Recei ed: Ma ch 30, 2025. Re ised: July 17, 2025. Accep ed: Augus 3, 2025
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Nico ine and Tobacco Resea ch, 2025, 00,1–8
h ps://doi.o g/10.1093/n /n a 168
Ad ance access publica ion da e 1 Augus 2025
O iginal In es iga ion
Pe cep ions o e-Ciga e es and Hea ed Tobacco P oduc s
Among Ne e Use s o Nico ine in he Eu opean Union
Cha lo e Xin Li, MPhil1,2 , Pin-Chun Wang, M Sc1, A iadna Feliu, PhD1,3, An hony A. La e y,
PhD1 , C is ina Ma inez, PhD3,4,5,6,7 , Filippos T. Filippidis, PhD1
1Depa men o P ima y Ca e and Public Heal h, School o Public Heal h, Impe ial College London, London, UK
2Eu opean Ne wo k o Smoking and T obacco P e en ion, B ussels, Belgium
3CIBER en En e medades Respi a o ias (CIBERES), Mad id, Spain
4Tobacco Con ol Uni , Cance Con ol and P e en ion P og am, Ins i u Ca alà d’Oncologia, L’Hospi ale de Llob ega , Ba celona, Spain
5Cance Con ol and P e en ion G oup, Ins i u d’In es igació Biomèdica de Bell i ge-IDIBELL, L’Hospi ale de Llob ega , Ba celona, Spain
6Depa men o Public Heal h, Ma e nal Heal h and Men al Heal h, School o Nu sing, Uni e si a de Ba celona, L’Hospi ale del Llob ega ,
Ba celona, Spain
7Philip R. Lee Ins i u e o Heal h Policy S udies, Uni e si y o Cali o nia San F ancisco, San F ancisco, CA, USA
Co esponding Au ho : Filippos T. Filippidis, PhD, Depa men o P ima y Ca e and Public Heal h, School o Public Heal h, Impe ial C ollege London, Whi e Ci y
Campus, 90 Wood Lane, London, W12 0BZ, UK; E-mail: .filippidis@impe ial.ac.uk
Abs ac
In oduc ion: Eme ging obacco and nico ine p oduc s, such as e-ciga e es and hea ed obacco p oduc s (HTPs), a e gaining popula i y,
pa icula ly among young people. This s udy examines he pe cep ions o e-ciga e es and HTPs among nico ine-nai e indi iduals and hei
a ia ions ac oss sociodemog aphic subg oups.
Me hods: We conduc ed a c oss-sec ional analysis o he Special Eu oba ome e 99.3 (May–June 2023) among ne e use s o obacco o
nico ine p oduc s in he Eu opean Union (EU) (n =13 436). We es ima ed he weigh ed p e alence o pe cep ions o e-ciga e es and HTPs:
appeal, pe cei ed e ec i eness o smoking cessa ion, suppo o hem being egula ed like ciga e es, and suppo o keeping hem ou o
sigh in poin s o sale. Mul i-le el Poisson eg ession models examined associa ions o sociodemog aphic ac o s wi h hese pe cep ions.
Resul s: Among ne e use s in he EU, 2.6% ound e-ciga e es appealing, while 2.0% ound HTPs appealing. Fi y-poin eigh pe cen and 58.8%
o pa icipan s suppo ed s ic egula ions and poin -o -sale es ic ions o hese p oduc s, espec i ely. Younge age g oups we e mo e likely o
find e-ciga e es (p e alence a io [PR] =1.70, o ages 15–39 s. ≥55) and HTPs (PR =1.88, PR =1.54 o ages 15–24 and 25–39) appealing and
iew hem as e ec i e o smoking cessa ion. Suppo o egula ions simila o ciga e es was highe among women, indi iduals wi h highe
educa ion, hose li ing wi h child en, and hose wi hou financial di ficul ies.
Conclusion: While he appeal o hese p oduc s o ne e use s emained low o e all, he s udy ound ha young people we e mo e likely o find
hem appealing, posing a isk o e xpe imen a ion. Meanwhile, o e 50% o esponden s suppo ed s ic e egula ions, which could influence
policy changes in his a ea.
Implica ions: Al hough appeal o e-ciga e es and Hea ed Tobacco P oduc s (HTPs) was ela i ely low among people who ha e ne e used e-
ciga e es, HTPs, o smoking obacco in he EU, appeal was highe among younge age g oups, which a e o en a ge ed by he indus y. We also
ound subs an ial suppo o s ic e egula o y policies o e-ciga e es and HTPs ac oss he EU. These findings migh encou age go e nmen s
o inc ease es ic ions a ound hese eme ging nico ine and obacco p oduc s.
In oduc ion
The obacco epidemic emains one o he mos signi ican
ye p e en able heal h h ea s in he Eu opean Union (EU),
accoun ing o app oxima ely 700 000 dea hs annually.1
Despi e conside able p og ess in obacco con ol in ecen
yea s, he p e alence o smoking emains high a 24%.2
Eme ging nico ine and obacco p oduc s, such as e-ciga e es
and hea ed obacco p oduc s (HTPs), pose public heal h
challenges, as hei popula i y has g own ac oss he EU,
pa icula ly among adolescen s and young adul s, some o
whom ha e ne e used obacco be o e.2 Al hough he e is
deba e o e whe he e-ciga e es and o he eme ging nico ine
and obacco p oduc s can lowe heal h isks compa ed o
adi ional ciga e es and, hence, may play a ole in obacco
con ol, i is uni e sally ecognized ha hey a e no isk-
ee and can cause ha m o indi iduals who ha e ne e
smoked.3 P oduc s con aining nico ine a e highly addic i e,
and e en expe ienced use s can de elop dependency l e els
simila o hose o adi ional smoke s.3-5 Mo eo e , e idence
sugges s ha ne e smoke s who ha e expe imen ed o used
e-ciga e es ha e highe odds o ansi ioning o con en ional
obacco smoking.6-8
Due o he ising popula i y o HTPs, he EU ac i a ed a
clause o he Tobacco P oduc s Di ec i e (TPD) in No embe
2022 o in oduce a ban on cha ac e izing la o s and pack-
aging ha al e s he senso y expe ience.9 Howe e , he mos
ecen EU-le el egula ions ega ding e-ciga e es da e back
o 2016, when measu es we e in oduced o limi maximum
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2Li e al.
nico ine concen a ions, egula e p oduc olume, and en o ce
child- esis an packaging and pu i y s anda ds.10
Exis ing li e a u e on pe cep ions o e-ciga e es and HTPs
has p ima ily ocused on cu en and o me smoke s, examin-
ing ac o s such as he p oduc s’ appeal and hei e ec i eness
in aiding smoking cessa ion.11-13 These s udies sugges ha
while e-ciga e es and HTPs a e o en ega ded as po en ial
cessa ion ools, hei pe cei ed e ec i eness is lowe among
younge indi iduals, hose wi h lowe educa ional le els, and
he unemployed.11-13 Mo eo e , younge people end o ind
hese p oduc s appealing, which unde sco es he po en ial
ulne abili y o his demog aphic, pa icula ly among socioe-
conomically disad an aged g oups.3
Howe e , a gap exis s in esea ch ega ding he pe cep ions
o hese eme ging obacco and nico ine p oduc s among ne e
use s o obacco o nico ine. Al hough his g oup has no
ye used hese p oduc s, hey a e o en a ge ed by ma ke ing
s a egies and socie al ends.14,15 P e ious s udies indica e
ha younge indi iduals, pa icula ly women, a e mo e likely
o be a ac ed o hese p oduc s.16,17 The inc easing in luence
o online e aile s, which ma ke e-ciga e es and HTPs as
socially accep able and less ha m ul al e na i es o adi ional
ciga e es, aises conce ns abou hei po en ial impac on
ne e use s.18,19 Addi ionally, isual exposu e o hese p od-
uc s has been shown o inc ease c a ings and may encou age
p oduc ini ia ion among ne e use s.20 These indings high-
ligh he po en ial impac o eme ging obacco and nico ine
p oduc s on nico ine-nai e indi iduals and call o u he
explo a ion o how hey iew e-ciga e es and HTPs.
