Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy

RESEARCH REPORT
Electronic cigarette: users profile, utilization,
satisfaction and perceived efficacyadd_35051.12
Jean-François Etter1 & Chris Bullen2
Institute of Social and Preventive Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland1 and Clinical Trials Research Unit, School of PopulationHealth, University of Auckland, Auckland, New Zealand2 ABSTRACT
To assess the profile, utilization patterns, satisfaction and perceived effects among users of electronic cigarettes (‘e-cigarettes’). Design and Setting
Internet survey in English and French in 2010. Measurements
questionnaire. Participants
Visitors of websites and online discussion forums dedicated to e-cigarettes and to smoking cessation. Findings
There were 3587 participants (70% former tobacco smokers, 61% men, mean age 41 years). The median duration of electronic cigarette use was 3 months, users drew 120 puffs/day and used five refills/day. Almost all (97%) used e-cigarettes containing nicotine. Daily users spent $33 per month on these products.
Most (96%) said the e-cigarette helped them to quit smoking or reduce their smoking (92%). Reasons for using the e-cigarette included the perception that it was less toxic than tobacco (84%), to deal with craving for tobacco (79%) and withdrawal symptoms (67%), to quit smoking or avoid relapsing (77%), because it was cheaper than smoking (57%) and to deal with situations where smoking was prohibited (39%). Most ex-smokers (79%) feared they might relapse to smoking if they stopped using the e-cigarette. Users of nicotine-containing e-cigarettes reported better relief of with- drawal and a greater effect on smoking cessation than those using non-nicotine e-cigarettes. Conclusions
were used much as people would use nicotine replacement medications: by former smokers to avoid relapse or as an aid to cut down or quit smoking. Further research should evaluate the safety and efficacy of e-cigarettes for administration of nicotine and other substances, and for quitting and relapse prevention.
Keywords
E-cigarette, electronic cigarette, electronic nicotine delivery systems (ENDS), internet, nicotine, Correspondence to: Jean-François Etter, Institute of social and preventive medicine, University of Geneva, CMU, case postale, CH-1211 Geneva 4, Switzerland. E-mail: [email protected] Submitted 8 February 2011; initial review completed 4 May 2011; final version accepted 11 May 2011 INTRODUCTION
tobacco cigarettes and may be important in their popu- larity and in assisting smokers to quit.
Electronic cigarettes (referred hereafter as e-cigarettes E-cigarettes are popular. Google searches for ‘elec- and by some authorities as electronic nicotine delivery tronic cigarettes’ have increased by 5000% over the past 2 systems, ENDS) look like tobacco cigarettes, but do not years [4], and 9% of UK smokers and 9% of Polish teenage contain tobacco. Instead, they comprise a metal casing smokers report having used them [5,6]. Many smokers within which a battery-powered atomiser produces a report using them to quit smoking [7,8], or to ‘smoke’ in vapour for inhalation from cartridges that contain smoke-free places [7]. However, because there are no data humectants (e.g. propylene glycol or glycerol), flavours, supporting the marketers’ claim that e-cigarettes help nicotine or in some cases other medications (rimonabant, smokers to quit, the World Health Organization (WHO) amino-tadalafil) [1–3]. Their appearance, size, handling and the US Food and Drug Administration (FDA) have and oral inhalation characteristics resemble those of asked them not to make therapeutic claims [9,10].
Conference presentation: This study was presented at the European Conference on Tobacco or Health, Amsterdam, the Netherlands,28–30 March 2011.
2011 The Authors, Addiction 2011 Society for the Study of Addiction Jean-François Etter & Chris Bullen Few research reports on e-cigarettes are available participants who had used the e-cigarette during a [11–19]. In clinical studies, e-cigarettes appear to attenu- ate craving for tobacco, despite delivering very little • Respiratory symptoms [clinical chronic obstructive nicotine to the blood [16,17,20]. Laboratory testing has pulmonary disease (COPD) questionnaire] [31,32].
shown that some e-cigarette cartridges may contain • Reasons for using and reasons for stopping use.
toxic components, including low levels of carcinogens • Side effects, acceptability and satisfaction.
