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Electronic cigarettes in Italy: a tool for harm reduction or a gateway to smoking tobacco?
  1. Xiaoqiu Liu1,
  2. Alessandra Lugo1,
  3. Enrico Davoli1,
  4. Giuseppe Gorini2,
  5. Roberta Pacifici3,
  6. Esteve Fernández4,
  7. Silvano Gallus1
  1. 1 Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
  2. 2 Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
  3. 3 National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
  4. 4 Institut Català d’Oncologia (ICO)-Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), School of Medicine, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
  1. Correspondence to Dr Silvano Gallus, Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS , Milano 20156, Italy; silvano.gallus{at}


Introduction More than a decade after electronic cigarettes (e-cigarette) hit the European market, we are still debating whether they may help or hinder tobacco control. It is therefore useful to explore the potential net effect of e-cigarette use in the general population.

Methods We annually conduct a face-to-face survey on smoking in Italy on a representative sample of the general population aged 15 years or over (52.4 million). A total of 15 406 subjects were interviewed in 2014–2018. We investigated the consequences of using e-cigarettes on tobacco smoking behaviour among ever and regular e-cigarette users.

Results In all, 5.7% of our sample reported ever e-cigarette use. Multivariate analyses showed more use by men, ex-smokers and current smokers. E-cigarette use decreased with age and increased with education and calendar year. Only 1.1% of subjects were regular e-cigarette users. This prevalence rose from 0.4% in 2014–2015 to 1.8% in 2016–2017 and was 1.3% in 2018. Among 522 ever users, 13.2% stopped smoking after trying e-cigarettes and 22.2% started smoking or relapsed after using e-cigarettes. The corresponding estimates among regular users were 24.7% and 28.0%, respectively.

Conclusions Among Italian e-cigarette users, those (re)starting smoking after using e-cigarettes outnumber those who stop smoking after using e-cigarettes. From a public health point of view, e-cigarettes may have an unfavourable net effect. Consequently, if we are not able to prevent sales of e-cigarettes to non-smokers, this product will more likely stimulate smoking tobacco than reduce harm.

  • cessation
  • electronic nicotine delivery devices
  • harm reduction
  • denormalization

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  • Contributors SG had the original idea for the study; RP provided the survey data; XL, AL, SG and RP gave substantial contribution to conception and design of data; AL and XL conducted the data analysis; XL and SG drafted the manuscript; all authors provided substantial contribution to the interpretation of data and critically revised the manuscript; all authors approved the final version of the manuscript.

  • Funding The surveys were conducted with the contribution of the Italian Ministry of Health. The work of AL was supported by a fellowship from the Italian Association for Cancer Research (AIRC). The work of SG and XL was partially supported by the Italian League Against Cancer (Milan). EF is supported by the Ministry of Universities and Research, Government of Catalonia (2017SGR319), and the Instituto de Salud Carlos III, Government of Spain (INT16/00211 and INT17/00103), cofunded by the European Regional Development Fund (FEDER). This study was partially supported by the European Union’s Horizon 2020 project TackSHS under grant agreement no. 681040.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The Ethics Committee of Istituto Neurologico Carlo Besta–Milano acknowledged the collection of anonymous data in face-to-face population-based, observational, cross-sectional studies (File number 37, 2017).

  • Provenance and peer review Not commissioned; externally peer reviewed.