Gi en hese conce ns, a deepe unde s anding o ne e
use s’ pe cep ions o e-ciga e es and HTPs is essen ial o
shaping e ec i e public heal h policies. To in o m u u e
egula ions on e-ciga e es and HTPs wi hin he EU, his
s udy examines he pe cep ions o hese p oduc s among ne e
use s o smoking obacco, e-ciga e es, o HTPs. The s udy
ocuses on ou key aspec s: appeal, pe cei ed e ec i eness
o smoking cessa ion, iews on w he he hey should be
egula ed like ciga e es, and suppo o s ic e poin -o -sale
es ic ions. Fu he mo e, i explo es how hese pe cep ions
a y ac oss di e en sociodemog aphic subg oups and EU
Membe S a es (MSs). Ahead o he an icipa ed e ision o he
TPD and in ligh o he adop ion o new ecommenda ions o
smoke- and ae osol- ee en i onmen s by he Council o he
EU,21 i is c ucial o examine public pe cep ions o eme ging
obacco and nico ine p oduc s among ne e use s o guide
u u e egula ions.
Me hods
Da a S ou ce
We u ilized da a om he Special Eu oba ome e 99.3, which
was conduc ed om May 10 o June 5, 2023. The Eu o-
ba ome e su ey employed a mul i-s age sampling app oach.
Ini ially, p ima y sampling uni s we e selec ed om each coun-
y egion in p opo ion o popula ion size. Then, households
we e selec ed h ough s anda d “ andom ou e” me hods,
wi h one pa icipan andomly chosen om each household
based on i s size o comple e he in e iew and p o ide
sel - epo ed da a in he ele an na ional language.2 We
p esen ques ions in he English language, al hough hese we e
ansla ed in o he ele an languages h ough a s anda dized
ansla ion p ocedu e. T o ensu e he ep esen a i eness o he
sample, he da ase was weigh ed acco ding o age, sex, and
esiden ial a ea.
This su ey ga he ed esponses om 26 358 indi iduals
aged 15 yea s and abo e, esiding in each o he 27 EU
MSs. Among hose, we analyzed esponses om indi iduals
who had ne e used obacco, e-ciga e es, o HTPs. Speci -
ically, we only analyzed pa icipan s who esponded “I ha e
ne e smoked”in he ques ion “Rega ding smoking ciga e es,
ciga s, ciga illos, o a pipe, which o he ollowing applies o
you?” and “I ha e ne e used i ” o he ques ion “Thinking
abou he ollowing p oduc s, which o he ollowing applies
o you? E-ciga e es/Hea ed obacco p oduc s.” As such, ou
analy ical sample size was 13 436 (Suppl. Table 1).
Measu es
Pe cep ions o Appeal
All pa icipan s we e asked wo sepa a e ques ions: “Do
you ind e-ciga e es appealing?” and “Do you ind HTPs
appealing?” Responses o each ques ion we e hen ecoded as
bina y ca ego ies: “yes” o “no/don’ know.”
E ec i e Aid o Smoking Cessa ion
Pa icipan s we e asked, “Do you hink he use o e-ciga e es
helps obacco smoke s o qui ?” and “Do you hink he use o
HTPs helps obacco smoke s o qui ?” Responses we e coded
as “yes” o “no/don’ know.”
Regula ed as S ic ly as Ciga e es
Responden s we e asked he ollowing ques ions ega ding
egula ion: “Do you hink e-ciga e es should be egula ed as
s ic ly as ciga e es?” and “Do you hink HTPs should be
egula ed as s ic ly as ciga e es?” Responses we e coded as
“yes” o “no/don’ know.”
Suppo o S ic e Poin -o -S ale Res ic ions
Responden s we e also asked: “Would you be in a o o
keeping e-ciga e es ou o sigh in shops o poin s o sale?”
and “Would you be in a o o keeping HTPs ou o sigh in
shops o poin s o sale?” Responses we e coded as “in a o ”
o “no in a o /don’ know.”
Co a ia es
The su ey collec ed sel - epo ed da a on gende (male,
emale). Twen y- wo esponses “none o he abo e,” “non-
bina y,” “do no iden i y as male/ emale,” o “p e e no o
say” we e excluded and ea ed as missing alues due o hei
low equency. Sociodemog aphic da a we e also collec ed on
age (15–24, 25–39, 40–54, ≥55 yea s), di icul ies in paying
bills a he end o he mon h o e he pas yea (almos
ne e /ne e , om ime o ime/mos o he ime), communi y
ype ( u al, u ban), age a which pa icipan s s opped ull-
ime educa ion (0–15, 16–19, ≥20, s ill s udying), li ing
wi h child en (no, yes), and employmen s a us (employed,
unemployed, s uden s/house pe sons/ e i ed).
S a is ical Analysis
This s udy analyzed ou pe cep ions o e-ciga e es and HTPs
among ne e use s o smoking obacco, e-ciga e es, o HTPs,
wi h a o al o eigh ou come a iables. We i s es ima ed
he weigh ed p e alence o hese pe cep ions o e-ciga e es
and HTPs sepa a ely ac oss he 27 EU MSs. O icial weigh s
p o ided in he Eu oba ome e da ase we e u ilized.
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Nico ine & Tobacco Resea ch, 2025, Vol. 00, No. 00 3
We pe o med mul i-le el Poisson eg ession analyses o
each o he eigh ou come a iables, accoun ing o clus e ing
o obse a ions wi hin EU MSs. All models we e adjus ed
o gende , age, di icul ies in paying bills, communi y ype,
age when s opped ull- ime educa ion, li ing wi h child en,
and employmen s a us. S a is ical analyses we e conduc ed
using S a a 17, and obse a ions wi h missing alues we e
excluded om he analysis. Missing alues o each a iable
a e shown in Supplemen a y Table 2. Signi icance le el o
he s a is ical analysis was de ined as p <.05, and e ec
es ima es a e p esen ed wi h 95% con idence in e als (CIs);
in e als no spanning 1 deno e s a is ical signi icance. Gi en
ha he Eu oba ome e da a a e open-access and anonymized,
e hical app o al om an ins i u ional e iew boa d was no
equi ed.
Resul s
Pe cep ions o e-Ciga e es Ac oss 27 EU MSs
A o al o 2.6% (95% CI: 2.2 o 3.1) o ne e use s o obacco,
e-ciga e es, o HTPs ac oss he EU ound e-ciga e es appeal-
ing. The highes pe cep ion o appeal was obse ed in Mal a a
10.8% (7.3 o 15.8), while he lowes was in C oa ia a 0.5%
(0.2 o 1.5). O e all, 11.2% (10.4 o 12.1) o ne e use s in he
EU belie ed ha e-ciga e es help obacco smoke s qui , wi h
La ia ha ing he lowes pe cen age a 3.3% (1.9 o 5.6) and
I eland he highes a 22.1% (18.7 o 25.9). Rega ding egula-
ion, 58.4% (57.0 o 59.7) belie ed ha e-ciga e es should be
egula ed as s ic ly as ciga e es, wi h suppo anging om
34.4% (30.4 o 38.6) in Romania o 85.1% (81.6 o 88.0)
in Slo enia. Addi ionally, 50.8% (49.4 o 52.1) o EU ne e
use s suppo ed keeping e-ciga e es ou o sigh in shops o
poin s o sale, wi h I aly ha ing he lowes suppo a 27.4%
(23.8 o 31.2) and Es onia he highes a 84.1% (80.4 o 87.2)
(Table 1).
