Scheer Report - Was steckt dahinter Teil 13

 Hallo Liebe Leser, 

Heute kommt dreizehnten Teil der Anmerkungen zum Scheer Report. Also die Dinge die mir zum Scheer Report aufgefallen ist und welche man als Anregung für eine Mail an die Abgeordneten mitnehmen kann.
Vorab liste ich Euch wie schon im vorigen Teil alle Artikel dieser Serie auf:

Wie auch im Teil vorher werde ich mich nur auf die Bereiche im Scheer Report beschränken, welche nicht explicit in den vorigen Artikeln behandelt wurden, es sei denn ich habe neue Anmerkungen dazu gefunden. Daher fangen wir auch mit Seite 62 des Scheer Reportes an. 

6.6 Role in the initiation of smoking (particularly focusing on young people)

In this section, electronic cigarette awareness, initiation, perception and reasons for use will be discussed, with a focus on adolescents as a vulnerable group. In total, 7 reviews were  found in the period 2016-2019 that covered this topic. It needs to be noted that most of the included studies have been carried out in the US. The SCHEER is aware, that US data may not necessarily reflect the exact situation in the EU, but trends coming from the US frequently also impact European markets. For the EU, information from the Eurobarometer was considered and comparison to the US was given as far as possible.

Electronic cigarettes are rapidly becoming a new trend among adolescents (Perikleous, et  al., 2018). In the US, they have become the most common tobacco products used by youth, driven in large part by marketing and advertising by electronic cigarette companies (Fadus, et al. 2019, Walley, et al. 2019). A 2016 review already showed that adolescents were nearing complete awareness of electronic cigarettes (Greenhill, et al. 2016). US current use among high school students increased from 1.5% in 2011 to 20.8% in 2018 (Fadus, et al. 2019, Walley, et al. 2019). This leads to concern that electronic cigarettes may be exposing a significant number of youth to nicotine who would have not otherwise be using tobacco, and additionally a "gateway" effect for combustible cigarettes and cannabis use has been suggested (Fadus, et al. 2019). Among adolescents, older age, male gender, conventional smokers, peer influence, daily smoking, and heavier smoking are the most common characteristics of electronic cigarette users (Perikleous, et al. 2018). In the EU, according to the "Special Eurobarometer 458" (May 2017), 15% of the respondents have at least tried electronic cigarettes and 2% use them regularly. Among young people (15-24), ever use is higher than average (25%), but no data are reported on current use per age group. However, these responses are from early 2017, and new data with a focus on youth use are warranted, given the dynamic electronic cigarette market, and the increase among youth use reported in the US. A recent review on the prevalence of electronic cigarette use among the general adult and young populations in Europe concluded that the prevalence of current electronic cigarette use ranged from 0.2% to 27%, ever-use ranged from 5.5% to 56.6% and daily use ranged from 1% to 2.9%. It also showed a higher prevalence of electronic cigarette use among males, adolescents and young adults, smokers of  conventional cigarettes, and former smokers (Kapan, et al. 2020). 21

A 2019 review describes the motivations for electronic cigarette use amongst young adults aged 18-25 and compares the reasons for using electronic cigarette of people who currently or formerly used tobacco products to those who had never smoked tobacco prior electronic cigarette use (Kinouani, et al. 2019). Independently of smoking status, curiosity was the most frequently reported reason for initiating the use of electronic cigarettes in young adults. Reasons for continuing to use electronic cigarettes were various. The continued use of electronic cigarettes could be either a means to replicate smoking habits, or a way for a different and personalized use of nicotine by inhalation. Overall, reasons for using electronic cigarettes in young adults are varied and are not limited to stopping smoking.

