Researchers from the United States, Australia, the United Kingdom, and Canada investigated ENDS awareness, use, and perceptions among current and former cigarette smokers.

"We were not aware of any studies to date that examined cross-national patterns of ENDS use," says lead investigator Richard J. O'Connor, PhD, Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York. "No studies have examined use in markets where ENDS are nominally banned."

Data from the International Tobacco Control (ITC) Four-Country Survey, collected from nearly 6,000 respondents through telephone and web surveys from July 2010 to June 2011, formed the basis of the study. Across countries, ENDS awareness reached nearly 47 percent, ranging from 73 percent in the United States where ENDS are legal, to 20 percent in Australia where they are banned. Awareness was higher among younger (aged 18-24), non-minority populations with higher incomes. Of those aware, 16 percent had tried ENDS.

Slightly more than 70 percent of respondents said that ENDS were less harmful than traditional cigarettes. Perceptions of harm were higher in the United States and the United Kingdom.

Current users included non-daily smokers and those who smoked twenty or more cigarettes a day. Nearly 80 percent reported they used ENDS because they were considered less harmful than traditional cigarettes. Seventy-five percent said they used ENDS to reduce the number of cigarettes they smoke. Eight-five percent reported using ENDS to help them quit smoking. Nearly three-quarters reported use of ENDS to access nicotine in smoke-free spaces, suggesting the use of ENDS to satisfy nicotine addiction during periods of temporary abstinence.

The high level of awareness of ENDS in countries where they are banned may demonstrate the importance of the Internet's promotion of the product.

Says Dr. O'Connor: "This study represents a snapshot in time of the use of ENDS from mid-2010 to mid-2011. As the market evolves, awareness, trial, and use of ENDS is likely to increase. Should regulatory authorities approve direct claims about reduced harm, one might expect greater adoption of these products, at least among current cigarette smokers. If credible evidence can be provided to regulators, through independently researched, well-controlled studies, that ENDS reduces the number of cigarette smokers and does not attract use among nonsmokers, then the net public health effect is likely to be positive."