In he eg ession esul s (Table 2), women we e less likely
han men o iew e-ciga e es as e ec i e o smoking ces-
sa ion (PR = 0.84, 0.75 o 0.95) and bo de line less likely
o ind hem appealing (PR = 0.80, 0.63 o 1.01). Compa ed
o hose aged ≥55 yea s, younge age g oups (15–24 and
25–39 yea s) we e mo e likely o ind e-ciga e es appealing
(PR = 1.70, 1.12 o 2.59 and PR = 1.70, 1.19 o 2.43, espec-
i ely) and o pe cei e hem as e ec i e o smoking cessa ion
(PR = 1.81, 1.36 o 2.40 and PR = 1.38, 1.15 o 1.65, espec-
i ely). Indi iduals expe iencing inancial di icul ies we e less
likely o suppo egula ing e-ciga e es as s ic ly as ciga e es
(PR = 0.88, 0.84 o 0.92) and en o cing s ic poin -o -sale
es ic ions (PR = 0.92, 0.87 o 0.98), compa ed o hose wi h
minimal o no inancial di icul ies. In con as , indi iduals
wi h highe educa ion le els (comple ed educa ion a age 20 o
olde ) we e mo e likely o suppo bo h measu es (PR = 1.16,
1.08 o 1.24 and PR = 1.15, 1.07 o 1.22, espec i ely) com-
pa ed o hose who comple ed hei educa ion be ween ages
0 and 15. Addi ionally, indi iduals li ing wi h child en we e
mo e likely o suppo egula ing e-ciga e es as s ic ly as
ciga e es and keeping hem ou o sigh in poin s o sale
compa ed o hose li ing wi hou child en (PR = 1.05, 1.01
o 1.10 o bo h). Compa ed o hose employed, s uden s,
homemake s, and e i ees also exp essed g ea e suppo o
hese measu es (PR = 1.10, 1.05 o 1.15 and PR = 1.08, 1.02
o 1.14, espec i ely) (Table 2).
Pe cep ions o HTPs Ac oss 27 EU MSs
Ac oss he EU, 2.0% (1.6 o 2.4) o ne e use s o obacco,
e-ciga e e, o HTPs ound HTPs appealing, wi h he lowes
p e alence in Spain a 0.0% (0.0 o 0.0) and he highes in
Romania a 11.5% (9.1 o 14.4). Among EU ne e use s,
7.1% (6.5 o 7.9) belie ed ha HTPs help obacco smoke s
qui , wi h he lowes p e alence in La ia a 1.5% (0.6 o 3.3)
and he highes in I eland a 16.6% (13.6 o 20.1). A o al o
58.8% (57.4 o 60.1) o he esponden s hough HTPs should
be egula ed as s ic ly as ciga e es, wi h he highes suppo
in Slo enia a 85.0% (81.5 o 87.9) and he lowes in Romania
a 37.3% (33.2 o 41.5). Addi ionally, ac oss he EU, 51.1%
(49.7 o 52.4) suppo ed keeping HTPs ou o sigh in poin s
o sale, wi h he highes suppo obse ed in Es onia a 84.1%
(80.4 o 87.2) and he lowes in I aly a 27.3% (23.8 o 31.2)
(Table 3).
In ully adjus ed eg ession models, women we e less likely
han men o pe cei e HTPs as e ec i e aids o smoking
cessa ion (PR = 0.82, 0.73 o 0.91). Younge indi iduals (ages
15–24 and 25–39) we e signi ican ly mo e likely han hose
aged ≥55 o ind HTPs appealing (PR = 1.88, 1.19 o 2.95
and PR = 1.54, 1.04 o 2.28, espec i ely) and o pe cei e
hem as e ec i e o smoking cessa ion (PR = 2.29, 1.58 o
3.33 and PR = 1.52, 1.15 o 2.02, espec i ely). Financial
di icul y was associa ed wi h educed suppo o egula -
ing HTPs as s ic ly as ciga e es (PR = 0.89, 0.85 o 0.93)
and o poin -o -sale es ic ions (PR = 0.93, 0.88 o 0.98).
Con e sely, indi iduals who had comple ed hei educa ion
a age 20 o olde we e mo e likely o suppo bo h s ic e
egula ion o HTPs (PR = 1.16, 1.08 o 1.25) and poin -o -
sale es ic ions (PR = 1.14, 1.07 o 1.22) compa ed o hose
wi h lowe educa ion le els (0–15 yea s). Li ing wi h child en
was associa ed wi h inc eased suppo o s ic e egula ion
o HTPs (PR = 1.06, 1.02 o 1.11) and poin -o -sale ad e is-
ing es ic ions (PR = 1.05, 1.01 o 1.09). Meanwhile, com-
pa ed o hose employed, s uden s, house pe sons, and e i ees
showed g ea e suppo o s ic e egula o y measu es and
o keeping HTPs ou o sigh a poin s o sale. Howe e , hese
g oups we e less likely o pe cei e HTPs as e ec i e aids o
smoking cessa ion (Table 4).
Discussion
This s udy highligh s he a ied pe cep ions o e-ciga e es
and HTPs among ne e use s o obacco, e-ciga e es, o
HTPs in he EU. Men and younge indi iduals we e mo e
likely o pe cei e hese p oduc s as e ec i e aids o smok-
ing cessa ion. Suppo o s ic e egula ion and poin -o -
sale display es ic ions was gene ally s onge among hose
li ing wi h child en, as well as s uden s, house pe sons, o
e i ees, while indi iduals acing inancial di icul ies we e less
suppo i e. These indings highligh he impo ance o consid-
e ing sociodemog aphic ac o s when de eloping egula o y
policies o eme ging obacco and nico ine p oduc s.
Al hough he EU in oduced he TPD and la e ac i a ed
he clause o HTPs o s eng hen he egula o y amewo k
o eme ging obacco and nico ine p oduc s, o e all policies
a y ac oss MSs, as each e ains ju isdic ion o e key a eas
such as bans, domes ic ad e ising, axa ion, and la o egu-
la ions.22,23 Fo example, coun ies like Finland ha e imple-
men ed egula ions ha exceed TPD equi emen s, including
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4Li e al.
Ta b l e 1. P e alence o Pe cep ions Rela ed o E-Ciga e es Among Ne e Use s o Tobacco, E-ciga e es, o HTPs Ac oss 27 EU Membe S a es
Coun y Appealing E ec i e aid o smoking
cessa ion
Regula e as s ic ly as
ciga e es
S ic e poin -o -sale ad e ising
es ic ions
Weigh ed% wi h 95% con idence in e al
Aus ia 1.3% (0.5% o 3.4%) 5.7% (3.7% o 8.6%) 57.7% (52.4% o 62.8%) 45.2% (40.0% o 50.6%)
Belgium 4.2% (2.7% o 6.5%) 19.1% (15.3% o 23.5%) 69.8% (65.1% o 74.2%) 70.0% (65.3% o 74.4%)
Bulga ia 6.7% (4.6% o 9.6%) 7.8% (5.6% o 11.0%) 53.8% (48.9% o 58.6%) 45.2% (40.4% o 50.1%)
C oa ia 0.5% (0.2% o 1.5%) 4.3% (2.7% o 6.9%) 66.2% (61.2% o 70.9%) 70.4% (65.5% o 74.9%)
Cyp us Republic 6.5% (3.6% o 11.4%) 6.5% (3.8% o 10.7%) 68.2% (61.5% o 74.2%) 50.9% (44.2% o 57.5%)
Czech Republic 1.8% (0.9% o 3.4%) 16.4% (13.2% o 20.3%) 48.6% (43.7% o 53.5%) 41.3% (36.6% o 46.3%)
Denma k 0.8% (0.2% o 2.8%) 21.8% (17.7% o 26.6%) 71.0% (66.2% o 75.5%) 74.8% (70.1% o 79.1%)
Es onia 7.2% (5.1% o 10.0%) 6.9% (4.8% o 9.7%) 78.7% (74.6% o 82.3%) 84.1% (80.4% o 87.2%)
Finland 1.1% (0.4% o 2.7%) 14.5% (11.1% o 18.8%) 77.3% (72.3% o 81.6%) 81.2% (76.3% o 85.3%)
F ance 1.3% (0.6% o 3.0%) 18.4% (14.7% o 22.9%) 61.7% (56.7% o 66.4%) 56.2% (51.1% o 61.1%)
Ge many 1.9% (1.1% o 3.3%) 9.0% (7.0% o 11.4%) 61.4% (57.7% o 65.0%) 52.4% (48.6% o 56.1%)
G eece 2.8% (1.6% o 5.1%) 14.6% (11.4% o 18.5%) 73.0% (68.5% o 77.1%) 44.7% (39.9% o 49.6%)
Hunga y 3.0% (1.8% o 5.1%) 8.6% (6.5% o 11.4%) 49.8% (45.6% o 54.0%) 46.6% (41.5% o 49.8%)
I eland 0.9% (0.4% o 2.1%) 22.1% (18.7% o 25.9%) 73.4% (69.4% o 77.1%) 71.2% (67.1% o 75.0%)
I aly 2.2% (1.3% o 3.9%) 9.2% (7.1% o 11.9%) 48.1% (43.9% o 52.2%) 27.4% (23.8% o 31.2%)
La ia 0.6% (0.2% o 2.0%) 3.3% (1.9% o 5.6%) 61.9% (57.2% o 66.5%) 46.2% (41.5% o 50.9%)