Similar conclusions can be drawn from a 2018 review of reasons for electronic cigarette use as reported by electronic cigarette users, cigarette smokers, dual users, and non-users, among both adults and youth. Adults’ perceptions and reasons for electronic cigarette use are often related to smoking cessation, while youth like the novelty of the product (Romijnders, et al. 2018). Young non-users perceived the electronic cigarette as a cool and fashionable product that mimics the smoking routine and is rather safe to use. In general, perceived benefits included avoidance of smoking restrictions, the product being cool and fashionable, having health benefits, lower costs compared to cigarettes, positive  experiences (mimics smoking routine, enjoyable taste, throat hit, weight control, increases  concentration), safety of use, smoking cessation or reduction purposes, social acceptability, and perceived benefits for second-hand exposed persons.
Expected benefits among one or more of the groups include the product having an enjoyable taste, being healthier than cigarettes, improving breathing, increasing concentration, satisfying nicotine need, availability of variety of flavours, and controlling weight. Experienced benefits among one or more of the groups include the possibility to avoid smoking restrictions by dual use of tobacco products and electronic cigarettes, curiosity and novelty, perceived health benefits (regained sense of smell and taste, improved breathing, decreased coughing, improved dental health, increased athletic performance, increased alertness, aid to concentration, reduces stress), product appeal, also as compared to cigarettes (pleasure of product use, taste of flavours, throat hit, convenience of product, possibility to alter technical specifications, lower costs compared to cigarettes, easily accessible, discrete in use (no lingering smell, able to hide use), practical in use (no lighter, no ashtray, one puff, and able to store the device)), smoking cessation purposes (alternative for smoking cigarettes, avoidance of withdrawal of nicotine, cut back cigarettes, use as smoking cessation aid, deal with cravings. Finally, the social environment is important (fitting in, pressure of social environment, recommended by friends or family, role models use e-cigarettes).

In the EU, according to the "Special Eurobarometer 458" (May 2017), the most frequently  mentioned reason (61%) for taking up electronic cigarettes was to stop or reduce tobacco consumption. Other reasons included electronic cigarettes being perceived as less harmful (31%), and lower cost (25%). Regarding the two most often-mentioned reasons, reducing tobacco consumption and being less harmful, more than three quarters of those aged 40 or over (76-78%) cite one of these as a reason, vs. 59% of those aged 15-24. Regarding product type, especially pod devices have become a more socially acceptable alternative to combustible cigarettes among adolescents and young adults, and have become popular among this age group as a result of
 (1) sleek designs,
 (2) user-friendly functions,
 (3) less  aversive smoking experiences, 
(4) desirable flavours, and
(5) the ability to be used discreetly in places where smoking is forbidden (Fadus, et al. 2019). 
One of these products is currently the most popular retail electronic cigarette brand in the USA, accounting for 76% of the retail electronic cigarette market at the end of 2018 (Fadus, et al. 2019). It would be interesting to collect such data from the EU as well. Unlike the US with no upper limit on nicotine levels in e-liquids, the EU TPD prescribes that nicotine levels in e-liquids should not exceed 20 mg/ml. It is important to note that the upper limit of 20 mg/ml nicotine can be compensated for by technological modifications in the device, yielding similar nicotine emissions levels as the American version that used high nicotine levels in the liquid (see below in the section on nicotine) (Mallock, et al., 2020).

Regarding flavours, a 2019 review found consistent evidence that flavours attract both youth and adults to use electronic cigarettes (Meernik, et al. 2019). Flavours decrease harm perceptions and increase willingness to try and initiate use of electronic cigarettes. Among adults, electronic cigarette flavours increase product appeal and are a primary reason for many adults to use the product. In the sections below, specific flavour, preferences are discussed.

Addictiveness and attractiveness related to ingredients

In this section, data from 8 reviews that covered electronic cigarette flavours and/or nicotine, from the period 2016-2019 will be discussed.
E-liquids are available in many flavours not found in traditional tobacco products, a commonly-cited reason for electronic cigarette use (reviewed in Goldenson, et al., 2019). Most e-liquid brands are available in a variety of youth-appealing flavours, ranging from fruits, desserts, candy, and soda to traditional tobacco (reviewed in Walley, et al., 2019). The number of available e-liquid flavours exceeded 7500 in 2014 and is still increasing (in Krusemann, et al., 2018). Forty-three main flavour categories have been found in literature, eg, tobacco, menthol, mint, fruit, bakery/dessert, alcohol, nuts, spice, candy, coffee/tea, beverages, chocolate, sweet flavours, vanilla, and unflavoured (Krusemann, et 42 al., 2018).