[12,14,19]. Many questions remain unanswered: are e-cigarettes safe, are they addictive, who uses them, why therapy, bupropion and varenicline).
and how are they used, are they effective for smoking • Smoking status, cigarettes per day and time to first cessation or reduction [21,22]? Also unanswered are questions about their wider impact: are they used by • Currently trying to quit or reduce smoking, intention to young non-smokers, could they be a gateway to tobacco quit, confidence in ability to quit.
use or nicotine dependence, and could their use in public • Age, sex, income, education, country and, from May places undermine smoke-free laws [4,6,19,22–24]? 2010 onwards, where respondents learned about the Conducting clinical trials of these devices is challeng- ing: there is a lack of safety data, the regulatory environ- ment makes conducting trials of such novel devices Statistical analyses
difficult [14,22,25] and trials are expensive and time- We compared current and former smokers, and users consuming to conduct. Therefore, until trials can be of e-cigarettes containing nicotine with those using undertaken, user surveys are a means of gathering infor- e-cigarettes without nicotine. There is a concern that mation about the effects of this product on a range of participants enrolled on forums and websites that defend outcomes [5–7]. The aim of this study was to describe the rights of e-cigarette users may deliberately answer in e-cigarette users, assess how and why they used this a way that is favourable to their agenda (e.g. exaggerating product, their satisfaction with the product and its satisfaction or under-reporting side effects). To test this hypothesis, we compared two groups: (i) the 1005 users who learned about the survey on websites where the right to use e-cigarettes is often debated and advocated: We posted a questionnaire on the smoking cessation (n = 129), Casaa.org (n = 32), the UK Vapers forum website Stop-Tabac.ch [26–28], in English and French, (n = 23), Vapersclub.com (n = 20) or Forum-ecigarette.
and used data collected between March and October com (n = 19), with (ii) the 83 participants who learned of 2010 (data collection will continue until December the survey on more neutral sites, including Stop-tabac.ch 2011). We contacted discussion forums and websites (n = 26) (a smoking cessation website with some factual, informing about e-cigarettes or selling them, and asked neutral information on e-cigarettes), on Google (n = 30) them to publish links to the survey (http://www.stop- or on other sites unrelated to e-cigarettes (n = 27).We tabac.ch/fr_hon/ECIG_EN). Participants were aged >18 used analyses of variance (ANOVAs) to compare means, years, and current, past and never-users of e-cigarettes Mann–Whitney U-tests to compare medians and c2 tests were eligible. We recorded IP addresses (i.e. computer to compare proportions. For most variables, we reported numbers) to identify and delete duplicate records, and medians rather than means, because medians are less collected saliva vials in a subsample of participants for sensitive to extreme values. We used linear regression cotinine analysis (results reported separately) [29]. The models to test associations between continuous variables, sample size expected initially was 1500, but participation with 95% confidence intervals (CI) around the point was greater than expected. The survey was approved by estimates as a measure of precision. Prices in currencies the ethics committee of the Geneva University Hospitals.
other than $US were converted to $US. A P-value of The questionnaire, based on previous work by the <0.05 was used as the cut-off for judging statistical • Prior or current use of e-cigarettes, and intention to use • Dosage, puffs/day, brand, flavours, cost and where Participant characteristics
• Duration of use, delivery of nicotine, ease in staying off The raw data file included 3659 records, but we deleted • Effect on smoking cessation and on tobacco withdrawal 66 double entries (i.e. duplicate answers by the same symptoms (Minnesota Withdrawal Form) [30], in people identified by computer numbers) and six records of 2011 The Authors, Addiction 2011 Society for the Study of Addiction people aged <18. The median age of the 3587 partici- France: Janty (27.5%), Joye (19.8%), Sedansa (13.7%), pants was 41 years (25th and 75th percentiles: 31 and Kyozen (6.9%) and CigLib (6.9%); and in the United 50 years), most were men (61%), former smokers (70%) Kingdom: TECC (19.9%), Totally Wicked (17.6%), Titan and answered the English version of the questionnaire (13.2%), Joye (11.8%) and Screwdriver (9.6%). The most- (79%) (Table 1). Distribution of respondents by country used models (sold under various brand names) were the was: United States (62%), France (14%), United Kingdom 510 (40.5% of daily e-cigarette users), the eGo (11.3%), (6%), Switzerland (4%), Canada (3%) and other countries the KR808 (9.1%), the 901 (6.4%) and the Tornado (11%). Participants learned about the survey on the fol- (5.1%). The flavours used most were tobacco (39% of lowing websites: E-cigarette-forum.com (53%), Vapersfo- users), mint–menthol (15%), various fruit flavours rum.com (9%), the Sedansa website (3%), the Totally (14%), coffee (9%), vanilla (5%) and chocolate (3%). The Wicked website (2%), Casaa.org (2%), Google (2%), Stop- tobacco flavour was rated lower (83% ‘good’ or ‘very tabac.ch (2%), the UK Vapers forum (2%) and other web- good’) than for all other flavours combined (93%, sites (25%). Most participants (58%) had obtained a c2 = 115, P < 0.001). The models tested in previous diploma that would give access to university, and house- studies [14–19,24,33] were seldom or never used by hold income tended to be above average. Among current respondents: Njoy (n = 10, 0.3%), Liberty (n = 8, 0.3%), smokers, most reported currently trying to quit or to Ruyan (n = 5, 0.2%), Smoking Everywhere (n = 4, 0.1%), reduce their tobacco use. Very few (n = 4) never smokers Gamucci (n = 4, 0.1%), Crown Seven (n = 0), inLife used nicotine-containing e-cigarettes, but of these, three (n = 0), Supersmoker (n = 0) and VapCig (n = 0).
