Jerusalem Post

ByJUDY SIEGEL-ITZKOVICH

Hebrew University of Jerusalem study reveals distinct adult-use patterns of electronic cigarettes in the US and Israel.

The use of electronic cigarettes (e-cigs) in Israel has, unfortunately, increased significantly – especially among young people – since the war with Hamas in Gaza began in October 2023.
Vaping with e-cigs is now divided between disposable, single-use, pre-filled, non-refillable, and often non-rechargeable devices thrown away when empty and non-disposable (reusable) devices designed for long-term use, with rechargeable batteries and refillable tanks or pods. Non-disposables require periodic coil or pod replacements.

The disposables offer convenience and high-nicotine levels, while the reusable type makes possible customization, lower long-term costs, and less environmental waste. Ready-to-use out of the package and discarded after the liquid or battery runs out, they may contain higher levels of toxic metals in their aerosols due to the nature of their closed, non-replaceable systems.

Now, a new international study has revealed that adults who use disposable and non-disposable e-cigarettes differ in meaningful ways, and that those differences vary between countries. It was led by a foreign student doing his international master’s degree in public health, MPH student Dr. Beghashaw Mulu, under the supervision of Prof. Yael Bar-Zeev of the Braun School of Public Health and Community Medicine at the Hebrew University of Jerusalem (HUJI). Before his international studies, he established his medical career in Ethiopia and served as a senior medical officer and medical director at the Koka Clinic. 
It has just been published in the Israel Journal of Health Policy Research under the title “Factors associated with using disposable versus non-disposable electronic cigarettes among adults in the US and Israel: a cross-sectional study with policy implications.” 

The dangers of electronic cigarettes
Single-use and non-disposable e-cigs pose a somewhat lower risk of serious respiratory diseases, heart disease, and cancers in their users, but they are more addictive than conventional cigarettes. If one worries about one’s health, however, all of them should be thrown in the garbage and not purchased or used.

In an interview with The Jerusalem Post, Bar-Zeev said that on the Gaza border, before masses of IDF soldiers were about to go to war, there were mountains of tobacco products donated by tobacco companies and individuals – as well as harmful processed salty and sweet snacks and cola. Smoking a cigarette can be very dangerous when on the battlefield or waiting in buildings for the enemy, as its smoke and light can be detected, she said, adding that this also exposes non-smokers to the harmful fumes. 
“As a result of the war, people smoke more, and people who had stopped took it up again. The subject of such donations should be discussed with the IDF medical authorities now that the war is over,” said Bar-Zeev. “We had suggested nicotine patches or nicotine gum/lozenge to be supplied to soldiers who smoke instead of cigarettes to offset withdrawal symptoms on the battlefield.”

Beginning in August, both tobacco cigarettes and e-cigs packages will have to bear graphic health warnings. “Smokers are well aware that they endanger health, but the graphics keep it in their mind and are most effective in persuading children not to smoke.”
The main problem, added Bar-Zeev, who has been researching the dangers of smoking for two decades, is “enforcement. There is very little, partly because of a dispute between the municipalities and the police. And city inspectors easily give parking tickets when vehicle owners are not present but don’t like arguing with smokers in public places who break the law or being assaulted by them.”
DISPOSABLES HAVE exploded in popularity worldwide, but not all users are alike, and that matters for public health. By comparing two countries with very different regulatory environments, the study highlights a simple but powerful message. When it comes to vaping policy, one size does not fit all.
The latest data reported in the journal article dates back to 2023. The researchers wrote that in the US, 6.5% of adults reported using e-cigs, up from 4.5% in 2021. They can be bought legally only by adults over 21. This rise is primarily driven by those aged 18 to 24, among whom e-cigarettes have overtaken combustible cigarettes in popularity.
Among adults who use e-cigs, 66% of those aged 18 to 24 had never smoked cigarettes, compared to 21.6% of those aged 25 to 44 and 11.3% of those aged 45 to 64. Disposable e-cigarette sales have also increased significantly, representing 19.8% of total e-cigarette sales between 2019 and 2020, while prefilled cartridge sales dropped. In 2022, e-cigarettes were the most popular nicotine product among American high school (14.1%) and intermediate school students (3.3%). Among those who reported using e-cigarettes, 53.7% reported using disposable devices.
In Israel, in a representative sample of adults in 2021, among those aged 18 to 24, e-cigarette use has tripled from 3.8% in 2020 to 10.1% in 2022, the team reported. The most significant increase in adult use of disposables was among the younger age group of 18 to 24. In contrast, the consumption of refillable e-cigarettes did not show age dependency, being slightly more common among those aged 18 to 29, and only slightly less frequent among those aged 30 to 64.
E-cigs should not be sold at kiosks on every corner, Bar-Zeev insisted. “Disposables are easily available on the street and via the Internet. The ability of toddlers to open the containers must be stopped with a special locking mechanism, like for pills; numerous toddlers around the world have been poisoned and even killed by consuming the liquids.”
In Australia, there was an effort to require a doctor’s prescription to buy e-cigs, but it didn’t work. The HUJI researcher doesn’t believe that sales of e-cigs can be prohibited, as “it doesn’t work,” as Prohibition in the US – ratified by the 18th amendment in 1919 to establish a nationwide ban on the manufacture, sale, and transportation of alcoholic beverages – was a failure.
It triggered many problems, including bootlegging and organized crime, a surge in illegal production and distribution, and enforcement was weak. In 1933, the 21st Amendment repealed the 18th Amendment and ended Prohibition.
However, some countries, including the UK, the Netherlands, and France, have either banned or are considering banning disposable e-cigarettes due to rising youth use and associated health risks. The researchers found that flavor preferences, perceptions of harm, and purchasing habits strongly influence device choice. Effective e-cig regulation must be tailored to local patterns of use rather than relying on a single global approach, she said.
In Israel, adults who viewed e-cigs as more harmful were actually more likely to use disposable devices, especially when buying them in convenience stores and kiosks. In the US, disposable use was strongly linked to a preference for sweet flavors and prior use of other tobacco or nicotine products.
“The fact that users of refillable devices were far more likely to vape cannabis or cannabinoid-containing liquids raises concerns about regulatory blind spots, especially as non-disposable devices allow greater customization and are harder to monitor. Findings also suggest that banning sweet-flavored e-cigarettes will support the effort in the reduction of disposable e-cig use in the US. While such bans may reduce access to sweet, highly appealing products, the researchers caution that unintended consequences are possible if regulations fail to address non-disposable devices and their use for cannabis consumption.
Future research, she concluded, “should evaluate how retail density, in-store marketing, and enforcement levels influence product choice, particularly among populations with limited online access or higher retail exposure. Especially in Israel, public education needs to clarify misconceptions about the relative risks of different e-cigarette products, as perception of e-cigarette harm was associated with disposable e-cigs here.”