internet have favored the advertising of these products in this environment, attracting young people, since they are promoted as a technological novelty44. Barrientos-Gutierrez I, Lozano P, Arillo-Santillan E, Morello P, Mejia R, Thrasher JF. “Technophilia”: A new risk factor for electronic cigarette use among early adolescents? Addict Behav 2019; 91: 193-200. https://doi.org/10.1016/j.addbeh.2018.09.004
, with different flavors55. Zare S, Nemati M, Zheng Y. A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type. PloS One 2018; 13 (3): e0194145. https://doi.org/10.1371/journal.pone.0194145
https://doi.org/10.1371/journal.pone.019...
and because of the social rituals involved in smoking waterpipe33. Instituto Nacional de Câncer José Alencar Gomes da Silva. Narguilé: o que sabemos? [Internet]. Rio de Janeiro: INCA; 2019 [accessed on May 1, 2021]. Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//narguile-o-que-sabemos.pdf
https://www.inca.gov.br/sites/ufu.sti.in...
. Worldwide, there was an explosion ENDS use among young people, and in the United States, where until 2016 these new products were not regulated, the prevalence of use of electronic cigarettes has surpassed that of manufactured cigarettes among high school students (27.5 versus 5.8% in 2019)66. CDCTobaccoFree. Youth and tobacco use infographics [Internet]. Centers for Disease Control and Prevention. 2019 [accessed on March 23, 2020]. Available from: http://bit.ly/2eoymcJ
http://bit.ly/2eoymcJ...
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However, studies are now showing that ENDS are not innocuous as the manufacturers claim, with indications that tobacco is actually carbonized in heated cigarettes77. Davis B, Williams M, Talbot P. iQOS: evidence of pyrolysis and release of a toxicant from plastic. Tob Control. 2019; 28 (1): 34-41. https://doi.org/10.1136/tobaccocontrol-2017-054104
https://doi.org/10.1136/tobaccocontrol-2...
, in addition to the presence of several toxic and carcinogenic substances in electronic cigarettes88. Liu Q, Huang C, Chris Le X. Arsenic species in electronic cigarettes: determination and potential health risk. J Environ Sci China 2020; 91: 168-76. https://doi.org/10.1016/j.jes.2020.01.023
https://doi.org/10.1016/j.jes.2020.01.02...
,99. Khan KM, Chakraborty R, Bundschuh J, Bhattacharya P, Parvez F. Health effects of arsenic exposure in Latin America: an overview of the past eight years of research. Sci Total Environ 2020; 710: 136071. https://doi.org/10.1016/j.scitotenv.2019.136071
https://doi.org/10.1016/j.scitotenv.2019...
. Besides that, systematic reviews show that electronic cigarettes significantly increase the risk of trying conventional cigarettes1010. Barufaldi LA. Risco de iniciação ao tabagismo com o uso de cigarros eletrônicos: revisão sistemática e meta-análise. 2020 [accessed on May 6, 2021]; Available from: http://www.cienciaesaudecoletiva.com.br/artigos/risco-de-iniciacao-ao-tabagismo-com-o-uso-de-cigarros-eletronicos-revisao-sistematica-e-metaanalise/17801?id=17801
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and the frequency of relapse to conventional smoking among former smokers1111. Barufaldi LA, Guerra RL, Albuquerque RCR, Nascimento A, Chança RD, Souza MC, et al. Risk of smoking relapse with the use of electronic cigarettes: A systematic review with meta-analysis of longitudinal studies. Tob Prev Cessat 2021; 29: 29. https://doi.org/10.18332/tpc/132964
https://doi.org/10.18332/tpc/132964...
.

