Use of electronic cigarettes among secondary and high school students from a socially disadvantaged rural area in Poland

Electronic cigarettes (e-cigarettes) are battery operated electronic nicotine delivery systems designed to provide nicotine in a form of an aerosol [1–3]. The wide variety of e-cigarettes – their multiple colors, shapes and flavors – is equivalent to their potential appeal for young people [4]. Additionally, even though accessibility of e-cigarettes to the youth has different legal status depending on a country, they usually fall into a grey area of jurisdiction [4–6]. As a consequence, a significant interest of the youth in e-cigarettes and an increase in their use over the recent years have been observed [4, 7–12]. For example, studies conducted in the U.S., have shown that ever and current e-cigarette use doubled among middle and high school students during 2011–2012 [8]. Similarly, a study conducted in Poland has indicated a significant increase in the current e-cigarette use among adolescents (from 5.5 % in 2010–2011 sample to 29.9 % in the 2013–2014 sample) [7, 10].

Despite a growing number of studies, still little is known about safety and health effects of e-cigarettes [5, 13]. For adolescents, the use of nicotine-containing e-liquids creates the risk of developing dependence and initiation of tobacco use. The other concern is related to the dual use (e-cigarettes and conventional cigarettes), in which individuals are exposed and addicted to higher levels of nicotine. Consequently, as they believe that by using e-cigarettes they reduce their conventional tobacco use and are getting healthier, their chances of cessation are reduced and cessation attempts delayed [14].

Prevention of the youth access to, initiation and continuous use of e-cigarettes, with special attention to vulnerable groups, is a subject of a health debate worldwide. However, still not much is known about characteristics of the underage e-cigarette users from different geographic and socio-economic backgrounds as well as other potential factors associated with the use of e-cigarettes, including simultaneous use with tobacco products or alcohol [2, 4, 7, 9, 11, 12, 14, 15]. What needs to be pointed, is the fact that majority of the existing studies in this field have focused on the samples from urban areas. At the same time, rural regions, which are more difficult to reach, have been less frequently covered.

E-cigarettes have been available on the Polish market since early 2008 [7]. According to the current regulatory framework, selling tobacco products to people under 18 is prohibited in Poland. However, e-cigarettes are not covered by legislation, and are easily accessible to the minors [6, 16]. Therefore, knowledge about risk and protective factors of e-cigarette use, especially in socially disadvantaged rural areas is of great importance so as to enable designing and implementation of appropriate preventive measures.

The aim of the study was to investigate the prevalence and factors associated with ever and current e-cigarette use, and correlates of the continued e-cigarette use among secondary and high school students (aged 13–19) from a socially disadvantaged rural area in Poland.

The study indicates that a high proportion of the youth from a socially disadvantaged rural area of Poland uses e-cigarettes; with male gender, alcohol consumption and tobacco smoking being predictors of the use of these products. The use of e-cigarettes was also significantly associated with harm perception and parental as well as friends smoking status. In addition, male gender, current tobacco smoking and lack of knowledge about a ban on smoking in the school were predictors of the continued e-cigarette use, whereas, higher parental education as well as perception of e-cigarettes as more harmful than tobacco cigarettes were protective factors of the continued e-cigarette use.

We found that almost 22 % of the adolescents from a socially disadvantaged rural area reported ever e-cigarette use and 27 % of them indicated e-cigarette use in the month preceding the study. These results are in line with the recent study conducted in Poland by Goniewicz et al. [10], where current e-cigarette use was declared by about 30 % of the youth population. Taking into consideration accessibility of tobacco products (including access via Internet) and exposure to e-cigarette advertisements, it can be suspected that in urban areas e-cigarette use may be even higher [20]. When comparing the prevalence of e-cigarette use between the countries, it is crucial to be aware of the year of investigation as the popularity of those products, especially among young people, has increased rapidly. It has been proven by existing research in this field. As an example, based on the data from the survey mentioned above, current e-cigarette use in the 2010–2011 sample was 5.5 %, whereas in the 2013–2014 sample it was almost six times higher [7, 10]. Other studies have also shown that ever and current e-cigarette use among students has increased significantly in the recent years [1, 8, 9, 21, 22].

It should be underlined that cigarette smoking as well as e-cigarette use is a learned behavior, which passes through various stages, namely: preparation, initiation, experimentation, regular and long-term use and addition [23]. Low prices of e-cigarettes, easy access to them as well as marketing activities and the fashion, all constitute factors that significantly contribute to e-cigarette initiation and continuous use [2]. It is also worth to mention that e-cigarette industry has a significant online presence, through which e-cigarettes have been promoted as both a safer alternative to cigarette smoking and a dual use product in place where smoking is not allowed [2]. The meaning of e-cigarettes in adolescents’ everyday life may be similar to that of conventional cigarette use since they share similar features [4]. In addition e-cigarettes may appeal to adolescents with novelty-seeking or sensation-seeking characteristics [4]. Another interpretation could be that e-cigarettes appeal to young people in the process of forming a smoker identity – a known risk factor for smoking escalation [4].

In line with the studies conducted in the U.S., Canada and Europe, gender was found to be a predictor of e-cigarette use with males being more likely to have tried this product [2, 4, 7, 14, 15, 24–29]. This may be due to socio-cultural determinants and it can also indicate to what extent young people are influenced and susceptible to marketing activities and current trends. In addition, boys may be “early adopters” of technology, and perhaps, they can get attracted to e-cigarettes earlier due to their novelty [4].

