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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 43
| Issue : 6 | Page : 252-257 |
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Factors associated with the use of electronic cigarettes among youths
Thaniya Klinsophon1, Premtip Thaveeratitham1, Pooriput Waongenngarm2
1 Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
2 Faculty of Health Science Technology, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| Date of Submission | 10-Apr-2023 |
| Date of Decision | 26-Jun-2023 |
| Date of Acceptance | 27-Jun-2023 |
| Date of Web Publication | 29-Aug-2023 |
Correspondence Address:
Prof. Pooriput Waongenngarm
Faculty of Health Science Technology, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok
Thailand
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmedsci.jmedsci_93_23
Background: Electronic cigarettes (e-cigarettes) are rapidly becoming a popular new trend among youths and adolescents. However, there is little information available about the causes of e-cigarette use in youths, especially the mental, belief/attitude, and marketing factors that lead to e-cigarette usage. Aim: This study aimed to evaluate the factors associated with e-cigarette use among youths. Methods: We conducted a cross-sectional study of 1164 youths, administering a self-report questionnaire relating to the risk factors for e-cigarette usage: individual, family and friends, mental, belief/attitude, and marketing factors. We used logistic regression analysis to examine the factors and their association with e-cigarette use. Results: The prevalence of current e-cigarette use was 10.6%, while 19.4% of participants had used e-cigarettes at some time in their lives. History of drug use and attitudes about e-cigarette use (e-cigarettes are not harmful to health, using e-cigarettes can help stop smoking, and e-cigarettes help people improve social skills) were significantly associated with the current use of e-cigarettes. GPAX was a protective factor against current e-cigarette use. Conclusion: E-cigarette use is relatively high among youths. We discovered erroneous beliefs and attitudes (misunderstanding or disinformation regarding the harmful effects of e-cigarette use). Interventions to enhance knowledge about e-cigarettes are required for youths to reduce current e-cigarette use.
Keywords: Electronic cigarette, youth, smoking, risk factor
How to cite this article:
Klinsophon T, Thaveeratitham P, Waongenngarm P. Factors associated with the use of electronic cigarettes among youths. J Med Sci 2023;43:252-7 |
| Introduction | |  |
Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a solution to create an aerosol that usually contains nicotine, flavorings, and other chemicals. A previous study showed increasing e-cigarette use in many countries.[1],[2] E-cigarettes have gained popularity, particularly among youths and young adults. Although e-cigarettes are considered illegal in Thailand, the prevalence of current e-cigarette use was 22.2% in college students and 3.7% in 7th-grade students.[3],[4] A previous systematic review showed that e-cigarettes were considered to be less expensive, less dangerous, trendier, and more pleasurable in taste than conventional cigarettes.[5]
In recent years, evidence has pointed out the negative effect of e-cigarettes on health. E-cigarettes deliver nicotine to the bloodstream, which leads to harmful effects on the cardiovascular system by activating the sympathetic nervous system.[6] Previous systematic reviews showed potentially harmful cardiovascular effects from e-cigarettes by inducing sympathetic nerve activation, oxidative stress, endothelial dysfunction, and platelet activation.[7] E-cigarettes also affect the pulmonary system: substantial evidence revealed that e-cigarettes and vaping products can lead to lung injury.[8],[9],[10],[11] In addition, evidence revealed that there is an association between e-cigarette use in adolescents and asthma exacerbation and chronic bronchitis.[12],[13] Moreover, another systematic review found that e-cigarette use may contribute to social maladjustments in adolescents and young adults, including poor concentration, increased aggressive and impulsive behavior, poor learning performance, increased depression and suicidal behaviors, reduced sleep quality, and impaired cognition and memory.[14]
E-cigarettes are increasingly being used by smokers for a variety of reasons, especially attempts to stop conventional cigarette smoking. Previous systematic reviews and meta-analyses revealed that e-cigarette use is associated with reduced smoking cessation in the real world. Those who used e-cigarettes had a 28% lower chance of stopping smoking than those who did not (odds ratio [OR] =0.72 and 95% confidence interval [CI] =0.57–0.91).[15] Moreover, a recent systematic review and meta-analysis showed that e-cigarette use increases the risk of future cigarette smoking in youths and young adults.[16]
The prevalence and risk factors of e-cigarette use in the 7th grade and college students in Thailand have been studied.[3],[4] However, factors associated with e-cigarette use among youths are less documented, and there has been no report regarding the mental, belief/attitude, and marketing factors related to e-cigarette use. Therefore, the specific purpose of the present study was to evaluate the factors associated with e-cigarette use among Thai youths.
| Materials and Methods | | |
Ethical policy
The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Review Committee for Research Involving Human Research Subjects, Health Sciences Group, Chulalongkorn University, Thailand (COA No. 195/2021). Informed written consent was obtained from all patients before their enrollment in this study.