said they used them to deal with their craving for tobacco Among daily users of the e-cigarette, the median and to avoid relapsing to smoking, indicating that duration of the current episode of use was 3 months, but they were actually former smokers misclassified as 15% had been using it for 1 or more years. Daily users never smokers. Most participants were current users of drew an average of 120 puffs per day (Table 2). Almost all e-cigarettes, but 15.2% were never users and 1.3% were daily users (97%) said their e-cigarette contained nico- tine. The median capacity of refill bottles was 20 ml and the median nicotine concentration in the liquid, uniform Daily users versus never users of e-cigarettes
across brands and models, was 18 mg/ml (Table 2). Daily users used two bottles of refill liquid per month, refilled There were more men (65% versus 46%, P < 0.001) and their e-cigarette five times a day, and each refill or car- more former smokers (77% versus 42%, P < 0.001) tridge lasted 2 hours. The average price per kit was 60 among daily e-cigarette users than among never users.
$US, and daily users spent 33 $US per month for their Daily users were more likely to have ever used bupropion e-cigarettes (including refill liquid and cartridges, batter- (30 versus 19%, P < 0.001) and nicotine therapy (70 ies, components). Almost all daily users (96%) bought versus 64%, P < 0.001), but not varenicline. Among their e-cigarettes on the internet and about half (45%) current smokers, daily e-cigarette users smoked fewer intended to continue using them for another year or cigarettes than never users (13 versus 16 cigarettes/day, more. Daily users used their e-cigarette mainly at home P < 0.001). However, before they first started using the (98% ‘often’ and ‘very often’), in their car (90%) and at e-cigarette, daily e-cigarette users smoked more tobacco work (71%), but less frequently in cafes/restaurants/ than never users (25 versus 16 cigarettes/day, P Յ bars/discos (43%), in public transport (15%) or during 0.001). Among smokers, e-cigarette users were also more likely than never users to be currently trying to quit smoking (71 versus 51%, P < 0.001) or trying to reduce Satisfaction
their tobacco use (96 versus 72%), more confident in Most current smokers reported that the e-cigarette helped their ability to quit (‘very sure’: 17 versus 6%, P < 0.001), them to reduce their smoking (92%), and most former and had lower scores on the clinical COPD questionnaire smokers (96%) said that it helped them to quit smoking.
(total score: 1.25 versus 1.79, P < 0.001). Among former Most ever users (89%) said that it was easy to abstain smokers, the duration of smoking abstinence was shorter from smoking while using the e-cigarette (Table 3). Most in daily users than in never users (105 versus 150 days, users (94%) were willing to recommend it to a friend, and satisfaction ratings were high (mean = 9.3 on a 0–10scale). Few (10%) still experienced the urge to smoke Utilization
while using the e-cigarette, and most former smokers The most-used brands varied by country. Among daily (79%) feared that they would relapse to smoking if they users living in the United States, the most-used brands were: Joye (40.5%), Vapor4Life (9.2%), Janty (5.8%), Most ever users (91%) liked the e-cigarette’s taste and Totally Wicked (5.8%) and PureSmoker (5.3%); in the sensation while inhaling (Table 3). However, 22% 2011 The Authors, Addiction 2011 Society for the Study of Addiction Jean-François Etter & Chris Bullen 2011 The Authors, Addiction 2011 Society for the Study of Addiction 2011 The Authors, Addiction 2011 Society for the Study of Addiction Jean-François Etter & Chris Bullen 2011 The Authors, Addiction 2011 Society for the Study of Addiction reported that it burned the throat or gave a dry mouth or dry throat (26%). Similar proportions suggested the vapour should be more concentrated (20%) and that it should be easier to draw (inhale) on the e-cigarette (20%). One-third thought that the cartridges and batter- ies ran out too quickly, 18% said that the liquid some- times leaked from the device, and 8% reported that their e-cigarette had broken down at some stage. Only a small proportion expressed concerns that the e-cigarette might be toxic (6%) or could lead to dependence (8%), but most feared that it might one day be banned by authorities Linear regression modelling showed that the price of e-cigarette kits was not associated with the length of battery life, but was associated with the duration that refill cartridges lasted: for each additional 10 $US spent per kit, refills lasted 0.5 hours longer (t = 3.1, 95% CI:0.2–0.9 hours, P = 0.002). There were no statistically significant associations between price and technical problems such as breakdowns or leakage.
