Date Published: July 1, 2018
Publisher: Elsevier Science
Author(s): Xinsong Wang, Xiulan Zhang, Xiaoxin Xu, Ying Gao.
•Little is known about e-cigarette use among adolescents in China and how it is associated with smoking cessation behavior.•Our 2015 survey on e-cigarette use and smoking cessation behavior covered 2042 Chinese adolescents aged between 12 and 18.•E-cigarettes were widely known and popular among Chinese adolescents.•There was a significant association between e-cigarette use and smoking cessation behavior.
Electronic cigarette (hereafter abbreviated to e-cigarette), also known as the Electronic Nicotine Delivery System (ENDS), is a battery-powered smoking device that releases vaporized nicotine solution inhalable by users (Trtchounian & Talbot, 2011). Designed to mimic the appearance and feel of conventional combustible tobacco products, e-cigarette has been advertised and advocated as a healthier replacement for tobacco smoking due to its more flexible control of nicotine ingredients and releasing less toxicants than conventional cigarettes (Goniewicz et al., 2014). Adolescents are particularly susceptible to e-cigarette use as, among other reasons, it is fashionable and features various flavors (Durmowicz, 2014). Although research has demonstrated that e-cigarette may generate a number of toxicants and the impact of long-term use of e-cigarette use on health is uncertain (Vardavas et al., 2012), many smokers tend to use e-cigarettes as smoking cessation aids (Bullen et al., 2010; Eissenberg, 2010; Wang & Etter, 2004).
We conducted a mobile internet survey to collect data on the attitude and behavior of cigarette and e-cigarette use. Previous tobacco research focusing on adolescents in China has relied on school-based surveys, which often are unable to reach the high schoolers in rural regions because many of them would enter the workforce after middle school. An internet survey should help us overcome the problem since adolescents of both urban and rural origins have access to the Internet. By June 2015, Internet users in China had reached 668 million or 48.8% of the total population, with 88.9% accessing the Internet through mobile devices. In both urban and rural regions, the majority of young population had access to the Internet. For example, among those aged between 10 and 19, 85.1% of urban and 65.6% of rural individuals had access to the Internet (CNNIC, 2015). Our questionnaires were distributed through the Kai-Di Community, a mobile-app based survey service with 152,622 registered app users, 91.75% of whom were under the age of 35. Among the app users, 53.1% were males and 46.9% were females. 46.1% of the app users had an education level of college and above, 33.5% had associate degrees, while 20.4% had a level of high school and below. In terms of occupation, the app users covered major professions including businesspersons (27.4%), service labor (20.2%), professionals (20.1%), and students (25.3%), although only a small percentage (6.9%) were government staff. The user locations approximately matched the population distribution across provinces in China, with the top five provinces where the app users were located being Guangdong, Sichuan, Shandong, Jiangsu, and Henan.
Among the 2042 adolescent respondents in our survey, 615 or 30.12% were current smokers, 192 or 9.4% were former smokers or those who had successfully quit smoking, and 1235 or 60.48% were never smokers. Among current smokers, 62.62% smoked daily while others smoked occasionally. Also, 57.10% of current smokers smoked 1–5 cigarettes/day, 27.44% smoked 6–10/day, 11.83% smoked 11–20/day, and 3.63% smoked >20 cigarettes/day. Table 1 shows the socio-demographic characteristics of the current, former and never smokers.Table 1Sample characteristics (N = 2042).Table 1All sample (N = 2042)Current smokers (N = 615)Former smokers (N = 192)Never smokers (N = 1235)N (%)N (%)N (%)N (%)SexMale1706 (83.55)552 (89.76)163 (84.90)991 (80.24)Female336 (16.45)63 (10.24)29 (15.10)244 (19.76) Economic statusVery wealthy198 (9.70)119 (19.35)23 (11.98)56 (4.53)Comfortable611 (29.92)173 (28.13)54 (28.13)384 (31.09)Fair1003 (49.12)269 (43.74)100 (52.08)634 (51.34)Difficult143 (7.00)40 (6.50)10 (5.21)93 (7.53)Very difficult87 (4.26)14 (2.28)5 (2.60)68 (5.51) Education levelHigh school or under1222 (59.84)356 (57.89)99 (51.56)767 (62.11)Junior college608 (29.77)206 (33.50)69 (35.94)333 (26.96)College and above212 (10.38)53 (8.62)24 (12.50)135 (10.93) Employment statusEmployed756 (37.02)284 (46.18)81 (42.19)391 (31.66)Not employed1286 (62.98)331 (53.82)111 (57.81)844 (68.34) Location and type of hukouLocal/urban656 (32.13)217 (35.28)55 (28.65)384 (31.09)Non-local/urban178 (8.72)68 (11.06)24 (12.50)86 (6.96)Local/rural995 (48.73)268 (43.58)101 (52.60)626 (50.69)Non-local/rural213 (10.43)62 (10.08)12 (6.25)139 (11.26)
This study is one of the first empirical research on the characteristics of e-cigarette awareness, perception and use, and on the relationship between e-cigarette use and smoking cessation behavior among Chinese adolescents. E-cigarettes are rather popular among Chinese adolescents. The awareness rate (89.52%) is comparable with the ones reported in other countries (86% in the U.S. and 75% in Hong Kong) (Jiang et al., 2016; King, Alam, Promoff, Arrazola, & Dube, 2013), while the usage rate (26.44%) is higher than the combined rate for both current and ever e-cigarette users reported in other countries (Czoli, Hammond, & White, 2014; S. Lee et al., 2014). The Internet provides easy access to the information and sales of e-cigarettes for current, former and never smokers, as seen from the high proportion of the respondents reporting their awareness and purchase of e-cigarettes from the Internet.
E-cigarettes are widely known and quite popular among Chinese adolescents. However, the association between e-cigarette use and smoking cessation deserves further examination until a clearer picture is revealed. As a regulatory system for the rapid development of e-cigarette industry is still missing in China, more empirical research is called for to help form evidence-based regulatory policy on e-cigarettes.
This study was funded by grants from Bill & Melinda Gates Foundation (Grant # OPP1123586). The Gates Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
XZ and XW designed the study and wrote the protocol. XX and YG collected the data. XZ and XW conducted the statistical analysis. XW and XZ wrote the first draft of the manuscript and all authors have contributed to and have approved the final manuscript.