Participants
We conducted a cross-sectional study of Thai youths who currently study in secondary school or university. We defined youths as persons between the ages of 15 and 24 years. Participants were recruited if they ever heard or knew about e-cigarettes and were able to read and understand the Thai language. The sample size used in this study was calculated based on the prevalence of current e-cigarette use observed in previous research,[4] a 95% CI, and a 2% margin of error. A total of 1066 participants were required for this study.
Equipment
We used a self-report questionnaire to investigate risk factors for e-cigarette usage, which we constructed based on evidence of risk factors for e-cigarette use. The questionnaire consisted of individual, family and friends, mental, belief/attitude, and marketing factors. After we developed the questionnaire, we asked 20 students (10 secondary school students and 10 college students) to provide comments and suggestions on the questionnaire and to identify words or phrases that were difficult to understand. Then, we adapted the questionnaire according to the comments. We tested the validity and reliability of the questionnaire. The index of item-objective congruence was one. The intraclass correlation coefficient (3, 1) demonstrated excellent reliability in both secondary school students (0.93) and college students (0.92).
Experimental procedure
We recruited participants from secondary schools, colleges, and universities in Thailand using an advertisement sent out on online platforms such as Line, Facebook, and Twitter. Interested students scanned the QR code or entered the link, and they were asked to consent to participate in this study after reading about it. Then, they were asked to complete a screening questionnaire. Those who agreed to participate and who met the inclusion criteria were able to continue to complete the main questionnaire. We collected data online in September–October 2021. Data included the extent of e-cigarette use and associated factors – individual, family and friends, mental, belief/attitude, and marketing. To avoid multiple submissions from the same participants, respondents were asked to sign in with their email addresses to access the form. However, their email addresses will not be recorded or documented in the response sheet.
Measures
E-cigarette use
E-cigarette use was measured with two items: (1) “Have you ever used an electronic cigarette (E-cigarette), even if it was just a puff?” (Yes, No); (2) “During the past 30 days (1 month), have you ever used an electronic cigarette (E-cigarette)?” (Yes, No).
Factors associated with the use of electronic cigarettes
Individual factor
We asked about age, gender, education level, income per month, accumulated grade point average (GPAX), residence (dorm or home), and history of drug use (drug in this study was defined as cigarettes, baraku, cannabis, or alcohol).
Family and friends factor
We asked about family income and history of substance use (e.g., cigarette, e-cigarette, baraku, cannabis, and alcohol) among family and friends.
Mental factor
We collected data on the number of days participants had a negative effect in the past 30 days. The definition of negative affect is feelings of emotional distress such as irritability, upset, and distress.
Belief and attitude factor
We asked the participants to rate their level of agreement (5-point Likert scale, ranging from “strongly disagree” to “strongly agree”) with the following items: (1) e-cigarettes are not harmful to health, (2) e-cigarettes are less harmful than cigarettes, (3) e-cigarettes are less addictive than cigarettes, (4) using e-cigarettes can help people stop smoking, (5) e-cigarettes help people improve social skills, (6) e-cigarette users are attractive, (7) using e-cigarettes is cheaper than using cigarettes, and (8) unpleasant smell from e-cigarettes is less than that from cigarettes.
Marketing factor
We asked the participants the following question: “Have you ever seen any advertisements or promotions for e-cigarettes?” In addition, we asked the participants to rate their level of agreement (5-point scale, ranging from “strongly disagree” to “strongly agree”) with the following statements: (1) e-cigarettes have many flavors and scents, (2) e-cigarette packaging is attractive, and (3) e-cigarettes have many channels of distribution and are convenient.