As for waterpipes, studies show their association with different types of cancer1212. López-Ozuna VM, Gupta I, Kiow RLC, Matanes E, Kheraldine H, Yasmeen A, et al. Water-pipe smoking exposure deregulates a set of genes associated with human head and neck cancer development and prognosis. Toxics 2020; 8 (3): 73. https://doi.org/10.3390/toxics8030073
https://doi.org/10.3390/toxics8030073...
,1313. Raad D, Gaddam S, Schunemann HJ, Irani J, Jaoude PA, Honeine R, et al. Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Chest 2011; 139 (4): 764-74. https://doi.org/10.1378/chest.10-0991
https://doi.org/10.1378/chest.10-0991...
,1414. Instituto Nacional de Câncer José Alencar Gomes da Silva. Nota técnica: uso de narguilé: efeitos sobre a saúde, necessidades de pesquisa e ações recomendadas para legisladores [Internet]. Rio de Janeiro: INCA; 2017 [accessed on May 14, 2021]. Available from: https://apps.who.int/iris/bitstream/handle/10665/161991/9789241508469-por.pdf;jsessionid=D5C03296A2EF6247C207158C5335A01C?sequence=5
https://apps.who.int/iris/bitstream/hand...
, given that in a one-hour session one can inhale an amount of smoke equivalent to one hundred cigarettes or more, and daily use can be equivalent to smoking ten cigarettes a day33. Instituto Nacional de Câncer José Alencar Gomes da Silva. Narguilé: o que sabemos? [Internet]. Rio de Janeiro: INCA; 2019 [accessed on May 1, 2021]. Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//narguile-o-que-sabemos.pdf
https://www.inca.gov.br/sites/ufu.sti.in...
.

In Brazil, the same restrictions imposed on conventional cigarettes are imposed on the sale of waterpipes1515. Brasil. Lei no 10.167, de 27 de dezembro de 2000. Altera dispositivos da Lei no 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígenos, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas. Brasil, 1996., while the sale of ENDS is prohibited1616. Brasil. Agência Nacional de Vigilância Sanitária. Resolução – RDC Nº 208, de 5 de janeiro de 2018. [Internet]. Brasil, 2018..

Monitoring the presence and dissemination of these tobacco products in society can contribute to the identification of gaps and threats in tobacco control policies across the country, which have been quite successful over time1717. Malta DC, Vieira ML, Szwarcwald CL, Caixeta R, Brito SM, Reis AA. Smoking trends among Brazilian population - national household survey, 2008 and the National Health Survey, 2013. Rev Bras Epidemiol 2015; 18 (Suppl 2): 45-56. https://doi.org/10.1590/1980-5497201500060005
https://doi.org/10.1590/1980-54972015000...
. Therefore, the objective of this study was to describe the prevalence of use of electronic smoking devices and waterpipe in Brazil while characterizing the most affected population subgroups and assessing the spread between 2013 and 2019, based on data from three nationwide surveys.

# METHODS

The main data analyzed come from the National Health Survey (PNS) 2019. The PNS is an integral part of the Integrated System of Household Surveys (SIPD) of the National Institute of Geography and Statistics (IBGE) and is the result of a partnership with the Ministry of Health. This is a nationwide household survey with a representative sample of the Brazilian population aged 15 years and over residing in permanent private households. The sample is clustered in three stages, with stratification of the primary sampling units (PSU), which are the census tracts or set of tracts; households are the second stage units, and residents are the tertiary units. The weight of the selected resident considers, besides selection probability, adjustments for correction of non-response by sex and calibration according to population totals by sex and age group. Details about the PNS methodology can be found elsewhere1818. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde : 2019 : percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões [Internet]. Rio de Janeiro: IBGE; 2020 [accessed on May 14, 2021]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...
.

To assess the use of ENDS in PNS-2019, the following question was asked: “Do you use electronic devices with liquid nicotine or chopped tobacco leaf (electronic cigarette, electronic waterpipe, heated cigarette or other electronic smoking device to smoke or vaporize)?”. Current ENDS use was determined when the answers were “yes, daily” or “yes, not daily”. Lifetime use included, in addition to current use, individuals who answered “no, but I have used it in the past”. All others were considered individuals who never used ENDS. For the assessment of waterpipe use, the question was about the average number of sessions per day/week, with the following answer options: “one or more per day”, “one or more per week”, “less than once a week”, “less than once a month” and “I do not use this product”. Therefore, anyone who reported using any amount was considered a current user.