A review on flavour preferences showed that sweet preference in children and adolescents was higher than in adults (Hoffman, et al., 2016). Examples of preferred food-related tastes and odours for young people included cherry, candy, strawberry, orange, apple and cinnamon (Hoffman, et al., 2016). All of these flavours are used for e-liquids (Hoffman, et 48 al., 2016). Tobacco products in flavours preferred by young people may impact tobacco use and initiation, while flavours preferred by adults may impact product switching or dual use (Hoffman, et al., 2016).

Flavoured electronic cigarettes are used at electronic cigarette initiation by the majority of youth (Goldenson, et al., 2019). These flavours enhance the appeal of electronic cigarettes  by creating sensory perceptions of sweetness and coolness and masking the aversive taste of nicotine (Goldenson, et al., 2019). Use of flavoured electronic cigarettes is higher among youth and young adults (vs. older adults) and among non-smokers (vs. combustible cigarette smokers) (Goldenson, et al., 2019). Overall, consumers preferred flavoured  electronic cigarettes, and such preference varied with age groups and smoking status (Zare, 2 et al., 2018).

Adolescents consider flavour the most important factor trying electronic cigarettes and were more likely to initiate using through flavoured electronic cigarettes (reviewed in Zare, et al., 6 2018). Young adults overall preferred sweet, menthol, and cherry flavours, while non-smokers in particular preferred coffee and menthol flavours (Zare, et al., 2018). Adults in general also preferred sweet flavours (though smokers like tobacco flavour the most) and disliked flavours that elicit bitterness or harshness (Zare, et al., 2018).

The above-mentioned pod device with the 76% US-market share is a brand of electronic cigarette that has recently received significant media attention because of its rapid uptake by adolescents (Walley, et al., 2019). The appealing flavourings available (e.g., mango, fruit medley, menthol) can mask unwanted tastes and smells, and are often cited as a reason for experimentation among young users (reviewed in Fadus, et al., 2019).

Several flavours (candy and fruit flavours) were associated with decreased harm perception, while tobacco flavour was associated with increased harm perception (Zare, et al., 2018) among adult and youth electronic cigarette users, adult and youth cigarette smokers, and non-users (reviewed in Romijnders, et al., 2018). If non-users were not to perceive fruit- and candy-flavoured e-liquids as harmless, they might be less inclined to initiate electronic cigarette use (Romijnders, et al., 2018). Moreover, manufacturing labels are not always comprehensive in regard to e-liquid constituents and therefore might not alert the consumer to the potential for harmful effects (Sood, et al., 2018).

Overall, thousands of e-liquid flavours are available in tobacco and other flavours. Flavours are an important part of e-liquid appeal, and most consumers prefer flavoured e-liquids. Non-tobacco, sweet flavours are preferred by youth and non-smokers, and non-tobacco flavours are associated with decreased risk perception of electronic cigarettes. In the current EU-TPD, the use of all flavours is allowed, as long as they “do not pose a risk to human health in heated or unheated form” (TPD Article 20.3) Currently, unlike tobacco and roll-your-own tobacco, where products with a strong smell or taste other than tobacco are  banned because of their attractiveness for young people, there are currently no provisions regarding the attractiveness of electronic cigarette taste and smell. In the EU, according to  the "Special Eurobarometer 458" (May 2017), a relative majority are in favour of banning flavours in electronic cigarettes (40% in favour vs. 37% against). Interestingly, younger respondents (15-24) and electronic cigarette users (49% and 84% resp.) are more likely to oppose a ban on flavours in electronic cigarettes, maybe because these groups are interested in using flavoured electronic cigarettes. Another option might be the regulate flavours that are specifically attractive to young people. The "Special Eurobarometer 458"  (May 2017) also reports that the most popular flavour of electronic cigarette is fruit flavour (47%), followed by tobacco flavour (36%), menthol or mint (22%) and candy flavour  (18%). Alcohol flavoured electronic cigarettes are the least popular, favoured by only 2% of respondents, while a small minority (3%) also mentioned other, unspecified, flavours. Tobacco-flavoured electronic cigarettes are much more popular among those aged 55 or 46 more (66%) vs those aged between 15 and 24 (19%), whereas younger respondents are much more likely to prefer fruit-flavoured electronic cigarettes (72%, compared with 17%  of the oldest cohort) and somewhat more likely to prefer candy-flavoured electronic cigarettes (22%, compared with 11%).