Statistical analysis
We expressed the characteristics of the participants as means and standard deviation, or proportions. We calculated the prevalence of e-cigarette use. To handle missing data in our study, we employed different approaches based on the type of data. For continuous variables, we used the “mean imputation” method. For categorical variables, we utilized the “hot deck” approach. By doing so, we aimed to maintain the statistical power of the data and ensure a complete dataset for analysis. We performed univariate analysis to examine the relationship between e-cigarette use and the factors of individual, family and friends, mental, belief/attitude, and marketing. Any univariate factors with P ≤ 0.05 will be added to the binary logistic regression analysis. We adjusted the ORs associated with specific factors for the effect of all other factors in the final model. The unadjusted and adjusted OR and 95% CI for the final model are presented in the results. We performed all statistical analyses using IBM SPSS Statistics for Windows, Version 28.0 (Armonk, NY: IBM Corp). We set statistical significance at the 5% level.
| Results | | |
Of the 1891 youths who received a link or QR code to participate in this study, 1421 agreed to participate (75.16%) and 1164 were eligible (61.55%) and did participate. We described the characteristics of the participants using means or proportions. [Table 1] shows the characteristics of the participants. The study population comprised mainly high school females. Only one participant did not disclose their age. Thus, we imputed one missing piece of data, and the results from the imputed dataset are reported.
One hundred and twenty-three participants (10.6%) reported using e-cigarettes during the previous 30 days. Two hundred and twenty-six participants (19.4%) had a history of e-cigarette use at least once in their lives.
Our univariate logistic regression analyses revealed that factors showing P ≤ 0.05 were age, gender, education level, income per month, family income per month, GPAX, history of drug use, history of parental e-cigarette use, history of parental Baraku use, history of parental cannabis use, history of parental alcohol use, history of friends' cigarette use, history of friends' e-cigarette use, history of friends' Baraku use, history of friends' cannabis use, history of friends' alcohol use, history of seeing e-cigarette advertisements, beliefs and attitudes about e-cigarette use (e-cigarettes are not harm to health, e-cigarettes are less harmful than cigarettes, e-cigarettes are less addictive than cigarettes, using e-cigarettes can help stop smoking, e-cigarettes help people improve social skills, e-cigarette users are attractive, using e-cigarettes is cheaper than using cigarettes, and unpleasant smell from e-cigarettes is less than from cigarettes), and marketing factors (e-cigarettes have many flavors and scents, e-cigarette packaging is attractive, and e-cigarettes have many channels of distribution and are convenient).
The results of our multivariable logistic regression analyses revealed that history of drug use, GPAX, and attitudes about e-cigarette use (e-cigarettes are not harmful to health, using e-cigarettes can help stop smoking, and e-cigarettes help people improve social skills) strongly correlated with the use of e-cigarettes in the preceding 30 days [Table 2]. | Table 2: Odds ratio and 95% confidence interval of the factors associated with e-cigarette use among youths in Thailand (n=1164)
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| Discussion | | |
In the present study, we investigated the prevalence and risk factors of e-cigarette use among youths in Thailand. The prevalence of having ever used e-cigarettes was 19.4%, and the current e-cigarette use was 10.6%. These findings are in line with the Savigamin et al.'s[4] study, which indicated that the prevalence of current e-cigarette use was 22.2% in college students. However, Patanavanich et al.'s[3] study found that the prevalence of current e-cigarette use was 3.7% in Thai youths. The reason for the discrepancy between the present and Patanavanich et al.'s[3] study could be related to different populations. The definition of Thai youths in our study included those aged between 15 and 24 years and currently studying in secondary school or university. In contrast, in the Patanavanich et al.'s[3] study, they recruited only 7th-grade students, with an average age of 13 years. For comparison, previous systematic reviews indicated that the prevalence of current e-cigarette use was 9.8% for Asian American youth,[17] and the Cullen et al.'s[18] study showed that the prevalence of current e-cigarette use among US youths was 10.5%, which was lower than our results. It should be noted that e-cigarette use in the US is legal. Therefore, current e-cigarette use among Thai youths is relatively high when compared to that in other legalized countries.
E-cigarettes have become particularly popular among young people worldwide due to their appealing flavors, sleek designs, and aggressive marketing tactics. The rise in youth e-cigarette use has raised alarms about addiction, leading to traditional tobacco use. Although e-cigarettes were banned for import and sale in Thailand, the prevalence of current e-cigarette use among youths in Thailand and other legalized countries (such as the US and European) is comparable. Thus, our findings indicated that Thailand's e-cigarette regulations and law enforcement were unsuccessful. Our results showed that most e-cigarette users buy e-cigarettes through online platforms (e.g. Facebook, Line, Instagram, and website). To prevent youths from initiating these purchases, the government must regularly monitor e-cigarette advertising and improve enforcement of tobacco advertising, promotion, and sponsorship, particularly on online platforms. Addressing this issue is crucial for safeguarding the health of future generations.