Li huania 1.1% (0.5% o 2.8%) 7.1% (4.8% o 10.2%) 80.8% (76.8% o 84.3%) 80.7% (76.5% o 84.3%)
Luxembou g 2.8% (1.4% o 5.6%) 16.8% (12.1% o 22.7%) 72.4% (66.2% o 77.8%) 61.1% (54.3% o 67.4%)
Mal a 10.8% (7.3% o 15.8%) 12.5% (8.5% o 18.0%) 78.5% (72.4% o 83.6%) 66.9% (60.0% o 73.2%)
Ne he lands 1.1% (0.4% o 2.7%) 16.5% (13.4% o 20.2%) 78.5% (73.9% o 82.5%) 80.3% (75.7% o 84.3%)
Poland 4.9% (3.1% o 7.8%) 5.1% (3.5% o 7.4%) 41.3% (36.9% o 45.9%) 39.2% (34.8% o 43.8%)
Po ugal 2.2% (1.3% o 3.7%) 6.2% (4.5% o 8.5%) 64.5% (60.8% o 68.1%) 61.4% (57.7% o 65.1%)
Romania 10.2% (8.0% o 13.1%) 10.8% (8.5% o 13.6%) 34.4% (30.4% o 38.6%) 35.7% (31.7% o 40.0%)
Slo akia 5.4% (3.6% o 8.1%) 8.3% (6.0% o 11.3%) 61.2% (56.7% o 65.6%) 55.0% (50.4% o 59.6%)
Slo enia 1.4% (0.7% o 3.0%) 8.4% (6.1% o 11.4%) 85.1% (81.6% o 88.0%) 71.3% (66.9% o 75.2%)
Spain 1.5% (0.7% o 3.2%) 10.4% (8.0% o 13.5%) 65.7% (61.5% o 69.7%) 59.9% (55.6% o 64.1%)
Sweden 1.4% (0.5% o 4.3%) 14.7% (11.1% o 19.1%) 76.5% (71.1% o 81.2%) 75.5% (69.9% o 80.3%)
EU 2.6% (2.2% o 3.1%) 11.2% (10.4% o 12.1%) 58.4% (57.0% o 59.7%) 50.8% (49.4% o 52.1%)
Appealing: Do you ind e-ciga e es appealing? E ec i e aid o smoking cessa ion: Do you hink ha he use o e-ciga e es helps obacco smoke s qui ?
Regula e as s ic ly as ciga e es: Do you hink ha e-ciga e es should be egula ed as s ic ly as ciga e es? S ic e poin -o -sale ad e ising es ic ions:
Would you be in a o o keeping e-ciga e es ou o sigh in shops o poin s o sale?
comp ehensi e bans on la o s and es ic ions on ma ke ing,
display, and dis ance selling.24 In con as , some MSs, such
as he Czech Republic, ha e only pa ially implemen ed he
TPD, lea ing gaps in egula ions like packaging and heal h
wa nings.25 These disc epancies in na ional egula ions likely
in luence pe cep ions, pa icula ly ega ding he appeal and
pe cei ed e ec i eness o e-ciga e es and HTPs as cessa ion
ools.26
This is pe haps illus a ed by he con as be ween Mal a,
which has he highes pe cen age o esponden s inding e-
ciga e es appealing, and La ia, which has he lowes . Mal a
does no equi e a speci ic e ail license o e-ciga e e sales,
and domes ic sales ia he in e ne a e no egula ed. In
con as , La ia has ully banned online sales and banned
e-ciga e e sales ia ending machines, along wi h imposing
es ic ions on hei use in public spaces.27 No ably, Romania
epo ed he highes p e alence o HTP appeal. Romania has
been one o he key Eu opean ma ke s o HTPs and has been
iden i ied as one o he EU MSs wi h he highes le els o HTP
ad e ising.28
Simila ly, suppo o s ic e egula o y measu es and
poin -o -sale display es ic ions a ies ac oss MSs. Rema k-
ably , Es onia, which has he highes p e alence o e-ciga e e
use in he EU,2 demons a es he highes public suppo o
poin -o -sale ad e ising es ic ions. This could e lec he
complex ela ionship be ween he p e alence o eme ging
obacco and nico ine p oduc s and suppo o s ic e
es ic ions. On one hand, i could be a gued ha high
p e alence may lead o no maliza ion o use and b oade
social accep ance. Fo ins ance, in some coun ies, a i udes
owa d e-ciga e es among heal h p o essionals may be mo e
posi i e, e en hough hey a e no o icially ecommended
as cessa ion ools. As such, he public may be mo e likely
o pe cei e hem as e ec i e aids o qui ing, ex end his
pe cep ion o o he simila p oduc s, and consequen ly be
less suppo i e o s ic egula ion. On he o he hand, in
egions whe e hese p oduc s a e less p e alen , ne e use s
may pe cei e hem as less o a conce n, esul ing in lowe
suppo o es ic ions,29 whe eas highe p e alence may
make ne e use s pe cei e hese p oduc s as mo e in usi e,
d i ing s onge suppo o obacco con ol policies.30
The o e all appeal was low among ne e use s, which aligns
wi h p e ious s udies in he Uni ed S a es, whe e indi iduals
who had ne e used obacco o nico ine p oduc s showed li le
in e es in HTPs and modi ied isk obacco p oduc s.31,32
Appeal was no ably highe in some MSs, pa icula ly among
young people. Since indi iduals who ind p oduc s appealing
a e a g ea e isk o u u e ini ia ion, his inc eased appeal
aises u he conce ns.33 Younge age g oups a e mo e likely
o be exposed o eme ging obacco and nico ine p oduc
ad e ising, which may con ibu e o hei glamo iza ion,
despi e he unce ain y su ounding hei mid- and long- e m
heal h impac .34,35 The design o hese eme ging p oduc s,
o en ea u ing appealing la o s o a ac younge indi id-
uals and ma ke ed as sa e al e na i es, shapes pe cep ions o
ha m.36 S ic e es ic ions on ma ke ing a ge ing ulne able
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Nico ine & Tobacco Resea ch, 2025, Vol. 00, No. 00 5
Ta b l e 2 . Mul i-le el Poisson Reg ession Es ima ing Associa ions Be ween Sociodemog aphic Fac o s and Pe cep ions Rela ed o E-Ciga e es Among
Ne e Use s o Tobacco, e-Ciga e es, o HTPs Ac oss he EU
Va iables Appealing E ec i e aid o smoking
cessa ion
Regula e as s ic ly as
ciga e es
S ic e poin -o -sale ad e ising
es ic ions
P e alence a io (95% con idence in e al)
Gende
Male (Re .) 1 1 1 1
Female 0.80 (0.63 o 1.01) 0.84 (0.75 o 0.95) 1.03 (1.00 o 1.07) 1.04 (1.00 o 1.08)
Age (yea s)
55+ (Re .) 1 1 1 1
15–24 1.70 (1.12 o 2.59) 1.81 (1.36 o 2.40) 0.95 (0.86 o 1.04) 0.96 (0.87 o 1.06)
25–39 1.70 (1.19 o 2.43) 1.38 (1.15 o 1.65) 0.98 (0.94 o 1.03) 0.97 (0.92 o 1.03)
40–54 1.04 (0.74 o 1.45) 1.16 (0.97 o 1.38) 1.01 (0.98 o 1.05) 0.98 (0.94 o 1.02)
Di icul y paying bills
Almos ne e /ne e (Re .) 1 1 1 1
F om ime o ime/mos o he
ime
1.32 (0.98 o 1.77) 1.13 (1.00 o 1.29) 0.88 (0.84 o 0.92) 0.92 (0.87 o 0.98)
Communi y ype
Ru al (Re .) 1 1 1 1
U ban 1.06 (0.81 o 1.38) 1.12 (0.95 o 1.32) 1.01 (0.96 o 1.07) 1.01 (0.95 o 1.07)
Educa ion (age a comple ion)
0–15 yea s (Re .) 1 1 1 1
16–19 yea s 1.27 (0.82 o 1.95) 1.10 (0.85 o 1.42) 1.06 (0.98 o 1.15) 1.05 (0.98 o 1.11)
≥20 yea s 0.97 (0.60 o 1.56) 1.22 (0.92 o 1.62) 1.16 (1.08 o 1.24) 1.15 (1.07 o 1.22)
S ill s udying 1.79 (0.82 o 3.93) 1.42 (0.90 o 2.26) 1.11 (1.00 o 1.24) 1.04 (0.93 o 1.17)
Li ing wi h child en
No (Re .) 1 1 1 1
Yes 1.00 (0.80 o 1.25) 1.10 (0.97 o 1.24) 1.05 (1.01 o 1.10) 1.05 (1.01 o 1.10)
Employmen s a us
Employed (Re .) 1 1 1 1
Unemployed 0.96 (0.56 o 1.63) 1.31 (0.97 o 1.76) 1.06 (0.98 o 1.15) 1.03 (0.95 o 1.12)
S uden s/house pe sons/ e i ed 0.76 (0.48 o 1.21) 0.74 (0.63 o 0.86) 1.10 (1.05 o 1.15) 1.08 (1.02 o 1.14)
Appealing: Do you ind e-ciga e es appealing? E ec i e aid o smoking cessa ion: Do you hink ha he use o e-ciga e es helps obacco smoke s qui ?
