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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 122-126

The profile of electronic cigarette users in Turkey


1 Department of Toxicology, Faculty of Pharmacy, Süleyman Demirel University, Isparta, Turkey
2 Department of Bioengineering, Faculty of Engineering, Firat University, Elazig, Turkey
3 Department of First and Emergency Aid, Atayalvaç Vocational School of Health Services, Süleyman Demirel University, Isparta, Turkey

Date of Submission24-Dec-2018
Date of Decision19-Jan-2019
Date of Acceptance24-Jan-2019
Date of Web Publication30-Aug-2019

Correspondence Address:
Dr. Gülsen Goney
Department of Toxicology, Faculty of Pharmacy, Süleyman Demirel University, Isparta 32260
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejop.ejop_79_18

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  Abstract 


OBJECTIVE: Data on electronic cigarette (e-cigarette) use patterns are limited worldwide. This paper examines user profile of e-cigarettes in Turkey.
MATERIALS AND METHODS: This is a descriptive study. E-cigarette users (≥18 ages) in Turkey were asked to participate in a web-based survey. The participants provided information on their use history, patterns of e-cigarette use, content of e-liquid (amount of nicotine, types of food additives, kinds of products purchased, etc.), attitudes regarding the product, and information on the concurrent use of classic cigarettes.
RESULTS: The online questionnaire was completed by 480 e-cigarette users. The results indicated that e-cigarette users have high incomes (100%), previous smoking dependency (100%), and a mean age of 35 ± 6, and the majority of them are male (99.2%). They use e-cigarettes primarily to quit smoking or to reduce the harm associated with smoking (65.4%, 11.1%, respectively). The e-cigarette users (15.6%) intend to quit smoking by gradually reducing their e-liquid nicotine concentrations. The majority of them (76%) think that e-cigarettes and e-liquids could be harmful to children. Of them, 46.6% used second-generation e-cigarettes and 53.3% used third-generation e-cigarettes with direct dripping.
CONCLUSION: This study is the first description of the attitudes and use of e-cigarette users in Turkey. Results show that most of the users began to use e-cigarettes in order to quit smoking. According to the study findings, we propose an urgent need for an evaluation by health authorities for e-cigarette use and smoking cessation.

Keywords: Cigarettes, e-cigarettes, electronic cigarettes, electronic nicotine delivery systems, online questionnaires


How to cite this article:
Goney G, Topdemir A, Nal B. The profile of electronic cigarette users in Turkey. Eurasian J Pulmonol 2019;21:122-6

How to cite this URL:
Goney G, Topdemir A, Nal B. The profile of electronic cigarette users in Turkey. Eurasian J Pulmonol [serial online] 2019 [cited 2019 Sep 15];21:122-6. Available from: http://www.eurasianjpulmonol.com/text.asp?2019/21/2/122/265839




  Introduction Top


Electronic cigarettes (e-cigarettes), also known as electronic nicotine delivery systems, personal vaporizers, vape pens, e-cigars, e-hookahs, or vaping devices, have become highly popular in recent years.[1] It is estimated that the rapidly growing e-cigarette market will reach 10 billion dollars in 2017.[2],[3] According to the World Health Organization, over 3 billion dollars of e-cigarettes were sold in 2013 in the US alone. This figure is predicted to reach 17 billion dollars in 15 years.[4],[5]

E-cigarettes, are designed to vaporize a liquid solution of propylene glycol and/or vegetable glycerin in which nicotine or other flavors (such as chocolate, coffee, mint, or fruits) may be dissolved. They use a battery to vaporize this liquid mixture. As it is quite a new product, there is not enough information in the literature about the risks and benefits of e-cigarette use.[6] The limited studies in the literature have shown that the liquid and vapor of e-cigarettes includes toxic chemicals such as nitrosamines, acrolein, formaldehyde, diethylene glycol, acetaldehyde, diacetyl, polycyclic aromatic hydrocarbons, and some metals.[7] In recent years, the question of whether e-cigarette use is safe or not has become a significant matter of public and scientific debate. There is not enough scientific evidence about the effects of e-cigarettes for public institutions to help regulatory authorities and consumers.[8]