According to the EHN, the fact that people, and particularly young people who have never smoked, are increasingly taking up electronic cigarette use deserves much attention as they are at substantial risk of becoming regular cigarette smokers. Moreover, it was  recommended 
(1) that flavours should be prohibited, mainly because they are likely to  attract children and young people
(2) the same regulations as for conventional cigarettes should be set for electronic cigarettes (i.e. regarding marketing, advertising, labelling and packaging, buying restrictions, age limits and the use of electronic cigarettes in public places, which should be prohibited).
Nicotine-containing e-liquids have a stimulating effect on the reward system within the brain, which is implicated in the development of addiction (in Krusemann, et al., 2018)). Whereas flavours are added to increase product liking, addictive substances such as nicotine play a role in motivation and influence the reward system through mechanisms of learning and wanting (in Krusemann, et al., 2018). Specific to youth, nicotine addiction and dependence leading to lifelong tobacco use is a major concern when considering electronic cigarette use (Walley, et al., 2019). Nicotine addiction is an adaption to nicotine exposure over time, and thus the high concentrations of nicotine in electronic cigarettes are of major concern.

Consumer preference for nicotine strength and types depends on smoking status, electronic cigarette use history, and gender (Zare, et al., 2018). Non-smokers and inexperienced electronic cigarette users tended to prefer no nicotine or low nicotine electronic cigarettes while smokers and experienced electronic cigarette users preferred medium and high nicotine electronic cigarettes (Zare, et al., 2018). Weak evidence exists regarding a positive interaction between menthol flavour and nicotine strength (Zare, et al., 2018).

Typical nicotine absorption from a conventional cigarette is 1 mg (range 0.3–2 mg), with blood nicotine levels ranging from an average of 15 to 30 ng/mL (Walley, et al., 2019). Studies of electronic cigarette use have revealed that, depending on duration of use and user puffing topography, serum levels of nicotine can be as high with electronic cigarette use as with use of a conventional cigarette (Walley, et al., 2019).

In one study, the urinary cotinine concentrations (a biomarker for nicotine exposure) among adolescents using the above-mentioned pod device with the 76% US market share was even higher than the urinary cotinine concentrations of those who smoked conventional cigarettes (Walley, et al., 2019). A recent study (2019) from Imperial Tobacco found that for electronic cigarettes with nicotine salts (lactate) the rate of nicotine absorption into the bloodstream was as rapid as that for conventional cigarette. The use of nicotine salts in electronic cigarettes enables cigarette-like pulmonary delivery of nicotine that reduces desire to smoke (O'Connell, et al., 2019).

The popular pod device utilizes protonated nicotine, which the company claims provides a more satisfying experience to the user by reducing aversive experiences of taste, smell, and throat irritation (Fadus, et al., 2019). In addition to PG and glycerol, the pod is advertised to contain benzoic acid (a naturally occurring acid found in the tobacco plant) and nicotine (Walley, et al., 2019). As of August 2018, it advertises pods with 2 nicotine concentrations of 5% (59 mg/mL) and 3% (35 mg/mL). Each pod is marketed as equivalent to ∼1 pack of 42 cigarettes (ie, 200 puffs).

As explained above, the EU TPD upper limit of 20 mg/ml does not mean that users will be exposed to lower levels of nicotine, as they can puff more intensely and adapt their device settings.