Regula e as s ic ly as ciga e es: Do you hink ha e-ciga e es should be egula ed as s ic ly as ciga e es? S ic e poin -o -sale ad e ising es ic ions:
Would you be in a o o keeping e-ciga e es ou o sigh in shops o poin s o sale?
popula ions, pa icula ly you h, could help p e en nico ine
addic ion and educe he isk o e-ciga e es and HTPs se ing
as ga eways o adi ional ciga e es.37
Addi ionally, ou indings align wi h a s udy om he
Uni ed S a es showing ha nico ine-nai e indi iduals om
lowe socioeconomic backg ounds a e mo e likely o mis-
pe cei e he isks o he modi ied isk obacco p oduc s.32
Howe e , we ound ha nico ine-nai e men we e mo e likely
o pe cei e e-ciga e es and HTPs as appealing, whe eas a
US s udy ound ha women we e mo e likely han men o
pe cei e la o ed e-ciga e es as easie o use.38 Al hough ou
s udy did no di e en ia e be ween la o ed and non- la o ed
p oduc s, a ailable e idence sugges s ha pe cep ions o ha m
and appeal may a y depending on p oduc cha ac e is ics.
This emphasizes he need o mo e a ge ed public heal h
in e en ions ac oss EU MSs, pa icula ly o p o ec ulne -
able popula ions, mi iga e he isk o nico ine addic ion, and
p e en ini ia ion.
Al hough pe cep ions a ound he e ec i eness o e-
ciga e es and HTPs as smoking cessa ion aids a e no
necessa ily associa ed wi h expe imen a ion o ini ia ion
o use among ne e use s, i ’s a measu e ha p o ides
addi ional insigh in o how people iew hem. Al hough
HTPs ha e no been shown o help wi h smoking cessa ion,13
he e is some e idence ha suppo s he ole o e-ciga e es
in smoking cessa ion in ce ain con ex s.39 Howe e , i ’s
unclea i his pe cep ion may lead ne e use s o nico ine o
conside hem less ha m ul and, hence, indi ec ly encou age
expe imen a ion. In e es ingly, he highes pe cen age o
esponden s who pe cei ed e-ciga e es and HTPs as e ec i e
smoking cessa ion aids was in I eland, al hough appeal o
bo h p oduc s was lowe han he EU a e age. E en hough
hey a e no o icially ecommended as aids o qui smoking by
he I ish heal hca e sys em,40 e-ciga e es a e popula among
hose ying o qui in I eland,2 pe haps due o in luences
om he neighbo ing Uni ed Kingdom, whe e e-ciga e es a e
used as cessa ion aids in he Na ional Heal h Se ice.41
Public suppo o o agains egula ions on he ma ke ing
and use o e-ciga e es and HTPs can signi ican ly shape policy
ou comes,37 as policymake s a e mo e likely o implemen
measu es wi h s ong public backing. No ably, ou s udy
ocuses on ne e use s; suppo o egula ion ends o be
lowe among cu en o o me use s.42 The obacco con ol
communi y in Eu ope can ocus on popula ion subg oups
iden i ied as less suppo i e in ou analysis and ad oca e
o he necessi y and public heal h alue o such measu es.
Inc eased public unde s anding and engagemen , especially
wi hin hese speci ic g oups, could help os e b oade suppo
o policies aimed a p o ec ing public heal h.
S eng hs and Limi a ions
This s udy employs a la ge, ep esen a i e sample o 13 436
pa icipan s ac oss 27 EU MSs and u ilizes a s anda dized
se o su ey ques ions. The da ase is ecen , ensu ing he
indings a e ele an o cu en policy discussions. By ocusing
exclusi ely on ne e use s o obacco, e-ciga e es, o HTPs,
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6Li e al.
Ta b l e 3 . P e alence o Pe cep ions Rela ed o HTPs Among Ne e Use s o Tobacco, e-Ciga e es, o HTPs Ac oss 27 EU Membe S a es
Coun y Appealing E ec i e aid o smoking
cessa ion
Regula e as s ic ly as
ciga e es
S ic e poin -o -sale ad e ising
es ic ions
Weigh ed% wi h 95% con idence in e al
Aus ia 1.2% (0.5% o 3.2%) 4.3% (2.6% o 7.1%) 58.9% (53.6% o 64.0%) 45.5% (40.2% o 50.9%)
Belgium 2.4% (0.5% o 1.2%) 6.3% (4.2% o 9.4%) 69.1% (64.3% o 73.6%) 69.8% (65.1% o 74.1%)
Bulga ia 5.7% (3.8% o 8.4%) 7.1% (5.0% o 10.2%) 54.1% (49.2% o 58.9%) 44.9% (40.2% o 49.8%)
C oa ia 0.7% (0.3% o 2.0%) 4.4% (2.8% o 7.0%) 66.4% (61.4% o 71.0%) 70.5% (65.6% o 75.0%)
Cyp us Republic 6.2% (3.4% o 11.1%) 6.6% (3.9% o 10.9%) 68.2% (61.5% o 74.2%) 50.9% (44.2% o 57.5%)
Czech Republic 0.6% (0.2% o 1.7%) 12.4% (9.7% o 15.8%) 49.1% (44.2% o 54.0%) 40.4% (35.6% o 45.4%)
Denma k 0.6% (0.1% o 4.4%) 11.7% (8.7% o 15.7%) 71.3% (66.5% o 75.7%) 75.5% (70.8% o 79.7%)
Es onia 4.2% (2.6% o 6.5%) 5.5% (3.7% o 8.2%) 77.8% (73.7% o 81.5%) 84.1% (80.4% o 87.2%)
Finland 0.1% (0.0% o 0.8%) 13.1% (9.8% o 17.3%) 77.7% (72.7% o 82.0%) 81.9% (77.1% o 85.8%)
F ance 0.3% (0.0% o 2.2%) 4.6% (2.5% o 8.3%) 60.6% (55.6% o 65.4%) 56.3% (51.3% o 61.2%)
Ge many 1.4% (0.7% o 2.7%) 5.3% (3.8% o 7.3%) 61.7% (58.0% o 65.3%) 52.4% (48.6% o 56.1%)
G eece 2.8% (1.6% o 5.1%) 14.7% (11.6% o 18.6%) 74.2% (69.7% o 78.2%) 44.4% (39.7% o 49.3%)
Hunga y 2.3% (1.3% o 4.0%) 6.6% (4.7% o 9.1%) 50.4% (46.2% o 54.6%) 45.8% (41.7% o 50.0%)