The results of this study show that a history of drug use (cigarette, Baraku, cannabis, or alcohol) is a risk factor for e-cigarette use in the previous 30 days. This finding is in line with previous studies,[19],[20],[21] showing that the use of cigarettes, cannabis, and alcohol was associated with current e-cigarette use. Our findings imply that e-cigarette users are mostly youths who are attracted to risky behaviors and are sensation-seeking.[22] Moreover, our results demonstrate that attitudes about e-cigarette use (e-cigarettes are not harmful to health, using e-cigarettes can help stop smoking, and e-cigarettes help people improve social skills) are risk factors of current e-cigarette use. E-cigarettes were believed to be not as addictive as conventional cigarettes.[23],[24] Previous research found that e-cigarette advertisements influence people's attitudes and beliefs about e-cigarettes, which may encourage e-cigarette use.[24] However, previous systematic reviews revealed that e-cigarette use was associated with reduced smoking cessation and harmful cardiovascular effects.[7],[15] Our findings may imply that college students lack knowledge, awareness, and information about the adverse effect of e-cigarette use. Educational programs are needed to reduce the knowledge gap and increase awareness. It is important to create more objective sources of information to balance the entrenched interests of television advertising and publicity.
Our study indicated that GPAX ≥ 3.00 was a protective factor against e-cigarette use. This finding is consistent with Patanavanich et al.'s[3] study. Their results showed that e-cigarette use was associated with a lower grade point average (GPA). Moreover, previous research revealed a significantly lower GPA in everyday e-cigarette users when compared to “never users.”[25] It is probable that students with higher GPAs have a greater capacity to acquire knowledge about health and to understand the impact of health-related problems caused by e-cigarettes. Further research should examine the effect of educational programs (knowledge about the harmful effects of e-cigarettes and self-efficacy) that help reduce the use of e-cigarettes.
Five methodological limitations should be taken into consideration when interpreting the results of our study. First, the design was cross-sectional; thus, it was not possible to establish the causal relationship between exposure and outcome. We examined only the association between exposure and outcome. Therefore, a prospective study is needed to validate our findings. Second, we used cross-sectional surveys, which are prone to selection bias due to the use of a convenience sample. Third, participants were Thai youths who were in secondary school or university and were between the ages of 15 and 24 years, which restricts external validity. Therefore, generalization of our findings to other populations (e.g., older adults) should be made with caution. Fourth, the relationship between prior drug usage and e-cigarette use could not be demonstrated due to a lack of information regarding the history of drug use for each substance. Further study should collect information about the history of cigarette, baraku, cannabis, or alcohol use separately. Lastly, the study's findings regarding the prevalence of e-cigarette use may be affected by certain biases. The participants in this study were only included if they had ever heard of or knew about e-cigarettes. Therefore, the prevalence of using e-cigarettes could be overestimated. In addition, the majority of the participants in this study were female high school students, which may result from convenience sampling. The cigarette smoking rate for males was more than four times the rate for females.[26] Thus, it is possible that the prevalence rate of e-cigarette use in this study is understated.
| Conclusion | | |
The present study revealed that e-cigarette use among Thai youths was relatively high. History of drug use and attitudes about e-cigarette use (e-cigarettes are not harmful to health, using e-cigarettes can help stop smoking, and e-cigarettes help people improve social skills) were risk factors of e-cigarette use. Higher academic performance (GPAX) was a protective factor against current e-cigarette use. We found false beliefs (lack of knowledge or misinformation about the negative health effects of e-cigarette use). Further research should focus on education as a tool to reduce the prevalence of e-cigarette use among Thai youths.
Acknowledgments
The authors wish to thank Miss Phakwan Charoenwattanasuksom, Miss Nutnicha Jongtragansombut, Miss Kanrapee Phalasirisith, Miss Varisa Wattanapichayakuland, Miss Suphisara Kaeosondi, and Miss Tanaporn Sirimaha who assisted in data collection.
Data availability statement
The data that support the findings of this study are available from the corresponding author, Waongenngarm P., upon reasonable request.
Financial support and sponsorship
This work was supported by the Thai Health Promotion Foundation and Faculty of Allied Health Sciences, Chulalongkorn University. 1. The Thai Health Promotion Foundation: No. 63-00-1493. 2. The Faculty of Allied Health Science: No. 1374201000.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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