- Email: [email protected]
Electronic cigarette awareness and use among adults in Hong Kong
Addictive Behaviors 52 (2016) 34–38
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
Electronic cigarette awareness and use among adults in Hong Kong Nan Jiang a, Jing Chen b, Man-Ping Wang b,⁎, Sarah M. McGhee a, Antonio C.S. Kwong c, Vienna W.Y. Lai c, Tai-Hing Lam a a b c
School of Public Health, The University of Hong Kong, 5/F William MW Mong Block, 21 Sassoon Road, Hong Kong School of Nursing, The University of Hong Kong, 4/F William MW Mong Block, 21 Sassoon Road, Hong Kong Hong Kong Council on Smoking and Health, Unit 4402-03, 44/F Hopewell Centre, 183 Queen's Road East, Wanchai, Hong Kong
H I G H L I G H T S • • • •
We reported the awareness and ever use of e-cigarettes among adults in Hong Kong. The awareness of e-cigarettes was widespread among both smokers and nonsmokers. E-cigarette use was associated with male gender, young age, and cigarette smoking. Main reasons for use were curiosity, the stylish design, and quitting smoking.
a r t i c l e
i n f o
Article history: Received 13 March 2015 Received in revised form 21 July 2015 Accepted 21 August 2015 Available online 29 August 2015 Keywords: Electronic cigarette Epidemiology Adult Hong Kong
a b s t r a c t Introduction: Electronic cigarettes (e-cigarettes) have gained popularity rapidly in the Western world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong. Methods: Cross-sectional data were collected in 2014 from Chinese adults aged 15–65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status. Results: 75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p = .03), younger adults (aged 15–29, 5.2%, p = .002), and current cigarette smokers (11.8%, p b .001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%). Conclusions: Awareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Electronic cigarettes (e-cigarettes) are battery-operated vaporizing devices that produce vapor by heating the liquid solution (usually containing nicotine, flavorings, glycerol, and propylene glycol) (Grana, Benowitz, & Glantz, 2013). Since their introduction to the market in China in 2005, e-cigarettes have rapidly gained popularity in the ⁎ Corresponding author at: School of Nursing, The University of Hong Kong, 4/F William MW Mong Block, 21 Sassoon Road, Hong Kong. E-mail address: [email protected] (M.-P. Wang).
http://dx.doi.org/10.1016/j.addbeh.2015.08.008 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
Western world (Adkison et al., 2013; Dockrell, Morrison, Bauld, & McNeill, 2013; Grana, Benowitz, & Glantz, 2014; Pepper & Brewer, 2014). Today, over 200 companies worldwide manufacture ecigarettes (Southeast Asia Tobacco Control Alliance, 2014) with more than 466 brands on the market (Zhu et al., 2014). Big tobacco companies (e.g., Lorillard, R. J. Reynolds, Altria, British American Tobacco, and Imperial Tobacco) have entered the e-cigarette market since 2012 (Pepper & Brewer, 2014; The Economist, 2014). The world's largest ecigarette producer and exporter, China, launched its own e-cigarette lines in 2014 (O'Neill, 2014). The rapidly growing business of ecigarettes represented a $2 billion (US dollar) global market in 2013,
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