Point prevalences and respective 95% confidence intervals (95%CI) of current and lifetime use of ENDS and waterpipe were calculated for Brazil and by sociodemographic and behavioral characteristics: macro-regions, age group (15–24 years; 25–39 years; 40 years and over), ethnicity/skin color (white, black [black + brown]), gender, education (zero to eight years of study [up to incomplete Elementary School]; nine to 11 years of study [Complete Elementary School to incomplete High School]; 12 or more years of study [Complete High School or more]), alcohol abuse in the last 30 days (yes, no), current use of industrialized cigarettes, ENDS and waterpipe (yes, no). Alcohol abuse was considered as the consumption of five or more doses of alcoholic beverages on a single occasion in the last 30 days. Given the low representation of indigenous and yellow people in the PNS sample, the estimates for these subgroups are not presented due to their low precision. However, important to note that whites, blacks and browns represent 98.5% of the PNS population. The absolute number of people with the selected characteristics was also estimated based on the total research population. A statistically significant difference (at 5%) was the absence of overlapping of confidence intervals in prevalence estimates.

In order to verify the relation between the use of ENDS and industrialized cigarettes in each age group, the χ2 test with Rao-Scott correction was performed, considering a significance level of 5%. Point estimates of the prevalence of individuals who currently use ENDS, who only used it in the past, or who never used it, according to use of industrialized cigarette (current smoker, former smoker or never smoked) were also evaluated.

To assess the trend in prevalence of ENDS in Brazil, in comparison to data from the PNS-2019, data from the III National Survey on Drug Use by the Brazilian Population (III-LNUD), coordinated by the Oswaldo Cruz Foundation (Fiocruz), were used, being the first nationwide survey to address this issue1919. Bertoni N, Szklo A, Boni RD, Coutinho C, Vasconcellos M, Nascimento Silva P, et al. Electronic cigarettes and narghile users in Brazil: do they differ from cigarettes smokers? Addict Behav 2019; 98: 106007. https://doi.org/10.1016/j.addbeh.2019.05.031
. The III-LNUD was carried out in 2015, with a representative sample of the Brazilian population aged 12–65 years. The sampling plan followed methodological criteria similar to those of the IBGE’s National Household Survey (PNAD): a stratified sampling plan for conglomerates at various stages. More details can be found elsewhere2020. Fundação Oswaldo Cruz, Bastos FI, Bertoni N, et al, organizadores. III Levantamento Nacional sobre o uso de drogas pela população brasileira [Internet]. Rio de Janeiro: ICICT/FIOCRUZ; 2017 [accessed on March 30, 2020]. Available from: https://www.arca.fiocruz.br/handle/icict/34614
https://www.arca.fiocruz.br/handle/icict...
.

The subgroup aged 15–65 years was selected in both surveys to compare the results of III-LNUD-2015 and PNS-2019. Although for LNUD the question about ENDS only included the use of electronic cigarettes, back in 2015, they were the ones dominating the world market. The best-known heated tobacco cigarette brand (“IQOS”), for example, was launched only in 2014, and the brand “glo” only in 2016, that is, after the survey. The III-LNUD estimated the use of electronic cigarettes in the last 12 months, while the PNS-2019 addresses current use. As such, the 2015 estimates are expected to be more “inflated” than current use only. Thus, an increase in the period would represent a real increase in ENDS presence in the country, although one cannot directly estimate the magnitude of this increase.

To compare the use of waterpipe over time, data from the PNS-2013 were used. The sampling plan of PNS-20132121. Instituto Brasileiro de Geografia e Estatística, organizador. Pesquisa nacional de saúde, 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da Federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014. 180 p. Available from: https://ww2.ibge.gov.br/home/estatistica/populacao/pns/2013/
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is similar to that of the 2019 edition, but only residents aged 18 and over were interviewed. For the purpose of comparison, the prevalence estimates considered only individuals aged 18 years and older in both surveys. It is noteworthy that PNS-2013 had no questions about the use of ENDS.