In conclusion, nicotine is an addictive substance and its levels range widely in e-liquids. Consumer preference for nicotine strength and types depends on smoking status, electronic cigarette use history, and gender. Serum levels of nicotine can be as high with electronic cigarette use as with use of a conventional cigarette. Traditional e-liquids use free-base nicotine. Use of nicotine salts, reduces throat irritation and enables high peak levels of  nicotine, similar to those of a tobacco cigarette. Note that according to the EU-TPD, the nicotine level in the liquid may not exceed 20 mg/ml (TPD Article 20.3). Additionally, liquids not containing nicotine are not covered by the TPD. However, such liquids are still on the market; e-liquids without nicotine are regulated via other laws (although in some EU
Member States, e-liquids without nicotine are regulated in the same way as nicotine-containing e-liquids, and covered by the Tobacco Law), and nicotine levels exceeding 20 mg/ml have also been signalled, even in physical shops. It is also interesting to note that a modified version of the popular pod device with the 76% market share is now available on the EU market, with technological adjustments to the wick (Mallock, et al., 2020) This product type compensates for the lower nicotine levels in the liquid, and the increased aerosolization results in nicotine delivery per puff approximately equal to the American original using high nicotine levels in the liquid. This suggests similar addictiveness potential of the enhanced European version and the original American product.
Role as a gateway product or renormalisation of traditional tobacco smoking
One of the four core purposes of this scientific opinion is to assist the Commission in assessing the most recent scientific and technical information on electronic cigarettes with regards to their role as a gateway to smoking and with respect to the initiation of smoking particularly focusing on young people. Within this context there are two hypotheses that need to be tested, the gateway hypothesis (in which the use of electronic cigarettes lead never tobacco users to begin using other tobacco products) (Bunnell et al., 2014; Kandel and Kandel 2014) and the renormalisation hypothesis (in which the public acceptance of  electronic cigarette use may lead to a renomalisation of tobacco use. (Fairchild et al., 2014)). Indeed, with adult and adolescent smoking rates decreasing due to tobacco control efforts, there remains concern if the expansion of electronic cigarettes may hinder tobacco control efforts and impact smoking rates as adolescents and young adults who were likely to never use any form of nicotine products start experimenting with electronic cigarettes and other forms of nicotine delivery.

Experimentation with tobacco products among non-tobacco using youth that experiment with electronic cigarettes (gateway)
To be able to attribute causality between an exposure and an outcome, a causal study design is necessary. One such study design that could potentially shed light on the potential  impact of electronic cigarette experimentation on subsequent tobacco use is a prospective cohort study design. To this extent, a recent systematic review and meta-analysis of cohort studies that assessed initial use of electronic cigarettes and subsequent cigarette smoking has been published and included individual cohort studies among youth – all of which are based in the US (Soneji et al., 2017). This meta-analysis included 389 adolescents and young adults, the ages ranged between 14 and 30 years at baseline, and 56.0% were female. The pooled probabilities of cigarette smoking initiation were 30.4% for baseline ever electronic cigarette users and 7.9% for baseline never electronic cigarette users. The pooled probabilities of past 30-day cigarette smoking at follow-up were 21.5% for baseline past 30-day electronic cigarette users and 4.6% for baseline non-past 30-day electronic cigarette users. Adjusting for known demographic, psychosocial, and behavioural risk factors for cigarette smoking, the pooled odds ratio for subsequent cigarette smoking initiation was 3.62 (95% CI, 2.42-5.) for ever vs never electronic cigarette users, and the pooled odds ratio for past 30-day cigarette smoking at follow-up was 4.28 (95% CI, 2.52- 7.27) for past 30-day electronic cigarette vs non-past 30-day electronic cigarette users at baseline. It is important to note that a moderate level of heterogeneity was identified, as the studies followed had different survey methods, sample sizes, age groups and differed in follow up. It is important to note however that the exposures and outcome in all cases were clearly defined. An earlier systematic review (Chatterjee, et al., 2016) also found similar results using data from four longitudinal studies that were subsequently also included in the meta analysis of Soneji et al. (2017).