and the revenue is estimated to rise to $10 billion by 2017 (Lopes, 2013; Mangalindan, 2014). E-cigarette manufacturers and retailers often marketed the products as healthier alternatives to conventional cigarettes and a smoking cessation device (Grana & Ling, 2014; Yao, Jiang, Grana, Ling, & Glantz, 2014). These marketing claims have been successfully transmitted to consumers as the most common reasons for smokers' initiating ecigarette use were to reduce the harm of traditional cigarettes or to help quit cigarette smoking (Adkison et al., 2013; Dawkinns, Turner, Roberts, & Soar, 2013; Etter, 2010; Etter & Bullen, 2011; Goniewicz, Lingas, & Hajek, 2013; Pepper, Emery, Ribisl, Rini, & Brewer, 2014). However, recent studies showed that e-cigarette users were less likely to quit smoking (Vickerman, Carpenter, Altman, Nash, & Zbikowski, 2013), or there was no difference in cessation between e-cigarette users and non-users (Adkison et al., 2013) or nicotine patch users (Bullen et al., 2013). Little is known about e-cigarette use in Asian countries. China produces 90% of the world's e-cigarettes (Barboza, 2014), but the Chinese government has no regulation on the device (O'Neill, 2014). Hong Kong, a special administration region of China, has no law targeting ecigarettes, but e-cigarettes containing nicotine are regulated as pharmaceutical products. As of August 2015, no one has applied for a license to sell e-cigarettes with nicotine in Hong Kong. E-cigarette use is banned in smoke-free venues in Hong Kong as the clean indoor air law bans smoking without specifying what is being smoked (The Government of the Hong Kong Special Administrative Region, 2013a). However people, including children, can easily get e-cigarettes (many claimed to be nicotine-free) in shopping malls, local stores, or through the Internet (Tsang, 2015). E-cigarettes containing nicotine are available from websites for online shopping, such as taobao.com, the largest online shopping destination in China. In 2012/13, 1.1% of secondary school students in Hong Kong reported current (past 30-day) e-cigarette use, and e-cigarette use is associated with smoking intention and nicotine dependence in adolescents in Hong Kong (Wang, Ho, Leung, & Lam, 2015). The government is now considering a total ban on e-cigarettes, including sales, advertising, distribution, sponsorship and manufacturing (Chan, 2015; Tsang, 2015). This study examined the awareness and use of e-cigarettes in a probability sample of Chinese adults in Hong Kong. We compared the responses among three subgroups, including never smokes, former cigarette smokers, and current cigarette smokers, and described their reasons for using e-cigarettes. Findings may help understand the potential need to regulate e-cigarette marketing in Hong Kong.
35
current cigarette smokers) who were randomly selected to answer the questions about e-cigarettes.
2.2. Main measures The awareness of e-cigarettes was assessed by a question “Have you ever heard of e-cigarettes? (E-cigarette is a battery-powered device that looks like cigarettes and delivers aerosol to a user while heating the cartridges.)” Respondents who answered “Yes” were asked “Have you ever tried an e-cigarette?” E-cigarette users were asked “Why do you use ecigarettes?” Multiple answers could be selected from 17 response options, including “I like the taste,” “It looks stylish and cool,” “It is novelty,” “It helps quit smoking,” “It helps reduce cigarette consumption,” “It is a gift from others,” “It is less harmful,” “No secondhand smoke, so it does not bother others,” “I can use it in smokefree areas,” “It is cheaper than traditional cigarettes,” “It is green, good for the environment,” “It is safer than traditional cigarettes,” “It is clean,” “I am curious about it,” “It is convenient to use,” “I saw friends using the device, so want to have a try,” and “other reasons”. Demographic characteristics such as gender, age, and education attainment were recorded.