E-cigarettes were first marketed 15 years ago and are now commonly used worldwide. In the last decade, e-cigarette use increased strikingly among teenagers and young adults in many countries, especially in Europe and the US.[9] The results of observational and randomized studies suggest that e-cigarettes can help users to quit or cut down classical cigarette smoking.[10],[11] Percentage of e-cigarette users who said that they used e-cigarettes various reasons are shown in [Figure 1].[12] There are only a few cross-sectional studies of e-cigarette users in the literature, and their behavioral characteristics during the time they use e-cigarettes remain unclear.[13],[14] The striking increase in e-cigarette use has raised the importance of questions such as why and how people use e-cigarettes, and if they only use e-cigarettes or also smoke classic cigarettes. For this reason, this study was planned to determine the characteristics of e-cigarette users.
Figure 1: Percentage of electronic cigarette users who said that they used electronic cigarettes for various reason. *According to the Adkison et al. (2013)

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  Materials and Methods Top


Since the sale and marketing of e-cigarettes are carried out mostly over the Internet, this descriptive study planned to reach e-cigarette users on the Internet. A web-based survey was applied to the e-cigarette users in Turkey over the Internet. This study was carried out from March to September 2018 with participants who were 18 or older. Since the number of e-cigarette users in Turkey is not known, the sample size of the study could not be calculated. For this reason, the minimum number of participants was determined by reviewing previous studies of this subject.[15] The aim was to reach to a higher number of people than the relevant previous studies. The survey was completed when the minimum required number of people was reached. The survey was administered to 480 e-cigarette users. Legal permission for the survey was obtained from the Ethical Commission of Clinical Research at Süleyman Demirel University (file number 2018/84).

The 24-question survey was administered to e-cigarette users to learn specific information about e-cigarette use such as reasons for using e-cigarettes, duration of use, types of e-cigarette, and e-liquid contents.


  Results Top


Participant profiles

This study's sample included 476 men and 4 women with a mean age of 35 ± 6 years. It included young adults with high incomes (≥3000 TL) and high education levels. In this sample, e-cigarette use was much more common among men. The demographic characteristics of the participants are shown in [Table 1].
Table 1: The participant's demographic information

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The nicotine quantities and flavorings in electronic cigarettes

Most e-cigarette liquids contain flavoring substances. This study's participants used coffee (18.33%), tobacco (16.04%), mint (12.29%), vanilla (11.87%), cherry (10.00%), energy drink (6.87%), apple (6.04%), chocolate (3.33%), and cappuccino (3.33%) flavorings in their e-liquids. The flavors used by the participants are shown in [Figure 2]. Of them, 7.70% used unflavored e-liquids. A few of them (3.75%) preferred to make their own e-liquids by mixing different flavors and substances in different concentrations. The fact that 0.41% of the participants used hallucinogenic absinth to their e-liquids was noted as significant information. The users' e-liquid nicotine quantities varied between 4 and 24 mg/ml. The nicotine concentrations of the e-liquids were as follows: 4 mg/ml (2. 08%), 6 mg/ml (6. 25%), 9 mg/ml (15.83%), 11 mg/ml (12.08%), 16 mg/ml (6.04%), 18 mg/ml (23. 75%), and 24 mg/ml (6.45%). Of the participants, 18.33% preferred to make their own e-liquids using various compounds and flavoring substances in different concentrations. Of them, 9.16% chose to use nicotine-free e-liquids. Few users preferred e-cigarette cartridges with zero nicotine or little nicotine over the cartridges with medium or high levels of nicotine content. The quantities of nicotine levels of e-liquids preferred by the e-cigarette users are shown in [Figure 3].
Figure 2: E-liquid flavors

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Figure 3: Nicotine levels of e-liquids

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The characteristics of electronic cigarette use

The most important reason (65.44%) why e-cigarette users preferred e-cigarettes was determined to be quitting smoking. Of the participants, 11.10% said that they began using e-cigarettes because they thought it has less side effect than classical cigarettes. They said that they used e-cigarettes in order to quit smoking (65.4%) because they thought it has less side effects than classic cigarettes (11.1%) and because they could use e-cigarettes in the places where smoking classic cigarette is prohibited (6.6%). They also said that, compared to classic cigarettes, e-cigarettes include less chemical substances (6.6%). They use them in order not to bother nonsmokers (4.4%), to avoid unpleasant smells (4.4%) and because, in the long term, e-cigarettes are more cost-effective than classic cigarettes (1.2%). Percentage of e-cigarette users who said that they used e-cigarettes for various reasons is shown in [Figure 4].
Figure 4: Percentage of electronic cigarette users who said that they used electronic cigarettes for various reasons