Reasons for use
E-cigarettes were used because they were perceived to be less toxic than tobacco (84%), to quit smoking or avoid relapsing (77%), to deal with craving for tobacco (79%) and tobacco withdrawal symptoms (67%), and because they were cheaper than smoking (57%) (Table 4). Other less common reasons were to avoid bothering other people with tobacco smoke (44%), to deal with smoke- free situations (39%) or to avoid having to go outside to smoke (34%). Fewer used the e-cigarette to reduce tobacco consumption (28%), and far fewer reported Reasons for stopping use
Those who had stopped using e-cigarettes (n = 47) indi- cated that they had done so because they did not need them any more (41% ‘rather’ plus ‘strongly agree’), because they thought they would not relapse to smoking even if they stopped (33%), because of the product’s poor quality (35%), because it did not reduce cravings (33%), because they relapsed to smoking (25%), because it did not help them to quit smoking (21%), because they feared its side effects (21%) or because they replaced it with a Withdrawal symptoms
For participants who had used the e-cigarette during a quit attempt and who reported withdrawal symptoms (‘moderate’ or ‘severe’) [30], Table 5 shows the propor- tion who also reported whether the e-cigarette relieved symptoms. Craving to smoke was the symptom most 2011 The Authors, Addiction 2011 Society for the Study of Addiction Jean-François Etter & Chris Bullen relieved by the e-cigarette (90%). The effects of e-cigarettes on suppressing withdrawal symptoms were reported as being greater by former smokers than current smokers, and greater by users of nicotine-containing e-cigarettes than users of non-nicotine e-cigarettes Use to inhale other substances
Very few ever users (n = 27, 0.9%) reported having used the e-cigarette to inhale other substances than the liquid designed for that purpose. The substances disclosed were cannabis (n = 5, 0.2%), vitamins (n = 3), flavours (n = 2),herbs (n = 2) and vodka (n = 1). The median duration ofe-cigarette use to inhale these substances was five days, but only 1 day among those who used cannabis.
Comparing users of e-cigarettes containing or not
containing nicotine
Compared with users of non-nicotine e-cigarettes, users of nicotine-containing e-cigarettes were more likely to be men and smoked more tobacco cigarettes per day before they first started using e-cigarettes (Table 1). However, there was no between-group difference for current smoking status. Those who used nicotine-containing e-cigarettes were more likely to be daily users, used their first e-cigarette of the day earlier in the day, drew more puffs on their e-cigarette, used more refills per day and more bottles per month, their refill cartridges lasted less, and more of them intended to use e-cigarettes for another year or more (Table 2). Users of nicotine-containing e-cigarettes were also more likely to answer that it helped them to quit or reduce their smoking, they were more satisfied with it, in particular with its taste and with the sensation while inhaling, more likely to say that they feared relapsing if they stopped using it, but they were also more likely to answer that e-cigarette use burned their throat (Table 3). Most of the reasons for using the e-cigarette were endorsed more frequently by users of nicotine-containing e-cigarettes than by users of non- nicotine e-cigarettes, in particular use to deal with Comparing current and former tobacco smokers
Former smokers were more likely than current smokers to use the e-cigarette and to have ever used smoking ces- sation medications (Table 1). Among daily e-cigarette users, the duration of use was longer in former smokers than in current smokers (Table 2). Former smokers also took more puffs per day, were less likely to use the tobacco flavour, used larger refill bottles, their refills or cartridges lasted less and they spent more per month than current smokers. Former smokers were also more likely to say 2011 The Authors, Addiction 2011 Society for the Study of Addiction that the e-cigarette helped them to quit or reduce their for using them (Table 6). When analyses were restricted smoking, to report that it helped improve their respi- to former smokers, differences in several satisfaction vari- ratory symptoms, and to use e-cigarettes to deal with ables were smaller and often non-significant: e.g. satisfac- tobacco withdrawal symptoms (Table 3).
tion rating (0–10 scale): mean = 9.6 in both groups(t = 0.2, P = 0.8), ‘e-cigarette burns the throat’ (16.3 Comparing participants enrolled on e-cigarette forums
versus 25.0%, c2 = 0.8, P = 0.7) and ‘fear e-cigarette with those enrolled on neutral sites
might be toxic’ (6.1 versus 0%, c2 = 2.0, P = 0.75).