2.3. Statistical analysis Data were analyzed using Stata version 13.0. Analyses were adjusted with sample weight according to Hong Kong 2014 census data (Government of Hong Kong Special Administrative Region, 2012; The Government of the Hong Kong Special Administrative Region, 2013b) and accounted for oversampling of former and current cigarette smokers according to the prevalence of former and current smoking for the entire adult population (aged 15–65 years) in Hong Kong (The Government of the Hong Kong Special Administrative Region, 2013b). Sample demographics, weighted prevalence of e-cigarette awareness and use, and reasons for using e-cigarettes were summarized using descriptive statistics. We conducted chi-square tests to compare ecigarette awareness and ever use by demographics and cigarette smoking status. We then conducted multivariable logistic regression to examine if e-cigarette awareness was associated with gender, age, education and cigarette smoking status with mutual adjustment. Table 1 The awareness and ever use of e-cigarettes among Chinese adults in Hong Kong. N
Awareness
2. Material and methods n
2.1. Data source We analyzed data from the 2014 Hong Kong Tobacco Control Policyrelated Survey (thereafter referred as “the Survey”) commissioned by the Hong Kong Council on Smoking and Health. This cross-sectional probability survey was conducted annually via computer-assisted telephone interviews among Chinese adults aged 15–65 years in Hong Kong since 2013. Households with a landline telephone (about 70% of the total population in Hong Kong) were covered by the Survey. Data for this study were collected in May–September 2014 by the Policy 21 Limited, a local renowned survey company (Policy 21 Limited, 2014). The questionnaire was anonymous, including core questions (responded by all participants) and random questions (responded by a random subset of participants). A total of 2419 respondents (including 819 never smokers who had never smoked cigarettes, 800 former smokers who smoked cigarettes before but did not smoke now, and 800 current smokers who smoked cigarettes in the past 30 days) completed the interviews with a response rate of 73.8%. The analysis was limited to a subset of 809 respondents (including 357 never smokers, 269 former cigarette smokers, and 183
Total Gender Male Female Age 15–29 30–49 50–65 Education Primary Secondary Post-secondary Cigarette smoking status Never smokers Former smokers Current smokers
%
Ever use p-Value for χ2
809 575 75.4
n
%
41
2.3
29 12
3.6 1.3
20 12 9
5.2 1.8 1.0
1 20 18
1.2 2.0 2.9
.04 416 317 80.4 393 258 71.2
.03
.20 248 186 83.1 224 161 73.7 327 220 72.5
.002
.39a
.06 86 49 57.5 436 305 74.8 267 208 79.4
b.001b
.51 357 268 76.3 269 180 70.1 183 127 71.2
p-Value for χ2
4 1.0 13 4.3 24 11.8
a Due to small cell size, we combined respondents with primary and secondary education levels into one group. Chi-square test examined the difference between the combined group and those with post-secondary education level. b Due to small cell size, we combined never smokers and former cigarette smokers into one group as non-cigarette smokers. Chi-square test examined the difference between non-cigarette smokers and current cigarette smokers.
36
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
3. Results Table 1 shows the frequency and weighted prevalence of e-cigarette awareness and ever use by demographics and cigarette smoking status. About 75.4% of the respondents had heard of e-cigarettes. Males were more aware than females (80.4% vs. 71.2%, p = .04). E-cigarette awareness marginally increased with education level (p = .06). The awareness was similar across age (p = .20) and cigarette smoking subgroups (p = .51). The multivariable logistic regression model confirmed that greater awareness was associated with male gender (Adjusted odds ratio [AOR] = 1.9, 95% confidence interval [CI] = 1.0–3.6, p = .04), and found that respondents with secondary (AOR = 2.0, 95% CI = 1.0–3.7, p = .04) or post-secondary education levels (AOR = 2.2, 95% CI = 1.0–4.6, p = .04) reported higher adjusted odds of e-cigarette awareness than those with primary education level (data not shown in tables). About 2.3% of respondents reported having tried e-cigarettes. The users were more likely to be male (3.6%, p = .03) and younger (aged 15–29) adults (5.2%, p = .002). Cigarette smoking status was related to e-cigarette use (p b .001), with current smokers reporting the highest rate of having tried e-cigarettes (11.8%), and never smokers reported the lowest rate (1.0%). Education was not related to e-cigarette use (p = .39). Table 2 lists the reasons for e-cigarette use by cigarette smoking status. Of the 17 answer options, 8 were selected by e-cigarette users. Ecigarettes were used mainly because of curiosity (e.g., “I saw friends using the device, so want to have a try” 41.0%; “I am curious about it” 6.4%), the stylish design (25.8%), and the perception that e-cigarettes can help quit smoking (13.6%). Former cigarette smokers (23.0%) reported that e-cigarettes were less harmful or did not bother other people. 4. Discussion This is the first study that examined the awareness and ever use of ecigarettes in a probability sample of Chinese adults in Hong Kong. In 2014, 75% of adults had heard of e-cigarettes, and over 2% reported having used e-cigarettes. These rates were low comparing to US adults (awareness: 86%; ever use: 6%) (King, Alam, Promoff, Arrazola, & Dube, 2013; Pepper, Emery, Ribisl, & Brewer, 2014). However, there was a high awareness rate in never smokers (76%). A study in the UK found that 38% of never smokers were aware of e-cigarettes in 2012 (Dockrell et al., 2013), but awareness could have increased rapidly since then. For ecigarette use, 12% of current cigarette smokers and 4% of former cigarette smokers had used e-cigarettes. These rates were much lower than those reported by smokers in the US (20% in 2011) and UK (52% in 2014), but were higher than cigarette smokers in Canada (4% in 2010–2011) and Australia (2% in 2010–2011) (Action on Smoking and Health, 2014; Adkison et al., 2013; Popova & Ling, 2013). Table 2 Reasons for using e-cigarettes among ever users in Hong Kong.