Additional evidence was assessed through a systematic review by Glasser et al., covering 26 heterogenous studies of longitudinal design that included both adolescents or young adults, and assessed electronic cigarette use at baseline and cigarette smoking at follow-up. Results suggest that, among never smokers, electronic cigarette use is associated with the future (6 months to 2.5 years) cigarette experimentation; findings which may be limited by small sample size, measurement of experimental use and potentially confounding variables
SCHEER Preliminary Opinion on electronic cigarette (Glasser, et al., 2019). In this systematic review, three studies were located within 1 European Member states (2 in the UK, one in NL). One in Scotland noted that ever electronic cigarette users at baseline had a higher odds compared to never electronic  cigarette users of transitioning to cigarette smoking one year later in adjusted analyses (aOR = 6.64, 95%C.I = 3.60-12.26) (Best et al, 2017). The other in England noted that ever smoking a cigarette at follow up was predicted by baseline ever use of electronic cigarettes (aOR 4.06, 95% C.I: 2.94-5.60) (Conner et al., 2017). Similarly although not included in the above systematic review, East et al. (2018), identified that the odds of smoking initiation in ever users of electronic cigarettes were (OR=12.31, 95% Cl: 5.06–9 29.94) (Adjusted OR=10.57, 95% CI: 3.33–33.50).

A systematic review and meta-analysis of studies in the UK by Aladeokin et al., (2019), which included eight studies (involving 73076 adolescents), from the UK, of which the above three were included in the meta-analysis and identified that the odds of smoking initiation for non-smoking adolescents who used electronic cigarettes was 3.86 (95%C.I:2.18-6.82). The only other EU study identified by the above review was in the Netherlands. Within this cohort study adolescents who ever used an electronic cigarette with nicotine at baseline were at 11.90 higher odds of having smoked a conventional  cigarette 6 months later, than those who never used an electronic cigarette with nicotine (95% CI 3.36–42.11) -albeit with the limitation of a small sample size as indicated by wide confidence intervals (Treur et al., 2018).
Other systematic reviews and meta-analyses of population studies have also assessed the role of electronic cigarette experimentation on subsequent tobacco use but either are compiled of either only studies of cross sectional design (which can infer associations but not causal associations) or studies that predominantly are of cross sectional design. Zhong et al., performed a systematic review and meta-analysis of six studies with 91,051 participants, including 1452 with ever electronic cigarettes use, and identified that never-smoking adolescents and young adults who used electronic cigarettes have more than 2 times increased odds of intention to cigarette smoking (OR = 2.21, 95% CI: 1.86-2.61) compared to those who never used, with low evidence of between-study heterogeneity (p = 31 0.28, I² = 20.1%). Among never-smoking adolescents and young adults, electronic cigarettes use was associated with increased smoking intention (Zhong et al., 2016).

On the antipode however are a number of studies that indicate that exposure to electronic cigarette use may not be directly related to smoking uptake among youth. A time trend analyses on national representative data on electronic cigarette and tobacco use in the US by Levy et al. (2019) noted a decline in past 30-day smoking prevalence between 2014-2017, which coincides with the timeframe of electronic cigarette proliferation in the US, however the authors noted that while there has been a decrease in smoking rates during the past years in the US, this could also be attributable to the influence of other tobacco control interventions. Another review of studies -a tobacco industry manuscript- of the gateway effect examining how extensively studies (n=15) accounted for confounders associated with smoking initiation in youths noted that the reported studies may not have addressed for all confounders of smoking initiation (Lee et al., 2018c).

Notably the studies used in the above meta-analyses and reviews are predominantly from the US and other non European Union countries many of which have a very different regulatory environment, different population perspectives of electronic cigarettes and substantially different prevalence of both tobacco and electronic cigarette use, all of which combined or individually may impact substantially the direction and the slope of the association between experimentation with electronic cigarettes and subsequent use of other tobacco products. Even among those studies performed in Europe, the majority are from the UK. However, it has to be noted, that the UK has taken some policy approaches different to the rest of the EU.

The 2018 US National Academies of Science, Engineering and Medicine (NASEM) report concluded that there is “strong evidence of plausibility and specificity of a possible causal effect of electronic cigarette use on smoking”. However, it is important to note that the current literature covers a period during which electronic cigarette products on the market did not contain nicotine salts and before the prolific expansion of such products in the US: this can impact the oucome of future studies. Research performed in the US indicate that such products may significantly contribute to overall nicotine product use among youth (Vallone et al., 2019).