I eland 0.3% (0.1% o 1.3%) 16.6% (13.6% o 20.1%) 72.6% (68.6% o 76.3%) 70.7% (66.6% o 74.6%)
I aly 2.2% (1.3% o 3.8%) 8.7% (6.6% o 11.4%) 48.5% (44.3% o 52.6%) 27.3% (23.8% o 31.2%)
La ia 0.9% (0.3% o 2.4%) 1.5% (0.6% o 3.3%) 61.5% (56.8% o 66.0%) 45.8% (41.2% o 50.5%)
Li huania 0.2% (0.0% o 1.3%) 5.7% (3.7% o 8.7%) 81.4% (77.3% o 84.8%) 80.0% (75.8% o 83.7%)
Luxembou g 1.8% (0.7% o 4.5%) 11.0% (7.2% o 16.3%) 71.5% (65.2% o 77.0%) 62.4% (55.7% o 68.6%)
Mal a 2.6% (1.2% o 5.7%) 6.0% (3.3% o 10.5%) 77.7% (71.4% o 82.9%) 66.9% (59.9% o 73.2%)
Ne he lands 0.5% (0.1% o 2.0%) 6.4% (4.6% o 8.9%) 80.8% (76.6% o 84.4%) 81.0% (76.4% o 84.8%)
Poland 3.9% (2.3% o 6.7%) 5.0% (3.3% o 7.4%) 41.3% (36.9% o 45.9%) 38.8% (34.4% o 43.4%)
Po ugal 3.3% (2.1% o 5.0%) 5.4% (3.9% o 7.6%) 64.7% (61.0% o 68.3%) 61.4% (57.7% o 65.1%)
Romania 11.5% (9.1% o 14.4%) 13.5% (11.0% o 16.5%) 37.3% (33.2% o 41.5%) 42.5% (38.3% o 46.9%)
Slo akia 4.3% (2.7% o 6.9%) 7.2% (5.0% o 10.1%) 61.8% (57.2% o 66.1%) 54.3% (49.7% o 58.8%)
Slo enia 0.1% (0.0% o 1.0%) 9.0% (6.6% o 12.3%) 85.0% (81.5% o 87.9%) 70.9% (66.5% o 74.9%)
Spain 0.0% (0.0% o 0.0%) 7.3% (5.3% o 9.9%) 66.6% (62.3% o 70.5%) 60.2% (55.8% o 64.4%)
Sweden 0.1% (0.0% o 1.0%) 8.9% (5.9% o 13.2%) 79.4% (74.5% o 83.5%) 75.3% (69.8% o 80.2%)
EU 2.0% (1.6% o 2.4%) 7.1% (6.5% o 7.9%) 58.8% (57.4% o 60.1%) 51.1% (49.7% o 52.4%)
HTP = hea ed obacco p oduc . Appealing: Do you ind HTPs appealing? E ec i e aid o smoking cessa ion: Do you hink ha he use o HTPs helps
obacco smoke s qui ? Regula e as s ic ly as ciga e es: Do you hink ha HTPs should be egula ed as s ic ly as ciga e es? S ic e poin -o -sale ad e ising
es ic ions: Would you be in a o o keeping HTPs ou o sigh in shops o poin s o sale?
Ta b l e 4 . Mul i-le el Poisson Reg ession Es ima ing Associa ions Be ween Sociodemog aphic Fac o s and Pe cep ions Rela ed o HTPs Among Ne e
Use s o Tobacco, e-Ciga e es, o H TPs Ac oss he EU
Va iables Appealing E ec i e aid o smoking
cessa ion
Regula e as s ic ly
as ciga e es
S ic e poin -o -sale
ad e ising es ic ions
P e alence a io (95% con idence in e al)
Gende
Male (Re .) 1 1 1 1
Female 0.80 (0.64 o 1.01) 0.82 (0.73 o 0.91) 1.02 (0.99 o 1.06) 1.04 (1.00 o 1.07)
Age (yea s)
≥55 (Re .) 1 1 1 1
15–24 1.88 (1.19 o 2.95) 2.29 (1.58 o 3.33) 1.00 (0.91 o 1.10) 0.98 (0.88 o 1.09)
25–39 1.54 (1.04 o 2.28) 1.52 (1.15 o 2.02) 0.99 (0.94 o 1.04) 0.98 (0.92 o 1.04)
40–54 0.91 (0.53 o 1.58) 1.15 (0.92 o 1.43) 1.02 (0.99 o 1.05) 1.00 (0.96 o 1.04)
Di icul y paying bills
Almos ne e /ne e (Re .) 1 1 1 1
F om ime o ime/mos o he ime 1.03 (0.73 o 1.46) 1.14 (0.97 o 1.34) 0.89 (0.85 o 0.93) 0.93 (0.88 o 0.98)
Communi y ype
Ru al (Re .) 1 1 1 1
U ban 1.06 (0.81 o 1.38) 1.08 (0.88 o 1.33) 1.02 (0.96 o 1.07) 1.01 (0.95 o 1.07)
Educa ion (age a comple ion)
0–15 yea s (Re .) 1 1 1 1
16–19 yea s 1.19 (0.71 o 2.01) 1.12 (0.84 o 1.50) 1.06 (0.98 o 1.15) 1.04 (0.98 o 1.11)
≥20 yea s 1.05 (0.61 o 1.81) 1.14 (0.82 o 1.57) 1.16 (1.08 o 1.25) 1.14 (1.07 o 1.22)
S ill s udying 2.08 (0.83 o 5.22) 1.12 (0.67 o 1.86) 1.07 (0.96 o 1.20) 1.02 (0.90 o 1.17)
Li ing wi h child en
No (Re .) 1 1 1 1
Yes 1.38 (1.12 o 1.70) 1.07 (0.92 o 1.25) 1.06 (1.02 o 1.11) 1.05 (1.01 o 1.09)
Employmen s a us
Employed (Re .) 1 1 1 1
Unemployed 0.29 (0.75 o 1.12) 1.29 (0.92 o 1.83) 1.04 (0.96 o 1.14) 1.02 (0.94 o 1.11)
S uden s/house pe sons/ e i ed 0.76 (0.41 o 1.42) 0.74 (0.58 o 0.96) 1.11 (1.05 o 1.17) 1.10 (1.03 o 1.17)
HTP = hea ed obacco p oduc Appealing: Do you ind HTPs appealing? E ec i e aid o smoking cessa ion: Do you hink ha he use o HTPs helps
obacco smoke s qui ? Regula e as s ic ly as ciga e es: Do you hink ha HTPs should be egula ed as s ic ly as ciga e es? S ic e poin -o -sale ad e ising
es ic ions: Would you be in a o o keeping HTPs ou o sigh in shops o poin s o sale?
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Nico ine & Tobacco Resea ch, 2025, Vol. 00, No. 00 7
we p o ide a unique pe spec i e on pe cep ions o hese
p oduc s among a c i ical popula ion subg oup. Howe e ,
limi a ions exis , pa icula ly ega ding he in e p e a ion o
ce ain su ey ques ions. Fo ins ance, he e m “appealing”
may be in e p e ed di e en ly by esponden s, po en ially
e e ing o ac o s such as s yle, as e, o o he quali ies.
Addi ionally, he ques ion “Do you hink ha e-ciga e es
should be egula ed as s ic ly as ciga e es?” is ela i ely
ague and depends on he local egula o y con ex , which
may lead o a ying in e p e a ions. Some indi iduals may
conside s ic egula ion o encompass comp ehensi e es ic-
ions on ad e ising, packaging, and sales simila o hose
imposed on adi ional ciga e es, while o he s may in e p e
i as including comple e bans on use in some public spaces.