All ever users (n = 41)
Former Never cigarette smokers smokers (n = 4) (n = 13)
Current cigarette smokers (n = 24)
%
%
%
%
47.2
49.3
36.1
26.4 0 26.4 0 0 0
1.8 24.0 0 13.4 0 23.0
29.0 20.2 0 9.1 6.5 0
0
23.0
0
I saw friends using it, so want to have 41.0 a try It looks stylish and cool 25.8 It helps quit smoking 13.6 It is novelty 9.0 I am curious about it 6.4 It is convenient to use 3.7 It is less harmful 2.0 No secondhand smoke, so it does not 2.0 bother others Note. Multiple response, not add up to 100%.
Although e-cigarette awareness was lower than many western countries, and e-cigarettes had not been widely used in Hong Kong, the prevalence of use may increase substantially in a short time like the US and UK (Action on Smoking and Health, 2014; King et al., 2013; Pepper & Brewer, 2014). The current low prevalence of use in Hong Kong might be related to the less aggressive marketing promotions than western countries, the regulations that ban e-cigarette use in smokefree venues, and the laws that restricted nicotine sale. However, there are loopholes in the current laws in Hong Kong as the laws cannot ban the promotion of smoking devices containing no nicotine. E-cigarette awareness in Hong Kong has increased from 66% in 2013 (Chen et al., 2015) to 75% in 2014. The trend of e-cigarette use remains unknown. Health surveillance systems must incorporate e-cigarette utilization into the surveys and monitor the trend to inform public policies and interventions. Consistent with previous studies, e-cigarette awareness was associated with male gender and higher education (Adkison et al., 2013; Choi & Forster, 2013; Pepper, Emery, Ribisl, & Brewer, 2014; Regan, Promoff, Dube, & Arrazola, 2011), but the relationship with age (King et al., 2013; Pearson, Richardson, Niaura, Vallone, & Abrams, 2012; Pepper, Emery, Ribisl, & Brewer, 2014; Regan et al., 2011) was not observed in our sample. One explanation might be that e-cigarette marketing in the US targets youth. The e-cigarette retail websites in the US often show images of young people and claim youthful lifestyle appeals (e.g., increase socialization and romance) (Grana & Ling, 2014). E-cigarettes are aggressively advertised via youth-dominated channels in the US such as Facebook and YouTube.com (Noel, Rees, & Connolly, 2011). In Hong Kong, the target of e-cigarette marketing might be different. One study examining e-cigarette marketing found that Chinese e-cigarette manufacturers seldom claimed youthful lifestyle appeals (Yao et al., 2014). Notably, cigarette smoking was unrelated to e-cigarette awareness. This finding is different from the western studies which found that current cigarette smokers were more likely to report e-cigarette awareness than never smokers (Choi & Forster, 2013; Dockrell et al., 2013; King et al., 2013; Pearson et al., 2012; Pepper, Emery, Ribisl, & Brewer, 2014; Regan et al., 2011) and former smokers (Dockrell et al., 2013; King et al., 2013; Pearson et al., 2012; Regan et al., 2011). Our finding might be explained by the different e-cigarette marketing strategies in Hong Kong and the western countries. Further studies are warranted to examine how e-cigarettes are promoted in Hong Kong, and the sources of e-cigarettes for different smoking subgroups. Although the three smoking subgroups exhibited the similar awareness level, current cigarette smokers were more likely to report ecigarette ever use than never and former cigarette smokers. This result is consistent with the findings from western populations (Choi & Forster, 2013; Dockrell et al., 2013; King et al., 2013; Regan et al., 2011). It indicated that e-cigarettes appealed mostly to current cigarette smokers. While exploring what motivated the users to choose ecigarettes, the most common reasons cited by all subgroups were related to curiosity and the stylish design of e-cigarettes. Current and former smokers also