The prevalence of ENDS and waterpipe use was estimated for Brazil, and according to macro-regions, age groups, gender and educational level, which can be obtained similarly between surveys and which, according to studies, are associated with the use of ENDS1919. Bertoni N, Szklo A, Boni RD, Coutinho C, Vasconcellos M, Nascimento Silva P, et al. Electronic cigarettes and narghile users in Brazil: do they differ from cigarettes smokers? Addict Behav 2019; 98: 106007. https://doi.org/10.1016/j.addbeh.2019.05.031
.

The analyses were performed using the “survey” and “srvyr” packages of the R v.3.5.1 software, given the complexity of the samples.

The National Research Ethics Commission (CONEP) approved the PNS in 2013 (Certificate of Presentation for Ethical Appraisal – CAAE 10853812.7.0000.0008) and in 2019 (CAAE 11713319.7.0000.0008), and the III-LNUD-2015 was approved by Research Ethics Committee of Joaquim Venâncio Polytechnic School of Health (EPSJV/FIOCRUZ) (CAAE 35283814.4.0000.5241). This study used data from approved researches, bur not that from nominal bases; therefore, there were no ethical implications for the interviewees.

# RESULTS

For 2019, the prevalence of lifetime and current use of electronic devices for smoking was estimated at, respectively, 1.63 and 0.64% of the Brazilian population aged 15 years and over. This percentage varied widely by macro-region, with the highest point prevalence of current use of ENDS in the Midwest region (1.45%) and the lowest in the Northeast region (0.13%). However, in absolute numbers, the Southeast region has the largest number of current users of ENDS: around 50% (approximately 533 thousand people) (Table 1).

Table 1.
Estimated prevalence of use of Electronic Nicotine Delivery Systems in lifetime and currently, according to socio-behavioral characteristics. Brazil, 2019.

The subpopulation of adolescents and young people aged 15–24 years had the highest prevalence of ENDS use (5.41% for lifetime use and 2.38% for current use), accounting for about 70% of ENDS users both in lifetime and currently. The prevalence of current use of ENDS among these young people was estimated to be nearly 40 times the prevalence among adults aged 40 years and over (2.38 versus 0.06%, respectively).

White and male individuals had higher prevalence of lifetime use of ENDS than black people and women, respectively. However, for current use, there was an overlap in the confidence intervals of these estimates. The prevalence of current use of ENDS was higher both among individuals with 12+ years of study and among those with 9 to 11 years of study than among the less educated (1.25, 0.73 and 0.19%, respectively) (Table 1).

The prevalence of current use of ENDS was higher among industrialized cigarette users than among non-users (0.87 versus 0.61%, respectively), with overlapping confidence intervals (Table 1). However, in absolute numbers, the greatest portion of current users of ENDS are non-smokers (∼86%). Also, waterpipe users and individuals who abuse alcohol had statistically higher prevalence of current use of ENDS than those who do not show these risk behaviors (23.74 versus 0.53% and 1.74 versus 0.42 %, respectively).

The status of ENDS use was associated with the use of industrialized cigarettes (p<0.001) in all age groups. Figure 1 shows the use of industrialized cigarettes and the use of ENDS for each age group. Among young people aged 15–24 who currently use ENDS, 62.6% have never smoked industrialized cigarettes, while among individuals aged 40 years and over this percentage is 29.1%. The point prevalence of current use of industrialized cigarettes, for all age groups, is higher among those who currently use ENDS or have used it in the past than among those who have never used ENDS (15–24 years: 11.3 and 11.0 versus 6.6%; 25–39 years: 14.4 and 25.8 versus 9.5%; 40 years or more: 30.9–36.1 versus 10.4%, respectively).

