The Importance of Including Questions on the Use of Electronic Cigarettes and Heated Tobacco Products in Tobacco Surveys




Romania implemented the first round of the Global Adult Tobacco Survey (GATS) in 2011 and then the second round in 2018. GATS Romania 2018 was conducted by the National Institute of Public Health and TOTEM Communication under the coordination of Romanian Ministry of Health and World Health Organization (WHO) Romania office, and WHO Regional Office for Europe. To prepare for GATS, the Romanian implementing agencies attended a GATS orientation workshop in Atlanta, Georgia, USA during 23-27 April 2018. The workshop was hosted and facilitated by the GATS collaborating organizations including the Centers for Disease Control and Prevention (CDC), CDC Foundation, RTI International, and WHO. During the workshop, the Romanian team presented and their GATS proposal, including the questionnaire and sample design that would be used to collect information on tobacco use and key tobacco control measures.

Changing Tobacco Product Landscape

Romania experienced significant change in the tobacco product landscape between the first and second round of GATS with the introduction of new and emerging products on the market. New and emerging products like heated tobacco products (HTPs) were introduced on the market, and electronic cigarettes (e-cigarettes) had become more widely available.

Various HTPs were introduced on the Romanian markets, including:

  • British American Tobacco (BAT) launched iFuse, a hybrid product that heated e-liquid to create a vapor that is passed through a tobacco pod, in Romania in 2015; this product is no longer available.
  • Phillip Morris International (PMI) launched IQOS in Romania in 2015. Since then, PMI invested USD 500 million in transforming the Otopeni factory into an RRP (reduced-risk products) production facility. 
  • BAT launched Glo in Romania in 2017. Moreover, in 2018, BAT invested €800 million over the next five years in its factory in Ploiești, Romania. The investment will support the expansion of BAT’s HTP – Glo – in countries across Europe. 

Dr. Magdalena Ciobanu, who helped implement GATS in Romania in 2018, remembers, “the rapid increase of sales figures and the public perception of a rapid adoption of HTPs by young people in Romania [proved] that the industry's tactics were successful. Romanians seemed to be charmed by these new, innovative, trendy products that could be ‘smoked’ in enclosed public places and workplaces, where smoking of combustible tobacco products was completely banned.”

The increase in sales of heated tobacco products in Romania were of concern to the GATS Romania team, but little was known about the actual use of these products in the country. Dr. Ciobanu states that, “public health experts needed to know how many people were using HTPs, who were these people, and what were the drivers for their behavior (e.g., price, advertising, knowledge or other policies).”

During the GATS orientation workshop for Romania in 2018, the GATS collaborating organizations were in the process of updating the GATS Core Questionnaire with Optional Questions manual. Updates to the questionnaire included additions to the core questionnaire and optional questions of items on emerging tobacco products including e-cigarettes and HTPs. An e-cigarette section was added to the core questionnaire and includes questions on awareness, ever use, current use, ever daily use, length of daily use, and reasons for use of e-cigarettes. The use of e-cigarettes and HTPs as methods for trying to stop smoking or using smokeless tobacco products were also added to the cessation section of the core questionnaire. Additionally, various questions on HTPs were added as optional questions.

While the updated manual was not yet finalized, the GATS Romania team opted to include questions on e-cigarettes and HTPs in their 2018 GATS questionnaire. In fact, Romania was the first country to include questions on HTPs in a GATS survey—or any other Global Tobacco Surveillance System (GTSS) survey.

As the GATS Romania team prepared their questionnaire, CDC and the GATS Questionnaire Review Committee (QRC) provided guidance on the development of questions regarding use of emerging products in Romania. 

It is critical to include new questions in tobacco control surveys to monitor the introduction and use of emerging tobacco products, including e-cigarettes and HTPs, for a number of reasons. With a constantly changing tobacco product market, it is important to understand how these products are being marketed and perceived, the implications of those perceptions on use patterns, and the public health risks associated with that use. 

-Dr. Maansi Bansal-Travers, Chairperson, GATS Questionnaire Review Committee

Romania completed GATS fieldwork in January 2019 and later released the initial findings to the public in September 2019. The data from GATS Romania 2018 provided valuable information to public health professionals on the use of tobacco products including e-cigarettes and HTPs.

Key Findings from GATS Romania 2018

GATS Romania 2018 showed that about 11% of adults aged 15 years or older in Romania have tried e-cigarettes while 4% of adults had ever tried HTPs (figures 1-2). About 3% of adults currently used e-cigarettes and about 1% of adults currently used HTPs.

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Figure 1. E-cigarettes in Romania, GATS 2018

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Figure 2. Heated Tobacco Products in Romania, GATS 2018

Opportunity to Strengthen Tobacco Control

The estimates on the use of e-cigarettes and HTPs serve as a baseline to monitor the use of emerging tobacco products in Romania and informs public health tobacco control and prevention policies and programs in Romania important to protecting people from the harms of these products.

Dr. Ciobanu believes that “GATS Romania 2018 represented an opportunity to find answers to [their] questions [on the use of HTPs] in order to tailor the tobacco and nicotine control policies and, hopefully, to reverse the industry's ‘success story’ into a public health success story.”

Emerging tobacco products, including e-cigarettes and HTPs, are a threat to tobacco control and prevention progress in Romania and around the world. Without strengthened tobacco control and prevention strategies, including strategies for e-cigarettes and HTPs, use of these products may continue to rise.