stated that e-cigarettes could help quit smoking. The high rate of ever use among current smokers might be associated with the perception of cessation efficacy as noted in previous studies (Choi & Forster, 2013; Choi & Forster, 2014). Interventions should educate the public about the unclear relationship between e-cigarette use and smoking cessation. Very few users stated that e-cigarettes were less harmful or did not bother others. The perception that e-cigarettes are less toxic than conventional cigarettes is widespread in western countries (Adkison et al., 2013; Choi & Forster, 2013; Etter, 2010; Etter & Bullen, 2011; Goniewicz et al., 2013; Pearson et al., 2012; Pepper, Emery, Ribisl, Rini, et al., 2014). The difference in such perception between our sample and the western population might be explained by the underreporting. Some respondents might believe that e-cigarettes were less harmful and did not bother others, but did not report while replying to the question why they used the products via phone interviews,
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
despite these answer options were present in the questionnaire. Another reason might be related to the marketing strategies. The ecigarette marketing claims in Hong Kong may be different from the western countries, and the products may be mostly promoted as a cessation aid among Chinese residents in Hong Kong. It would be useful to know the e-cigarette marketing in Hong Kong, and how the marketing affects the initiation of e-cigarette use, the usage patterns, and the selection of smoking cessation aids. E-cigarette use was related to male gender and younger age. Previous findings on the relationship between e-cigarette use and demographic variables were mixed (Pepper & Brewer, 2014). Regan et al. (2011) found that males were more likely to report e-cigarette use, whereas others found no relationship with gender (Dockrell et al., 2013; King et al., 2013; Pearson et al., 2012). Two studies reported that e-cigarette use was inversely associated with age (Dockrell et al., 2013; Pearson et al., 2012), while other reports showed no relationship (King et al., 2013; Regan et al., 2011). Future studies need to confirm these demographic relationships to e-cigarette use. This study has several limitations. First, current and former cigarette smokers were oversampled. However, analyses were weighted to account for sampling design and census data so that our estimates should be representative. Second, the small sample size limited our ability to generalize the findings, and the small number of e-cigarette users in our sample (n = 41) did not allow multivariable analysis of factors associated with e-cigarette use. Third, data of e-cigarette use were selfreported, and the validity was uncertain. 5. Conclusions The awareness of e-cigarettes was widespread in Hong Kong. Though e-cigarette use was relatively low, its relationship to younger age and cigarette smoking is of concern. Health surveillance of e-cigarette use is urgently needed. Tobacco control efforts should address the marketing claims of e-cigarettes, especially the messages regarding the effect of ecigarettes on smoking cessation. Interventions should target young adults and cigarette smokers. Role of funding sources The Hong Kong Tobacco Control Policy-related Survey was sponsored by Hong Kong Council on Smoking and Health. Hong Kong Council on Smoking and Health played no role in the selection of the research questions, conduct of the research, or data analysis and interpretation. Contributors NJ and JC designed the study. JC conducted the statistical analysis. NJ wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript. Conflict of interest The authors declare no conflict of interest. Acknowledgments We would like to thank Dr. Lai-Ming Ho and Ms. Xin Wang from the University of Hong Kong for their advice on statistical analysis.