Figure 1.
Population profile by status of use of Electronic Nicotine Delivery Systems, according to status of use of manufactured cigarettes. Brazil, 2019.

When comparing the prevalence of ENDS use between 2015 and 2019 (Figure 2), we found an increase in estimates for Brazil, especially for the younger age group, 15–24 years old. The point prevalence was also inflated in all macro-regions and for all educational categories. As for sex, although there was an increase for both, among women it was even more marked.

Figure 2.
Prevalence of use of Electronic Nicotine Delivery Systems among individuals aged 15 to 65 years, by survey, according to selected characteristics. Brazil, 2015–2019 III-LNUD-2015: III National Survey on Drug Use by the Brazilian Population, 2015; PNS: National Health Survey.

Regarding the use of waterpipe, for 2019 the prevalence of current use was estimated in 0.47%, representing about 800 thousand individuals aged 15 years or more, of which about 80% were between 15 and 24 years old. The highest values are found in the Midwest (0.94%), South (0.90%) and Southeast (0.55%) regions. Men had a statistically higher prevalence than women (0.71 versus 0.26%), and people with 12 years of study or more and with nine to 11 years of study were included in statistically higher prevalences compared to people with up to eight years of study (1.14, 0.44 and 0.17%, respectively). There was no statistically significant difference in prevalence by ethnicity/skin color. The prevalence of waterpipe use was significantly higher among industrialized cigarette users (2.58 versus 0.25%), ENDS users (17.66 versus 0.36%) and people who abuse alcohol (1.85 versus 0.20%) (Table 2).

Table 2.
Estimated prevalence of current use of waterpipe, according to sociodemographic and behavioral characteristics. Brazil, 2019.

Assessing estimates of current and lifetime use of waterpipe (Figure 3), the prevalence increased from 0.14% in 2013 to 0.43% in 2019, and for the 18–24 age group the increase was around 300% in this period. In the North region, where in 2013 the use of waterpipes was quite rare (0.01%), there was a significant increase to 0.16% in 2019. Another region that experienced a statistically significant increase in the prevalence of waterpipe use was the Southeast region (from 0.10 to 0.56%). This upward trend was also noticed for both sexes; among women, the prevalence increased from 0.07% in 2013 to 0.27% in 2019. The prevalence also increased in all educational levels, and the point estimate went from 0.39 to 1.08% between the most educated (12 or more years of study) in the period.

Figure 3.
Prevalence of current use of waterpipe among individuals aged 18 and over, by survey, according to selected characteristics. Brazil, 2013-2019.

# DISCUSSION

Although the prevalence of use of manufactured cigarettes has been decreasing over time in Brazil2222. Maia EG, Stopa SR, Santos RO, Claro RM. Trends in prevalence of cigarette smoking in Brazil: 2006-2019. Am J Public Health 2021; 111 (4): 730-8. https://doi.org/10.2105/AJPH.2020.306102
https://doi.org/10.2105/AJPH.2020.306102...
, this study shows that, between 2015 and 2019, other tobacco products such as electronic smoking devices and the waterpipe gained ground. This research shows that the vast majority of current users of electronic smoking devices and waterpipe in Brazil are adolescents and young people, or people who have never smoked industrialized cigarettes.