While the use of e-cigarettes may be driven by the desire to quit smoking in the population of older, more established smokers, the findings suggest that intention to quit does not play a crucial role in the e-cigarette use among the youth [30]. In our study, among the never tobacco users 6 % declared current and 10 % ever e-cigarette use. Adolescence is the time when individuals often experiment with and initiate the use of some substances [31]. This can create a risk of developing dependence and initiation of tobacco use. In addition, dual use (current tobacco smoking and e-cigarette use) was indicated by 58 % of our study respondents. Similarly, in other studies the higher risk of e-cigarette use was observed among daily tobacco smokers [2, 4, 7, 15, 24, 30]. This can result in a situation when the individuals are exposed and addicted to higher levels of nicotine and thus, it reduces their chances of cessation.

We also identified alcohol consumption as a risk factor for e-cigarette use, which strengthens the concept formulated as a result of the studies, conducted both in the adults and the youth, that e-cigarettes may be an element of multiple product use – users of other products, such as tobacco, alcohol, have greater odds of e-cigarette use [9, 15, 30].

Problem behavior theory suggests that risky behaviors cluster because they serve the same purpose socially, developmentally and psychologically or are a manifestation of similar underlying factors [12, 32, 33]. Alternatively, the gateway and reverse gateway theories suggest that adolescent use of one substance increases the likelihood of using other substances [34].

Additionally, sensation seeking, or the need for new, different, or complex sensations and experiences, and the willingness to take risks to achieve them, associate with adolescent substance use and may increase e-cigarette experimentation [35].

Based on our assessment, similarly to the study by Goniewicz and Zielinska-Danch [7], the adolescents who had parents and friends who smoked were more likely to use e-cigarettes than those with no smoking persons in their family and surrounding. It is proven that people tend to choose their friends based on shared characteristics, including tobacco smoking or e-cigarette use [36]. However, having close friends who use these products does not need to mean that they caused the person to do so. On the other hand, strong commitment not to smoke or use an e-cigarette if offered is crucial as a protective factor for not taking up such a behavior [37, 38].

In our analysis those who perceived e-cigarettes as less harmful than tobacco cigarettes were more likely to use e-cigarettes. This indicates that a favorable perception in terms of harm, benefits of use and general appeal (i.e. flavors and colors) of novel products are related to their attractiveness, especially among the youth [15, 39, 40]. In addition, harm perception can express familiarity with the product in such a way that individuals who have not tried e-cigarettes might not have a full understanding of the risk and benefits associated with their use [30]. In this context, more research evaluating health effects of e-cigarettes and their impact on young children motivation to start using traditional cigarettes is needed. Educational activities in school curriculum increasing young people’s awareness in this area also need to be pointed.

We also evaluated correlates of the continued e-cigarette use. Among a variety of factors, male gender, current tobacco smoking and the lack of knowledge about a ban on smoking in the school predispose the youth to the continued e-cigarette use. Similar results, although conducted on a smaller sample size (which can limit the level of significance), have been observed by Babineau et al. [24]. This population should be the target group for public health action.

The current analysis has several strengths. The study has been conducted in a socially disadvantaged rural district of Poland which, as located in a remote and difficult to reach area, is usually less frequently covered by national representative surveys and preventive actions including tobacco control measures. The fact that all the secondary and high schools in Piotrkowski district were covered by the study, and a high response rate (above 85 %) constitute other significant advantages of the current assessment.

Limitations of the study also need to be pointed. Firstly, all estimates in our assessment were based on self-reports, which might be affected by reporting bias. However, the study results are similar to the previous data for the youth population in Poland, which proved reliability of the obtained results [10]. Secondly, as the study was developed to investigate different forms of tobacco or nicotine products and it was not specifically dedicated to e-cigarettes, we did not assess if the youth used e-cigarettes continuously or occasionally, or only experimented with them within the period covered by the study. In addition, there are no data about e-cigarette smoking by friends and family members of the respondents. Our assessments indicated that parents and friends smoking traditional cigarettes are significant predictors of e-cigarette use. This can be also the case when considering e-cigarette use as social influence is a very strong driver of the initiation and habituation of health behaviors. Finally, we do not have the detailed data allowing to assess their willingness to quit tobacco smoking and more psychologically oriented motivation for using e-cigarettes.

Despite the limitations, the current study provides a valuable insight into the prevalence, patterns and correlates of e-cigarette use in the adolescents from a socially disadvantaged rural area of Poland.

The study indicates the widespread use of e-cigarettes among the youth from a socially disadvantaged rural district in Poland. The study findings underscore the need for further research assessing whether e-cigarettes may serve as a starter product for nonsmokers, or as the alternative or cessation measure for tobacco. Moreover, motives and risk factors for dual use of e-cigarettes and tobacco cigarettes still remain not resolved. The impact of e-cigarettes promotion and advertising, on one hand, and of educational campaigns, on the other, on the use of such products among the youth needs to be evaluated. Finally, more research is needed to fully understand safety and health effects of e-cigarette use.

95 % CI, 95 % confidence interval; CDC, Center for Disease Control and Prevention; E-cigarettes, electronic cigarettes; ETS, environmental tobacco smoke; GYTS, Global Youth Tobacco Survey; OR, odds ratio; WHO, World Health Organization.