Experimentation with electronic cigarettes among non-smoking adults and youth in the EU
There is limited national or regional evidence using population based cross sectional or cohort studies, with the Eurobarometer one of the key albeit cross sectional, datasets available. Evidence in these datasets indicate an increase in the prevalence of electronic cigarette use, and transition from experimentation to regular use, however the Eurobarometer surveys by design cannot attribute causality nor have they assessed transitions from electronic cigarette use to tobacco product use.

Previous secondary data set analyses using the 2012, 2014 and 2017 Eurobarometer datasets had indicated that ever use of an electronic cigarette in the EU Member states increased from 7.2% (95% CI 6.7 - 7.7) in 2012, to 11.6% (95% CI 10.9 - 12.3) in 2014 to 14.6% (95% CI 13.9–15.3) in 2017. Across the whole of the EU 1.8% of the adult population (95% CI 1.5 to 2.1) were current regular electronic cigarette users in 2017, compared with 1.5% (1.2–1.8) in 2014 (Filippidis et al., 2018; Laverty et al., 2018). In 2014, across the EU MS having ever used electronic cigarettes was 5.75 times more likely among 18-24 year olds compared to those >55 years of age, with aORs found to decrease with the increase in the respondents age after controlling for potential confounding factors. 27 Among those who had ever used electronic cigarettes, participants aged 15–24 years were less likely to be regular user than those aged ≥55 years (16.9% vs. 38.1%). After adjusting for age and smoking status both ever use (OR = 1.46, 1.37 to 1.55) and current regular use of electronic cigarettes were more common in 2017 than 2014 (OR = 1.32, 1.11 to 31 1.55).

In 2017, it is important to note that 25% of 15-24 year olds had reported ever trying electronic cigarettes, a substantially higher rate than experimentation in other age categories. This difference in experimentation was 8.23 times higher in the 15-24 year old group when compared to those 55 and older, but also was substantially higher than reported ever use among other age groups s (p for trend across age groups < 0.001). Notably, among the 15-24 year olds who were ever users of electronic cigarettes, 16.9% transitioned to regular users, however the rate of transition between experimentation and regular use was higher in other age groups. (Laverty et al., 2018).

Denormalization of cigarette smoking is a successful strategy to reduce cigarette smoking as smokers who perceived societal disapproval of smoking are more likely to intend to quit smoking, and subsequently quit smoking (Hammond, 2006). Thus, renormalization of cigarette smoking could lead to a resurgence of cigarette smoking (Choi, 2017). To this extent, there is a possibility that the use of design, manufacture, or marketing strategies that are implemented for electronic cigarettes and are prohibited or extensively regulated for cigarettes, such as flavours, advertising strategies, and packaging, may be used to attract the youth market to electronic cigarettes. Using data from the 2014 Eurobarometer for tobacco survey across the EU MS, among ever dual product users (ever cigarette and ever electronic cigarette users), respondents who identified price; packaging; flavour; brand; amount of nicotine; or design as important factors for the choice of cigarettes were more likely to identify the same factor as important for their choice of electronic cigarettes. Indeed those aged 15–24 were more likely than older respondents to cite external packaging [adjusted prevalence ratio (aPR = 2.06, 95% CI 1.00–4.23)] and design features (aPR = 1.99, 1.20–3.29) as important reasons for their choice of electronic cigarettes, (Laverty et al., 2016).
There is information at the EU Member state level, a cross-sectional survey of 6902 German students recruited in six German states, noted that in that population, 38.8% of the students were exposed to electronic cigarette advertisements; ever-use of electronic cigarettes was 21.7%, of combustible cigarettes was 21.8% (Hansen et al., 2018), through which the authors noted that exposure to electronic cigarette marketing actions might increase the susceptibility to use of tobacco products directly, due to similarity in product shape and marketing themes for combustible cigarette and electronic cigarette products.
Overall, the SCHEER is of the opinion that there is strong evidence that electronic cigarettes are a gateway to smoking/for young people. There is also strong evidence that nicotine in e-liquids is implicated in the development of addiction and that flavours have a relevant contribution for attractiveness of use of electronic cigarette and initiation.
Ab hier werde ich mir wieder die einzelnen Textpassagen vornehmen und dazu etwas schreiben. Zu der Logik der Datenlage aus Studien in der USA werde ich aber nicht weiter eingehen, dazu habe ich schon zu oft etwas geschrieben. 