Since studies show an association between ENDS use and the initiation of conventional cigarettes1010. Barufaldi LA. Risco de iniciação ao tabagismo com o uso de cigarros eletrônicos: revisão sistemática e meta-análise. 2020 [accessed on May 6, 2021]; Available from: http://www.cienciaesaudecoletiva.com.br/artigos/risco-de-iniciacao-ao-tabagismo-com-o-uso-de-cigarros-eletronicos-revisao-sistematica-e-metaanalise/17801?id=17801
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, and an association between ENDS and waterpipe2323. East KA, Reid JL, Rynard VL, Hammond D. Trends and patterns of tobacco and nicotine product use among youth in canada, england, and the United States from 2017 to 2019. J Adolesc Health 2021; 69 (3): 447-56. https://doi.org/10.1016/j.jadohealth.2021.02.011
, the trend of successful decline in the prevalence of smokers in Brazil is at risk of being reversed in the future. Data from the Surveillance of Risk and Protection Factors for Chronic Diseases by Telephone Survey (Vigitel)2424. Bertoni N, Szklo AS. Dispositivos eletrônicos para fumar nas capitais brasileiras: prevalência, perfil de uso e implicações para a Política Nacional de Controle do Tabaco. Cad Saude Publica 2021; 37 (7): e00261920. https://doi.org/10.1590/0102-311X00261920
https://doi.org/10.1590/0102-311X0026192...
and from the PNS already point to a stability over time (2013-2019) in the point prevalence of young smokers (18–24 years old)1818. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde : 2019 : percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões [Internet]. Rio de Janeiro: IBGE; 2020 [accessed on May 14, 2021]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101764.pdf
https://biblioteca.ibge.gov.br/visualiza...
,2121. Instituto Brasileiro de Geografia e Estatística, organizador. Pesquisa nacional de saúde, 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e unidades da Federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014. 180 p. Available from: https://ww2.ibge.gov.br/home/estatistica/populacao/pns/2013/
https://ww2.ibge.gov.br/home/estatistica...
, which may already be a reflection of ENDS. So, the monitoring of the prevalence of ENDS is essential and should be highlighted. By leading never smokers to try/use nicotine on a regular basis1010. Barufaldi LA. Risco de iniciação ao tabagismo com o uso de cigarros eletrônicos: revisão sistemática e meta-análise. 2020 [accessed on May 6, 2021]; Available from: http://www.cienciaesaudecoletiva.com.br/artigos/risco-de-iniciacao-ao-tabagismo-com-o-uso-de-cigarros-eletronicos-revisao-sistematica-e-metaanalise/17801?id=17801
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, these devices can contribute to forming a new group of nicotine addicts, who, in the future are assumed to be able to seek in conventional cigarettes a more efficient and viable way to satisfy their dependence on nicotine, thus contributing to a further increase in the prevalence of smokers of industrialized cigarettes.

