Introduction
Electronic cigarettes, or e-cigarettes, emerged on the European market in 2010 (Orth and Merkel, 2018, European Commission. Study on the identification of potential risks to public health associated with the use of refillable electronic cigarettes and development of technical specifications for refill mechanisms., 2016) and have since been available throughout Germany. Since then, e-cigarette use has increased rapidly, particularly among young people. The percentage of persons between the ages of 16 and 29 years reporting ever use of e-cigarettes in Germany increased from 11% in 2014 to 18% in 2017 (The [German] Federal Government Commissioner on Narcotic Drugs, 2018). From 2016 to 2017, e-cigarette use was highest among German youth (14–17 years of age) and young adults (18–24 years of age) (Kotz et al., 2018).
Various e-cigarette devices exist, such as disposable e-cigarettes that are meant for one-time use and considered the first generation of e-cigarettes; tank-style e-cigarettes holding vape liquid, known also as e-liquid, that can be refilled and reused; and e-cigarettes used with pre-filled e-liquid cartridges or pods that insert into a rechargeable device and are replaceable. The newest generation of e-cigarettes are called “pod-mods”, which have pre-filled pod cartridges and an e-cigarette system that can be modified. Nicotine type used in e-cigarettes include freebase nicotine, which is known to be bitter and irritating to airways, and nicotine salt formulations, which allows for high levels of nicotine to be inhaled easily and with less throat irritation (Leventhal et al., 2021).
E-cigarette use among adolescents and young adults is particularly troubling as nicotine exposure during young age can harm brain development, lead to nicotine addiction, and can increase the probability of tobacco cigarette initiation (Berry et al., 2019, Academies, 2018, Staff et al., xxxx). The e-liquid used for vaping, which is heated in order to produce an aerosol that is inhaled, can be sold with different nicotine concentrations. However, the nicotine concentration in e-liquid has shown to be inconsistent to labeling (Girvalaki et al., 2020), and even e-cigarettes marketed as containing 0% nicotine have been found to contain nicotine (Goniewicz et al., 2015). Contrary to what young people may assume, e-cigarette aerosol is not harmless (Kelesidis et al., 2021, Center for Disease Control and Prevention. About Electronic Cigarettes (E-Cigarettes)., 2021, U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;, 2016). Besides from nicotine, cancer-causing chemicals, heavy metals (i.e., lead), particulates, and volatile organic compounds have been found in e-cigarette aerosol (Academies, 2018, Academies, 2018).
Current trends on e-cigarette use and consumption patterns of e-cigarette product types and e-liquid nicotine concentration levels among adolescents and young adults in Germany is not fully known. Recent studies on e-cigarettes in young people have pointed to the introduction of JUUL, a pod-style e-cigarette, as the reason for the surge in e-cigarette use among young people (Bach, 2021). A study of Californian youth (9th to 12th grade high school students) from 2014 to 2018 found an increase in total e-cigarette use and the endorsement of JUUL/pod-based devices by a majority of new e-cigarettes users (Lin et al., 2020). Data from the 2019 US National Youth Tobacco Survey showed similar findings of pods/cartridges as the most often e-cigarette device used by middle and high school students (Anic et al., 2021). However, in Europe the availability of JUUL product was short-lived. Between 2018 and 2019 JUUL operations expanded to Europe (Davies et al., 2019), but by May 2020 it was reported that JUUL was shrinking its presence in Europe (Le, 2020) and in October 2020 it was announced that by the end of the year JUUL was no longer going to sell its product in Germany (Reporter and Labs, 2020, Agency, 2020). Furthermore, regulatory steps from the European Union (EU) European Tobacco Product Directive 2014/40/EU (TPD) limits nicotine concentration in e-liquid to 20 mg/mL (European Parliament Council of the European Union, 2014), whereas in the United States (US) a JUUL pod has nicotine concentrations up to 59 mg per milliliter (equivalent to 5% strength) (JUUL, 2020). Given the constant changes in e-cigarette types and their availability, as well as the policies on tobacco and nicotine products, it is important to understand trends and consumption patterns of e-cigarettes among adolescents and young adults.
The World Health Organization recommends monitoring the use of tobacco products and e-cigarettes, especially on adolescents and young adults (World Health Organization, 2019). To date, consumption patterns of e-cigarettes, time trends of e-cigarette use, and sociodemographic factors (e.g., gender, education, household income) associated with current e-cigarette use and dual-use (e.g., combination of cigarettes and e-cigarettes) are not well understood for the population of adolescents and young adults in Germany. Using data from the German Study on Tobacco Use (Deutsche Befragung zum Rauchverhalten, DEBRA), we examined the prevalence of e-cigarette use and tobacco smoking, and consumption patterns of e-cigarette use among representative samples of adolescents and young adults from 2016 to 2020. We also explored the relationship between smoking status, sociodemographic factors, and e-cigarette use by age group.
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