One of these products is currently the most popular retail electronic cigarette brand in the USA, accounting for 76% of the retail electronic cigarette market at the end of 2018 (Fadus, et al. 2019). It would be interesting to collect such data from the EU as well. Unlike the US with no upper limit on nicotine levels in e-liquids, the EU TPD prescribes that nicotine levels in e-liquids should not exceed 20 mg/ml. It is important to note that the upper limit of 20 mg/ml nicotine can be compensated for by technological modifications in the device, yielding similar nicotine emissions levels as the American version that used high nicotine levels in the liquid (see below in the section on nicotine) (Mallock, et al., 2020).
 Das Produkt was hier gemeint ist ist die Juul und nun kommt es Juul zieht sich weitgehenst vom Europäischen Markt zurück somit ist die Aussagekraft gleich Null. Immerhin wurden schon Entlassungen angekündigt. 
 Flavoured electronic cigarettes are used at electronic cigarette initiation by the majority of youth (Goldenson, et al., 2019).....
 Und hier muss ich doch noch mal nen Einwand einwerfen, in Form einer Studie aus 2017 welche belegt, das diese Aussage nicht belegt werden kann. )18 Ausserdem fällt mir dazu noch eine Studie ein, welche belegt das Aromen die antibakterielle Wirkung von PG eindeutlich verbessern. Wozu also dieses ganze Trara um die Aromen? Wieder mal nen Gefälligkeitsabsatz für die Jugendschutzlobby?

Role as a gateway product or renormalisation of traditional tobacco smoking
One of the four core purposes of this scientific opinion is to assist the Commission in assessing the most recent scientific and technical information on electronic cigarettes with regards to their role as a gateway to smoking and with respect to the initiation of smoking particularly focusing on young people. Within this context there are two hypotheses that...
Auch hier verweise ich wieder auf die Studie aus der Quelle)17 (Herrgott manchmal ist widerlegen fast schon zu einfach) einen signifikanten Anstieg von Jugendlichen die Dampfen gibt es nicht)19 und das von denen welche zu rauchen anfangen ist auch nicht wahrscheinlich.


Eigentlich wollte ich hier einen viel längeren Kommentartext schreiben. Aber es wiederholt sich einfach zu viel. Daher verzichte ich darauf und komme gleich zum Fazit. Zuviel Wiederholungen, zu viele unsauber recherchierte Studien, zuviel Aussagen die von der Zeit eingeholt wurden. Dieser gesamte Absatz ist eigentlich für die berühmte Ablage rund. Ich bin echt begeistert wofür Steuergelder rausgeschmissen werden. Ich habe diesen Artikel eigentlich bewusst verzögert, weil mir beim Schreiben und Lesen der Lügen welche ich in den vorigen Artikeln schon so oft widerlegt habe diesmal wirklich der berühmte Kafffee hochkam. Wer meiner Timline bei Twitter folgt wird das auch mitbekommen haben. Dieser Artikel ist einfach so inhaltlich falsch und ideologisch aufgepumpt, das ist echt zum ko....

in diesem Sinne
Seid Achtsam 

  1. Public Consultation on E-ciagrettes
  2. Sheer Report
  3. Annex (Anhang mit Regeln zur Erstellung des Reports) 
  5. Sicherheitsdatenblatt pflanzliches Glycerin (Nachweis PH-Wert)  file:///C:/Temp/7301.pdf
  6. Sicherheitsdatenblatt Propylenglykol (Nachweis PH-Wert)
  16.  file:///C:/Temp/ijerph-14-00973-v2.pdf






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