We found a difference in use between Brazilian regions. Considering that the sale of ENDS is prohibited in Brazil, the higher prevalence observed in the Midwest may be related to the smuggling of these products from Paraguay, following the same pattern of consumption of smuggled industrialized cigarettes2525. Szklo AS, Iglesias RM, Stoklosa M, Figueiredo VC, Welding K, Souza Junior PRB, et al. Cross-validation of four different survey methods used to estimate illicit cigarette consumption in Brazil. Tob Control 2020: tobaccocontrol-2020-056060. https://doi.org/10.1136/tobaccocontrol-2020-056060
https://doi.org/10.1136/tobaccocontrol-2...
,2626. Jansen T. Usuários driblam proibição de venda de cigarro eletrônico no Brasil. O Globo [Internet]. 2015 [accessed on May 14, 2021]. Available from: https://oglobo.globo.com/sociedade/saude/usuarios-driblam-proibicao-de-venda-de-cigarro-eletronico-no-brasil-16182500
,2727. Freitas H. PM é preso com contrabando de cigarro eletrônico avaliado em R$220 mil. Campo Grande News [Internet]. 2019 [accessed on May 14, 2021]. Available from: https://www.campograndenews.com.br/cidades/interior/pm-e-preso-com-contrabando-de-cigarro-eletronico-avaliado-em-rs-220-mil https://www.campograndenews.com.br/cidad... . This result draws attention to the need for unrestricted implementation of a protocol against the illicit trade of tobacco products2828. World Health Organization. Protocol to eliminate illicit trade in tobacco products [Internet]. 2013 [accessed on May 14, 2021]. Available from: https://ahpsr.who.int/publications/i/item/9789241505246 https://ahpsr.who.int/publications/i/ite... . It is also worth noting that we still lack population evidence that the use of electronic cigarettes can contribute to the cessation of use of conventional cigarettes2929. Wang RJ, Bhadriraju S, Glantz SA. E-Cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021; 111 (2): 230-46. https://doi.org/10.2105/AJPH.2020.305999 https://doi.org/10.2105/AJPH.2020.305999... . However, in Brazil, as most ENDS users are people who have never smoked, it is suggested that the main motivation is more related to the fad built by advertisements and the promotion of its high-tech attributes and performance than to the attempt to quit conventional smoking. And also, in young people, who represent approximately 70% of ENDS users, as a rule, nicotine dependence is still not as established as in adults3030. Radzi NAM, Saub R, Yusof ZYM, Dahlui M, Sujak SL. Nicotine dependence among adolescents single and dual cigarette users. Children (Basel) 2021; 8 (2): 144. https://doi.org/10.3390/children8020144 https://doi.org/10.3390/children8020144... , and it may even have increased with the dual use of industrialized cigarettes3131. Post A, Gilljam H, Rosendahl I, Bremberg S, Galanti MR. Symptoms of nicotine dependence in a cohort of Swedish youths: a comparison between smokers, smokeless tobacco users and dual tobacco users. Addict Abingdon Engl 2010; 105 (4): 740-6. https://doi.org/10.1111/j.1360-0443.2009.02852.x https://doi.org/10.1111/j.1360-0443.2009... ,3232. Martínez Ú, Martínez-Loredo V, Simmons VN, Meltzer LR, Drobes DJ, Brandon KO, et al. How does smoking and nicotine dependence change after onset of vaping? A retrospective analysis of dual users. Nicotine Tob Res 2020; 22 (5): 764-70. https://doi.org/10.1093/ntr/ntz043 https://doi.org/10.1093/ntr/ntz043... . We also observed a large increase in the use of ENDS and waterpipe among women and also a higher prevalence among individuals with a higher level of education, which are subpopulations that historically are encompassed by lower prevalence of industrialized cigarettes than their peers1919. Bertoni N, Szklo A, Boni RD, Coutinho C, Vasconcellos M, Nascimento Silva P, et al. Electronic cigarettes and narghile users in Brazil: do they differ from cigarettes smokers? Addict Behav 2019; 98: 106007. https://doi.org/10.1016/j.addbeh.2019.05.031 https://doi.org/10.1016/j.addbeh.2019.05... ,3333. Szklo AS, Souza MC, Szklo M, Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25 (5): 564-70. https://doi.org/10.1136/tobaccocontrol-2015-052324 https://doi.org/10.1136/tobaccocontrol-2... . When the individuals are never smokers, they may evolve to dual or exclusive use of industrialized cigarettes1010. Barufaldi LA. Risco de iniciação ao tabagismo com o uso de cigarros eletrônicos: revisão sistemática e meta-análise. 2020 [accessed on May 6, 2021]; Available from: http://www.cienciaesaudecoletiva.com.br/artigos/risco-de-iniciacao-ao-tabagismo-com-o-uso-de-cigarros-eletronicos-revisao-sistematica-e-metaanalise/17801?id=17801 http://www.cienciaesaudecoletiva.com.br/... . Although ENDS use in 2019 was higher among men than among women, the comparison between 2015 and 2019 suggests a greater upward trend among women, which may indicate a trend of dissemination of ENDS that follows a similar pattern historically observed in the spread of consumption of industrialized cigarettes in terms of gender. The classic descriptive model of temporal evolution of the tobacco epidemic in developed and developing countries by Lopes et al.3434. Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tob Control 1994; 3 (3): 242-7. PMCID: PMC1759359. identified an evolutionary dynamic of initial growth among men followed by growth among women, generally maintaining a lower level of prevalence in the latter group. ENDS have been extensively presented by manufacturers as a technological innovation to replace conventional cigarettes3535. Infante M. “Queremos deixar de vender cigarros o quanto antes, mudar nosso modelo”, diz diretor da Philip Morris. Projeto Draft [Internet]. 2018 [accessed on May 14, 2021]. Available from: https://www.projetodraft.com/queremos-deixar-de-vender-cigarros-o-quanto-antes-mudar-nosso-modelo-diz-diretor-da-philip-morris/ https://www.projetodraft.com/queremos-de... ,3636. Iodice G. Philip Morris quer parar de vender cigarros. Forbes Brasil [Internet]. 2020 [accessed on May 14, 2021]. Available from: https://www.forbes.com.br/principal/2020/01/philip-morris-quer-parar-de-vender-cigarros/ https://www.forbes.com.br/principal/2020... . Our study points out that ENDS use is concentrated in populations with higher educational levels, a proxy for income, which may indicate a pattern of diffusion based on social status, similar to the dynamics of spread of industrialized cigarettes in the beginning of the 20th century, which represented a technological and cultural innovation3737. Pampel FC, Bricard D, Khlat M, Legleye S. Life Course Changes in Smoking by Gender and Education: A Cohort Comparison Across France and the United States. Popul Res Policy Rev 2017; 36 (3): 309-30. https://doi.org/10.1007/s11113-016-9424-y https://doi.org/10.1007/s11113-016-9424-... . A recent systematic review1111. Barufaldi LA, Guerra RL, Albuquerque RCR, Nascimento A, Chança RD, Souza MC, et al. Risk of smoking relapse with the use of electronic cigarettes: A systematic review with meta-analysis of longitudinal studies. Tob Prev Cessat 2021; 29: 29. https://doi.org/10.18332/tpc/132964 https://doi.org/10.18332/tpc/132964... showed that the risk of relapse among former smokers of conventional cigarettes is higher among those who used electronic cigarettes than among those who did not. Although our study is not longitudinal, one can suggest that, among individuals aged 40 years and over who used ENDS only in the past, more than a third currently smoke cigarettes, which may indicate an attempt to use them as a cessation aid that was not successful, or that these users returned to smoking after using these devices. The cross-sectional design of the surveys used in this study limits us to statements about the causality of events. Furthermore, in addition to the differences between PNS and III-LNUD on the issue of time and type of devices described above, they have sample differences, for example, the sample size. This means that there may be differences in the accuracy of estimates between surveys, however both have national coverage and representation so that such issues would not interfere with the findings presented here. Another limitation is the fact that it is not possible to separate ENDS by type of product in the PNS, and they are known to present different risks mainly due to their compositions, including the concentrations of nicotine in each, that can directly impact the dependency caused by them. Although the question about ENDS specifies the types of products that should be considered, there may have been a misunderstanding of respondents about the conventional waterpipe and the electronic waterpipe, leading to an overestimation of the prevalence of ENDS and, consequently, the relationship between ENDS and the waterpipe. However, the relation between the use of ENDS and other tobacco products has already been shown in other studies2323. East KA, Reid JL, Rynard VL, Hammond D. Trends and patterns of tobacco and nicotine product use among youth in canada, england, and the United States from 2017 to 2019. J Adolesc Health 2021; 69 (3): 447-56. https://doi.org/10.1016/j.jadohealth.2021.02.011 https://doi.org/10.1016/j.jadohealth.202... , and thus, even with some information bias, this could impact the magnitude of the problem, but would not annul the relation itself. This study shows that ENDS have been mostly used by young people and by people who have never smoked industrialized cigarettes, and not by adults with the aim to stop using conventional cigarettes. The prevalence of ENDS and waterpipe use has been increasing in spite of the country’s regulatory restrictions, which may jeopardize the successful history of tobacco control policies in Brazil. • Financial support: This study was supported by the Research Support Foundation of the State of Rio de Janeiro (FAPERJ) through the project “Redes de Pesquisa em Saúde no Estado do RJ” (“Research Networks in Health in the State of RJ”) (E-26/010.002428/2019). # Reference • 1. World Health Organization. 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# Publication Dates

• Publication in this collection
10 Dec 2021
• Date of issue
2021