Some MSs ha e small sample sizes, which may educe he
powe o subg oup analyses and limi he g anula i y o
coun y-speci ic insigh s. Exclusion o esponses om indi id-
uals iden i ying ou side he bina y gende ca ego ies included
may limi inclusi i y and he gene alizabili y o indings o
unde ep esen ed g oups. Mo eo e , he su ey’s ques ions
measu e pe cep ions and suppo o egula ions bu do no
cap u e nuanced indi idual expe iences o mo i a ions, such
as he con ex o appeal o he ac o s d i ing suppo o
egula o y measu es. Fu he mo e, sel - epo ed su ey da a
may be subjec o misclassi ica ion be ween e-ciga e es and
HTPs. While in e iewe s p o ided e bal desc ip ions o each
obacco and nico ine p oduc assessed a he beginning o he
su ey, he absence o accompanying images may ha e caused
some con usion. Simila i ies in de ice design, along wi h he
mo e es ablished ma ke p esence o e-ciga e es ac oss EU
MSs, may ha e led esponden s o inad e en ly epo use o
one p oduc ype as he o he . Howe e , his is unlikely o ha e
esul ed in subs an ial misclassi ica ion. These limi a ions may
esul in an unde es ima ion o o e simpli ica ion o sociode-
mog aphic dispa i ies and c oss-na ional di e ences.
Conclusion
In conclusion, he signi ican a ia ion in pe cep ions o e-
ciga e es and HTPs ac oss EU MSs, pa icula ly among
young people, highligh s he c i ical need o mo e ailo ed
and comp ehensi e legisla ion and implemen a ion in egu-
la ing hese p oduc s. As demons a ed by he public suppo
o egula o y measu es in ce ain MS, he scope o he TPD
could be expanded o conside he di e se pe cep ions o
eme ging obacco and nico ine p oduc s and hei po en ial
appeal o ne e use s, pa icula ly young people. Policymake s
may conside enhancing es ic ions on ma ke ing and display
while ailo ing in e en ions o add ess he needs o speci ic
sociodemog aphic subg oups. An upda ed e sion o he
TPD is equi ed o add ess hese eme ging ends and ensu e
e ec i e egula ion ha p o ec s public heal h.
Supplemen a y Ma e ial
Supplemen a y ma e ial is a ailable a Nico ine and T obacco Resea ch
online.
Funding
This p ojec has ecei ed unding om he Eu opean Union’s Ho izon
2020 Resea ch and Inno a ion p og am unde he Ma ie Skłodowska-
Cu ie G an Ag eemen No 101008139 (EUREST-RISE). AF is he
ecipien o an Impe ial College Resea ch Fellowship g an unded by
Impe ial College London.
Decla a ion o In e es s
None decla ed .
Da a A ailabili y
Da a no cu en ly publicly a ailable.
Re e ences
1. Eu opean Commission . Tobacco O e iew. Accessed Janua y 9,
2025. h ps://heal h.ec.eu opa.eu/ obacco/o e iew_en
2. Eu opean Commission . A i udes o Eu opeans owa ds obacco
and ela ed p oduc s. Upda ed June 2023. Accessed Janua y 9,
2025. h ps://eu opa.eu/eu oba ome e /su eys/de ail/2995
3. McNeill A, Simona iˇcius E, B ose L, e al. Nico ine aping in eng-
land: An e idence upda e including heal h isks and pe cep ions,
2022 a epo commissioned by he o ice o heal h imp o e-
men and dispa i ies. 2022. 29 Sep embe . Accessed Janua y
9 2025. h ps://asse s.publishing.se ice.go .uk/media/633469 c8
a8 5066d28e1a2/Nico ine- aping-in-England-2022- epo .pd
4. Ma ques P, Pique as L, Sanz MJ. An upda ed o e iew o e-
ciga e e impac on human heal h. Respi Res. 2021;22(1):151.
h ps://doi.o g/10.1186/s12931-021-01737-5.
5. D ummond MB, Upson D. Elec onic ciga e es. Po en ial ha ms
and bene i s. Ann Am Tho ac Soc. 2014;11(2):236-242. h ps://
doi.o g/10.1513/AnnalsATS.201311-391FR.
6. Feliu A, Espina C, Ma inez C, Fe nandez E. No el obacco
and nico ine p oduc s and you h in he Eu opean Union.
Nowo wo y J Oncol. 2023;71(2):94-102. h ps://doi.o g/10.5603/
NJO.2021.0022.
7. O’B ien D, Long J, Quigley J, Lee C, McCa hy A, Ka anagh
P. Associa ion be ween elec onic ciga e e use and obacco
ciga e e smoking ini ia ion in adolescen s: a sys ema ic e iew and
me a-analysis. BMC Public Heal h. 2021;21(1):954. h ps://doi.o
g/10.1186/s12889-021-10935-1.
8. Ade ma k L, Galan i MR, Ryk C, Gilljam H, Hedman L.
P ospec i e associa ion be ween use o elec onic ciga e es and
use o con en ional ciga e es: a sys ema ic e iew and me a-
analysis. ERJ Open Res. 2021;7(3):00976-02020. h ps://doi.o
g/10.1183/23120541.00976-2020.
9. Eu opean Commission . Commission Delega ed Di ec i e (EU)
2022/2100 on he wi hd awal o ce ain exemp ions in espec o
hea ed obacco p oduc s. Upda ed No embe 3 2022. Accessed
Janua y 9, 2025. h ps://heal h.ec.eu opa.eu/publica ions/commi
ssion-delega ed-di ec i e-eu-20222100-wi hd awal-ce ain-exe
mp ions- espec -hea ed- obacco_en
10. Eu opean Commission . Elec onic ciga e es. Upda ed 2025.
Accessed Janua y 9, 2025. h ps://heal h.ec.eu opa.eu/ obacco/p o
duc - egula ion/elec onic-ciga e es_en
11. El Asma ML, La e y AA, Va da as CI, Filippidis FT. How do
Eu opeans qui using obacco, e-ciga e es and hea ed obacco
p oduc s? A c oss-sec ional analysis in 28 Eu opean coun ies.
BMJ Open. 2022;12(4):e059068. h ps://doi.o g/10.1136/bmjope
n-2021-059068.
12. Lo ean LM, T o o A, Radu-Loghin C, e al. Awa eness and use
o hea ed obacco p oduc s among adul smoke s in six Eu opean
coun ies: indings om he EUREST-PLUS ITC Eu ope su eys.
Eu J Pub Heal h. 2020;30(Supplemen 3):iii78-iii83. h ps://doi.o
g/10.1093/eu pub/ckz228.
13. Odani S, Tsuno K, Agaku IT, Tabuchi T. Hea ed obacco p oduc s
do no help smoke s qui o p e en elapse: a longi udinal s udy
in Japan. Tob Con ol. 2023;33:472-480. h ps://doi.o g/10.1136/
c-2022-057613.
Downloaded om h ps://academic.oup.com/n /ad ance-a icle/doi/10.1093/n /n a 168/8230282 by gues on 06 No embe 2025
8Li e al.
14. Alpe JM, Jaisle A, Chen H. A con en analysis o he
p omo ional s a egies employed by e-ciga e e b ands on
wi e . Heal h Ma k Q. 2019;36(4):307-321. h ps://doi.o
g/10.1080/07359683.2019.1680121.
15. Payne JD, O ellana-Ba ios M, Med ano-Jua ez R, Buscemi
D, Nugen K. Elec onic ciga e es in he media. P oc
(Baylo Uni Med Cen ). 2016;29(3):280-283. h ps://doi.o
g/10.1080/08998280.2016.11929436.
16. Ju H, Lee H, Choi J, Kim S, Kang E. The online p omo ion
s a egies o e-ciga e e and hea ed obacco p oduc e aile s in
Sou h Ko ea ollowing he COVID-19 pandemic: implica ions o
egula ion. Tob Induc Dis. 2024;22(Feb ua y):1-11. h ps://doi.o
g/10.18332/ id/178380.
17. La e y AA, Va da as CI, Filippidis FT. P e alence and easons
o use o hea ed obacco p oduc s (HTP) in Eu ope: an analysis
o Eu oba ome e da a in 28 coun ies. Lance Reg Heal h Eu .
2021;8:100159. h ps://doi.o g/10.1016/j.lanepe.2021.100159.
