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smoking ). However, a substantial increase in e-
cigarette smoking in a short period has been reported in
North American and European countries. For example, ever
e-cigarette use among students in grades 6–12 in the United
States increased from 3.3% in 2011 to 11.9% in 2013; the
corresponding increase in current (past month) e-cigarette
use was from 1.1% to 4.5% Ever use of e-cigarettes in
the French population aged 15 increased from 7% in
2012 to 18% in 2013 . In 2012, 1% of people in France
reported regular or occasional use of e-cigarettes , but in
2013, 6% had used e-cigarettes in the last month
. Similar increases have likely occurred since 2012 in
many countries in the European Union, in which a survey by
the European Commission reported that the prevalence of
ever use of e-cigarettes varied from 2% in Sweden to 14% in
Belgium .
One of the primary concerns of e-cigarette use is how it
affects cigarette use. E-cigarette use may not be an issue of
concern if it occurs only in current smokers and only if it led
to smoking cessation or at least a substantial decrease in
smoking intensity. However, e-cigarette smoking in non-
smokers, or in current or former smokers, that might result
in a maintenance (with no substantial decrease in smoking
intensity) or surge in tobacco use is an issue that may need
preventive measures. Cigarette smokers should be strongly
encouraged to quit smoking using any evidence-based
methods, with or without nicotine replacement therapy.
3.6. Tobacco control policies
3.6.1. MPOWER measures
Tobacco control policies reduce tobacco use and related
harm. Because earlier policies usually were sporadic and
isolated and could not prevent the global tobacco epidemic,
in 2003 the World Health Assembly adopted the WHO
Framework Convention on Tobacco Control (WHO FCTC),
the first international treaty negotiated under the auspices
of WHO, although the WHO FCTC did not come into force
until 2005 . In 2008, WHO identified six effective
evidence-based measures for reducing tobacco use and
began promoting them under the acronym MPOWER . In
2011, UN member states committed to reduce premature
mortality from noncommunicable diseases (a 25% reduc-
tion from 2010 levels by 2025) by addressing their major
risk factors, including a 30% relative reduction in prevalence
of current tobacco use in persons 15 yr .
The worldwide coverage of MPOWER policies is briefly
described in the following sections and is summarized in
(percentage of countries with coverage) and
Supplementary Table 2 (median levels of coverage). It
should be noted that tobacco control policies might vary
within countries in which jurisdiction is subnational for
some policies and/or regulations. In the United States, for
example, the northeastern and western states have
generally been more successful in tobacco control than
the southern states
3.6.1.1. Monitoring tobacco use and prevention policies. Monitoring
tobacco use and prevention policies is necessary to assess
the effectiveness of current policies and the need for any
policy modifications. Tobacco monitoring has traditionally
been better in countries with developed health surveillance
systems, including Australia, Canada, the United States, and
most EU member states. Broader initiatives such as the
Global Tobacco Surveillance System Surveys , which
provide funding and training from high-income countries
(notably from the US government and private foundations),
can help improve tobacco monitoring in LMICs.
3.6.1.2. Protecting people from tobacco smoke. As exposure to
secondhand smoke is harmful smoking in public places
has been banned to some degree in many countries. In 2012,
however, only 16% of the world’s population was covered by
comprehensive smoke-free laws , demonstrating the
need for improved implementation and/or enforcement of
these laws. Middle-income countries are the best covered
with smoke-free policies, with South America being the
leading region in implementation
Smoking in cars outdoor places and multiunit
buildings can also be sources of exposure to secondhand
Table 2 – Prevalence of e-cigarette smoking in adults and youth.
Country Year Age group Ever use, % Current use, %
Adults
Canada 2012 16–30 yr 16.1 5.7
France 2013 15 yr 18 6
Italy 2013 15 yr 6.8 1.2
Spain (Barcelona only) 2013–2014 16 yr 6.5 1.6
United States 2012–2013 18 yr 4. 1.9
Youth
Canada 2012 16–19 yr 12.5 2.6
France 2013 15–24 yr 31 7
Poland 2011 15–19 yr 23.5 8.2
South Korea 2011 School grade 7–12 19.7 4.7
United Kingdom 2013 11–15 yr 4 1
16–18 yr 10 2
United States 2013 School grade 6–8 3.0 1.1
School grade 9–12 11.9 4.5
a Every day, someday, or rarely users.
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