The 1005 participants enrolled on e-cigarette forums/ websites were more likely to be former smokers than DISCUSSION
the 83 participants enrolled on ‘neutral’ websites (72 versus 43%, P < 0.001), more likely to be daily e-cigarette The main finding of this survey, which enrolled predomi- users (93 versus 31%, P < 0.001), had used the nantly self-selected visitors of websites dedicated to e-cigarette longer (current episode of use: 91 days versus e-cigarettes, is that e-cigarettes were used largely by 14 days [medians], P = 0.003), were generally more sat- former smokers as an aid to quit smoking, to avoid relapse isfied with the e-cigarette, but indicated the same reasons and to deal with withdrawal symptoms, much as Table 6 Comparison of participants enrolled on e-cigarette forums with those enrolled on other websites.
E-cigarette helped reduce smoking? (a lot, %) Would recommend e-cigarette to a friend (absolutely, %) In ex-smokers: e-cigarette helped quit smoking (a lot + definitely, %) Afraid of becoming addicted to e-cigarette Reasons for using e-cigarette (very true, %) 2011 The Authors, Addiction 2011 Society for the Study of Addiction Jean-François Etter & Chris Bullen people use nicotine replacement therapy (NRT). Use of above [16,17]. The uniformity of nicotine content across e-cigarettes in smoke-free places was cited relatively less the different brands makes it possible to compare them.
frequently, but many participants used them because they The average content of nicotine per bottle, 360 mg were perceived to be less toxic and cheaper than tobacco.
(20 ml ¥ 18 mg/ml), is of concern because the fatal dose Daily users spent 33 $US per month for e-cigarettes, which of nicotine is estimated to be 30–60 mg for adults and is much cheaper than smoking one pack a day (incurring 10 mg for children [2]. Thus, these refill bottles are a cost of about 150–200 $US per month in the respon- extremely dangerous and should be replaced by sealed, dents’ countries). This is also substantially cheaper than tamper-proof, leak-resistant cartridges.
smoking cessation medications (which, at the recom- Daily use (120 puffs and five refills per day, that is, 24 mended dosage, cost about the same as smoking one pack puffs per refill) was in the range of the number of puffs a day). Thus, an important reason for the popularity of inhaled by daily cigarette smokers. However, the average e-cigarettes [5,6] is most probably their price.
24 puffs per refill is considerably less than the 170–300 Several other findings raise questions needing further smokeable puffs reported from in vitro tests (i.e. the research. For example, it would be interesting to investi- number of puffs before the aerosol density decreased) gate why e-cigarettes have more appeal to men than to [18]. This could mean that users switch cartridges when women. Only one never smoker used nicotine-containing the flavour or the nicotine taste fade out, and this may e-cigarettes, a finding that could reflect the fact that occur much sooner than a decrease in aerosol density. A under-age consumers were ineligible for the survey, or dosage of 120 puffs/day suggests a more intense use than that contrary to the hypothesis expressed by some the 10 puffs or 5 minutes puffing tested in clinical reports authors [4,23,24], e-cigarettes do not facilitate initiation [15–17]. An implication of this is that laboratory tests to nicotine use in young never smokers.
should allow users to puff substantially more before The duration of use in former smokers (5 months) was outcomes are measured, to mimic actual utilization by substantially longer than use of NRT (usually a few days to a few weeks) [34,35, Etter & Schneider; unpublished The flavour used most was tobacco, even though this data]. This suggests either that our sampling method flavour rated lowest for satisfaction, possibly because resulted in the self-selection of long-term users, or that some users did not sample all available flavours before e-cigarettes are actually used longer-term than NRT, for choosing one. The sensation of a burning throat and dry mouth or throat was due in part to nicotine; whether it is It is not clear why one brand (Joye) and one model (the also due to the humectants should be investigated.