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The participants were also asked about how long they had used e-cigarettes and how often they used them each day. The participants said that they used e-cigarettes once or more every half hour (50.83%), once an hour (25.00%), once every 1.5 h (10.62%), once every 2 h (1.87%), once every 3 h (5.00%), once or twice a day (2.50%), and twice to 4 times a day (4.16%). While 5% of the participants had been using e-cigarettes for 3 months or less, 49.16% had been using them for 3–6 months and 11.04% had been using them for more than 6 months. Of the participants, 21.87% had been using e-cigarettes for 1–2 years and 12.91% had been using them for more than 2 years. The participants' duration and frequency of use of e-cigarettes are shown in [Figure 5] and [Figure 6].
Figure 5: Frequency of electronic cigarette use

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Figure 6: Use duration

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Attitudes toward electronic cigarettes

The e-cigarette users heard about e-cigarettes from their friends (25%), e-cigarette commercials (40%), and social media and websites with e-cigarette users (43%). The exposure profiles of e-cigarette users are shown in [Figure 7]. Among the participants, 15.41% intended to quit smoking by gradually reducing the quantity of nicotine in their e-liquids, and in the final stage, by using e-cigarettes with no nicotine. Of the participants, 75.87% thought that e-cigarettes could have harmful effects on children. None of the participants used first-generation e-cigarettes, 46.6% of them used second-generation e-cigarette, and 53.3% used third -generation e-cigarettes with direct dripping. The kinds of e-cigarettes preferred by the e-cigarette users are shown in [Figure 8].
Figure 7: Exposure to electronic cigarettes

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Figure 8: Type of electronic cigarettes

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The side effects of electronic cigarettes

The participants were asked whether e-cigarettes have potential side effects or not, and they mentioned six side effects as follows: shortness of breath, dry coughing, lip dryness, nasal dryness, sore throat, and heart palpitations. Of the participants, 15% said that they had respiratory problems such shortness of breath and dry coughing, 8.95% had lip dryness, and 0.20% complained about nasal dryness. Since a few of the participants had sore throat and heart palpitations and felt that their mouths were covered inside by a layer of fat, these issues were noted as adverse effects of e-cigarette use.


  Discussion Top


Since e-cigarettes are quite a new product, the data on the profile of their users are also quite inadequate.[16] Although measures and precautions have been taken to reduce classic cigarette smoking and the smoking of classic cigarette has decreased for the last 20 years in Turkey, e-cigarette use has started to become widespread. Studies have shown that e-cigarette use is common in the populations' high incomes and especially among young people.[17],[18] This study found that, in Turkey, e-cigarette users have high incomes and levels of education, and that most of them are male young adults. E-cigarette users use various flavoring substances in their e-liquids. Some users are attracted by e-cigarettes because of these flavorings. However, there is not enough information about the chemical content of the substances used in e-liquids and their toxicity because too few scientific studies have been conducted.[12],[19],[20],[21],[22] The majority of this study's participants indicated that they used e-cigarettes in order to quit smoking classic cigarettes or to reduce side effects of classic cigarettes. The reasons of e-cigarette use in several countries are shown in [Table 2]. The results of the survey suggest that most e-cigarette users had smoking addictions before they used e-cigarettes, that they use classic cigarettes at the same time, and that they began using e-cigarettes in order to cut down or quit smoking cigarette.[12],[16],[22],[23],[24],[25] This study's participants' main reason for beginning e-cigarette use was to quit smoking. The scientific literature has drawn attention to a distinctive increase in e-cigarette use among young people and young adults. Recently, e-cigarette use for nicotine replacement therapy and its effectiveness has been an important debate in the literature. Our study results are important since they include the first information about e-cigarette users and e-liquids. Further studies should be performed with more users, and research about passive exposure to e-cigarettes should be carried out.
Table 2: Reasons of electronic-cigarette use in several countries

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  Conclusion Top


E-cigarettes are increasingly being used by young people in recent years. Recent data showed that 1.78 million young people have tried e-cigarettes, and of them, 160,000 had never smoked before.[4],[5] Middle school use of e-cigarettes increased by 48%, and high school use increased by 78% in the US from 2017 to 2018.[25] Thus, e-cigarette use is a significant public health problem. This study determined the characteristics of e-cigarette use and the e-liquid contents of adult e-cigarette users in Turkey. Our survey is important because it contains the first data about e-cigarette users in Turkey. Most of them began to use e-cigarettes to quit smoking. Although the participants started to use e-cigarettes in order to quit smoking, the issue of whether e-cigarettes can be used for smoking cessation is quite new, and there is not enough research on the subject. The increase in e-cigarette commercials and their sale and marketing on the Internet have made their use common. Therefore, measures and precautions should be taken for public health.

Acknowledgments

The authors wish to thank all of this study's participants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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