18. Alpe JM, Chen H, Riddell H, Chung YJ, Mu YA. Vap-
ing and Ins ag am: a con en analysis o e-ciga e e pos s
using he con en appealing o you h (CAY) index. Subs Use
Misuse. 2021;56(6):879-887. h ps://doi.o g/10.1080/10826084.
2021.1899233.
19. O’B ien EK, Ho man L, Na a o MA, Ganz O. Social media use
by leading US e-ciga e e, ciga e e, smokeless obacco, ciga and
hookah b ands. Tob Con ol. 2020;29(e1): obaccocon ol-2019-
055406-e97. h ps://doi.o g/10.1136/ obaccocon ol-2019-055
406.
20. B e EI, Lee Z, Lea ens ELS, F idbe g DJ, King AC. Cue eac i i y
e ec s o hea ed obacco p oduc use in cu en , o me , and ne e
smoke s in he Uni ed S a es. Nico ine Tob Res. 2023;25(5):1014-
1021. h ps://doi.o g/10.1093/n /n ac228.
21. Council o he Eu opean Union. P oposal o a Council Recom-
menda ion on smoke- and ae osol- ee en i onmen s eplacing
Council Recommenda ion 2009/C 296/02. Upda ed No embe 14
2024. Accessed Janua y 9, 2025. h ps://da a.consilium.eu opa.eu/
doc/documen /ST-15059-2024-INIT/en/pd
22. Ollila H, Ta asenko Y, Ciobanu A, Lebede a E, Rai asalo K. Exclu-
si e and dual use o elec onic ciga e es among Eu opean you h
in 32 coun ies wi h di e en egula o y landscapes. Tob Con ol.
2024;33(5):622-627. h ps://doi.o g/10.1136/ c-2022-057749.
23. B own R, Van Godwin J, Page N, e al. Implemen a ion o e-
ciga e e egula ion h ough he EU obacco p oduc s di ec i e
(2016) in Wales, Sco land and England om he pe spec i es
o s akeholde s in ol ed in policy in oduc ion and en o ce-
men . Tob P e Cessa . 2021;7(May):36. h ps://doi.o g/10.18332/
pc/134370.
24. Shah A, B i on J, Bogdano ica I. De eloping a no el e-ciga e e
egula o y and policy con ol scale: esul s om he Eu opean
Union. D ugs (Abingdon Engl). 2022;29(6):719-725. h ps://doi.o
g/10.1080/09687637.2021.1959520.
25. Join Ac ion on Tobacco Con ol . Repo on egula ion o
no el obacco p oduc s and e-ciga e es in di e en EU Membe
S a es (Deli e able 7.1). 2022. h ps://jao c.eu/wp-con en /uploa
ds/2023/10/D7.1-Repo -on- egula ion-o -no el- obacco-p odu
c s-and-e-ciga e es-in-di e en -EU-Membe -S a es.pd
26. Collins L, Glasse AM, Abudayyeh H, Pea son JL, Villan i AC. E-
ciga e e ma ke ing and communica ion: how E-ciga e e compa-
nies ma ke E-ciga e es and he public engages wi h E-ciga e e
in o ma ion. Nico ine Tob Res. 2019;21(1):14-24. h ps://doi.o
g/10.1093/n /n x284.
27. Tobacco Con ol Laws . Legisla ion by Coun y/Ju isdic ion |
La ia. Upda ed Augus 27, 2021. Accessed July 12, 2025. h ps://
www. obaccocon ollaws.o g/legisla ion/la ia/e-ciga e es/main-
policies
28. Al-Ghoumani H, Va da as CI, Aslanoglou K, La e y AA, Filip-
pidis FT. Exposu e o smoking obacco, oll-you -own obacco,
hea ed obacco p oduc , and e-ciga e e ad e ising in 28 Eu o-
pean coun ies. Pop Med. 2024;27(6 (Sep embe )). h ps://doi.o
g/10.18332/popmed/193944.
29. La e y AA, Filippidis FT, Fe nandez E, Va da as CI. E-ciga e e
use and suppo o banning e-ciga e e use in public places in
he Eu opean Union. P e Med. 2017;105:10-14. h ps://doi.o
g/10.1016/j.ypmed.2017.08.007.
30. Feliu A, Filippidis FT, Joossens L, e al. Impac o obacco
con ol policies on smoking p e alence and qui a ios in 27
Eu opean Union coun ies om 2006 o 2014. Tob Con ol.
2019;28(1): obaccocon ol-2017-054119- obaccocon ol-2017-
054109. h ps://doi.o g/10.1136/ obaccocon ol-2017-054119.
31. Cu in GM, Ge lach KK, Pilli e i JL, Ba is a DR, Chae R, Pols e
M. Pu chase in en and in ended use o he glo hea ed obacco
p oduc . Am J Heal h Beha . 2024;48(2):105-115. h ps://doi.o
g/10.5993/AJHB.48.2.10.
32. Ahuja N, Kedia SK, Dillon PJ, Jiang Y, Yu X. Pe cep ion and
in en ion o using less ha m ul and less addic i e hypo he ical
modi ied isk obacco p oduc s among ne e obacco use s in
he Uni ed S a es. Addic Beha . 2021;122:107016. h ps://doi.o
g/10.1016/j.addbeh.2021.107016.
33. Vasilje ic M, Pe escu DC, Ma eau TM. Impac o ad e ise-
men s p omo ing candy-like la ou ed e-ciga e es on appeal o
obacco smoking among child en: an expe imen al s udy. Tob
Con ol. 2016;25(e2):e107-e112. h ps://doi.o g/10.1136/ obacco
con ol-2015-052593.
34. Simon P, Camenga DR, Mo ean ME, e al. Socioeconomic s a us
and adolescen e-ciga e e use: he media ing ole o e-ciga e e
ad e isemen exposu e. P e Med. 2018;112:193-198. h ps://
doi.o g/10.1016/j.ypmed.2018.04.019.
35. Vi gili F, Nenna R, Ben Da id S, e al. E-ciga e es and you h:
an un esol ed public heal h conce n. I al J Pedia . 2022;48(1):97.
h ps://doi.o g/10.1186/s13052-022-01286-7.
36. Cha ee BW, Couch ET, Wilkinson ML, e al. Fla o s inc ease
adolescen s’ willingness o y nico ine and cannabis ape p od-
uc s. D ug Alcohol Depend. 2023;246:109834. h ps://doi.o
g/10.1016/j.d ugalcdep.2023.109834.
37. Sande s-Jackson A, Tan AS, Bigman CA, Mello S, Niede deppe J.
To egula e o no o egula e? Views on elec onic ciga e e eg-
ula ions and belie s abou he easons o and agains egula ion.
PLoS One. 2016;11(8):e0161124. h ps://doi.o g/10.1371/jou na
l.pone.0161124.
38. Chen-Sankey JC, Kong G, Choi K. Pe cei ed ease o la o ed e-
ciga e e use and e-ciga e e use p og ession among you h ne e
obacco use s. PLoS One. 2019;14(2):e0212353. h ps://doi.o
g/10.1371/jou nal.pone.0212353.
39. Lindson N, Bu le AR, McRobbie H, e al. Elec onic
ciga e es o smoking cessa ion. Coch ane Da abase Sys Re .
2024;2024(1):CD010216. h ps://doi.o g/10.1002/14651858.CD
010216.pub8.
40. Heal h Se ice Execu i e . Vaping (using e-ciga e es). Upda ed 1
Feb ua y 2025. Accessed July 12, 2025. h ps://www2.hse.ie/li i
ng-well/qui -smoking/ aping/
41. Na ional Heal h Se ice . Using e-ciga e es o s op smoking.
Upda ed 10 Oc obe 2022. Accessed July 12, 2025. h ps://www.
nhs.uk/li e-well/qui -smoking/using-e-ciga e es- o-s op-smoki
ng/
42. Kock L, Shahab L, Moo e G, Sho NK, Pea ce J, B own J. Assess-
ing he p o ile o suppo o po en ial obacco con ol policies
a ge ing a ailabili y in g ea B i ain: a c oss-sec ional popula ion
su ey. Tob Con ol. 2024;33(2):221-231. h ps://doi.o g/10.1136/
c-2022-057508.
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