510) dominated the market. This may result from success- ful marketing, or perhaps users may communicate about Perceived effect on smoking and withdrawal symptoms
their preferred brands in online forums, and the best Our data suggest that e-cigarettes may help smokers to brands may gain popularity this way. It may be that some quit smoking, reduce their cigarette consumption and brands were over-represented in this survey because attenuate craving and tobacco withdrawal symptoms.
of links from websites selling these brands, in particular Users of nicotine-containing e-cigarettes reported only Totally Wicked and Sedansa. The models used in previous slightly superior effects on withdrawal than users of non- studies were seldom or never used by participants in this nicotine e-cigarettes, suggesting that nicotine delivery study [14–19,24]. To ensure validity and generalizability, explains only part of the effect of these devices on with- future studies should use the most popular models.
drawal, and that the sensory and behavioural compo- Very few respondents (3% of users) used e-cigarettes nents of the e-cigarette are also important. Of interest, without nicotine. This could suggest that, despite two current smokers who used the e-cigarette had fewer res- studies showing very low absorption of nicotine [16,17], piratory symptoms than smokers who did not use it it may be an important ingredient of this product, (a difference of 0.54 points on the clinical COPD ques- perhaps because of its taste in addition to its pharmaco- tionnaire), which we speculate might be a consequence logical properties on withdrawal relief. Alternatively, of reduced smoking. This difference is substantial, as it is users might have greater expectations for nicotine- larger than the minimally clinically important difference containing products, so these products are purchased for this questionnaire (0.4 points) [32], and very close to more commonly. Interestingly, the concentration of nico- the difference of 0.6 points reported previously between tine in the liquid was uniform across the various brands patients with moderate and severe COPD [31].
(18 mg/ml), suggesting that manufacturers reached a consensus. It is not clear how this particular concentra- Use for other substances
tion was arrived at, but few users said that e-cigarettes should provide more nicotine, despite the low nicotine E-cigarettes represent a new way to administer sub- absorption observed in the two clinical studies noted stances to the respiratory tract. However, very few people 2011 The Authors, Addiction 2011 Society for the Study of Addiction reported using e-cigarettes to inhale substances other World Health Organization regarding electronic nicotine than the liquid designed for that purpose, and when they delivery systems (ENDS). He consulted for Pfizer, a manu- did, it was only briefly. Of course, some respondents may facturer of smoking cessation medications, in 2006–07 not have disclosed illicit drug use. Some e-cigarettes have (on the Swiss varenicline advisory board), and received been found to contain tadalafil analogues, rimonabant medications for a clinical trial from Pfizer in 2006; no and several other substances and medications [3], with competing interests since then. Chris Bullen’s salary is paid by The University of Auckland and his research is supported by grants from the New Zealand Health Study limitations
Research Council (HRC), the University of Auckland and the NZ Heart Foundation. He has previously undertaken This study was conducted in a self-selected sample of tobacco control research supported by the New Zealand visitors of discussion forums and websites dedicated Ministry of Health, and by Niconovum, Sweden, prior to to e-cigarettes, some of which defend the right to use the purchase of this company by RJ Reynolds. He is cur- e-cigarettes in the face of mounting pressure for regula- rently an investigator on a study involving reduced nico- tion or prohibition of this product [19,36,37]. However, tine cigarettes in which the products were purchased by organized multiple responding did probably not occur: a the University of Auckland from Vector Group Ltd, USA.
check of IP addresses showed that there were few double He has previously undertaken research on ENDS funded entries by the same participants, and double entries were by HealthNZ, in which the study products were supplied deleted. Users enrolled on e-cigarette forums/websites by Ruyan, Hong Kong; and he is the principal investigator differed from participants enrolled on ‘neutral’ sites on on an HRC-funded efficacy trial of ENDS that will use several accounts (mainly smoking status and current use products provided by a NZ-based ENDS retailer. Other of e-cigarettes), but when taking smoking status into than these relationships, he has no conflicts of interest account, the opinions of these two groups did not differ greatly. Nevertheless, it is still possible that some respon- dents gave the answers that they thought might help Acknowledgements
to defend their position (e.g. by reporting more satisfac- tion, more effects on smoking cessation, fewer concerns Vincent Baujard, from the HON Foundation, Geneva, about safety). Whether we also over-sampled satisfied Switzerland (http://www.hon.ch) developed the software users, long-term users or heavy users of e-cigarettes is unknown. Thus, while our results provide new and inter- References
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2011 The Authors, Addiction 2011 Society for the Study of Addiction

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