References Action on Smoking and Health (2014). ASH briefing: Electronic cigarettes. Retrieved from http://www.ash.org.uk/files/documents/ASH_715.pdf. Accessed January 16, 2015. Adkison, S.E., O'Connor, R.J., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H. -H., et al. (2013). Electronic nicotine delivery systems: International tobacco control fourcountry survey. American Journal of Preventive Medicine, 44(3), 207–215. http://dx. doi.org/10.1016/j.amepre.2012.10.018. Barboza, D. (2014, December 13). China's e-cigarette boom lacks oversight for safety. Retrieved from http://www.nytimes.com/2014/12/14/business/international/chinas-ecigarette-boom-lacks-oversight-for-safety-.html?_r=0. Accessed December 25, 2014. Bullen, C., Howe, C., Laugesen, M., McRobbie, H., Parag, V., Williman, J., et al. (2013). Electronic cigarettes for smoking cessation: A randomised controlled trial. Lancet, 382 (9905), 1629–1637. http://dx.doi.org/10.1016/S0140-6736(13)61842-5.
37
Chan, S. (2015, March 30). Hong Kong anti-smoking watchdog calls for ban on electronic cigarettes. South China Morning Post. Retrieved from http://www.scmp.com/news/ hong-kong/article/1751034/hong-kong-anti-smoking-watchdog-urges-ban-ecigarettes?page=all. Chen, J., Wang, M.P., McGhee, S., Kwong, A., Lai, V., & Lam, T.H. (2015). Awareness and perceived harmfulness of e-cigarettes and their associations with smokers' intention to quit in Hong Kong. Paper presented at the 16th World Conference on Tobacco or Health, Abu Dahbi, United Arab Emirates. Choi, K., & Forster, J. (2013). Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young US Midwestern adults. American Journal of Public Health, 103(3), 556–561. http://dx.doi.org/10.2105/AJPH. 2012.300947. Choi, K., & Forster, J.L. (2014). Beliefs and experimentation with electronic cigarettes: A prospective analysis among young adults. American Journal of Preventive Medicine, 46(2), 175–178. http://dx.doi.org/10.1016/j.amepre.2013.10.007. Dawkinns, L., Turner, J., Roberts, A., & Soar, K. (2013). ‘Vaping’ profiles and preferences: an online survey of electronic cigarette users. Addiction, 108(6), 1115–1125. http://dx. doi.org/10.1111/add.12150. Dockrell, M., Morrison, R., Bauld, L., & McNeill, A. (2013). E-cigarettes: Prevalence and attitudes in Great Britain. Nicotine & Tobacco Research, 15(10), 1737–1744. Etter, J. -F. (2010). Electronic cigarettes: A survey of users. BMC Public Health, 10(231) http://dx.doi.org/10.1186/1471-2458-10-231. Etter, J. -F., & Bullen, C. (2011). Electronic cigarette: Users profile, utilization, satisfaction and perceived efficacy. Addiction, 106(11), 2017–2028. http://dx.doi.org/10.1111/j. 1360-0443.2011.03505.x. Goniewicz, M.L., Lingas, E.O., & Hajek, P. (2013). Patterns of electronic cigarette use and user beliefs about their safety and benefits: An internet survey. Drug and Alcohol Review, 32(2), 133–140. http://dx.doi.org/10.1111/j.1465-3362.2012. 00512.x. Government of Hong Kong Special Administrative Region (2012). Hong Kong population projections 2012–2041. Hong Kong: Government of Hong Kong Special Administrative Region, Census and Statistics Department (retrieved from http://www.statistics.gov. hk/pub/B1120015052012XXXXB0100.pdf. Accessed September 17, 2014). Grana, R., Benowitz, N., & Glantz, S.A. (2013). Background paper on e-cigarettes (electronic nicotine delivery systems). Center for Tobacco Control Research and Education, University of California, San Francisco, WHO Collaborating Center on Tobacco Control (retrieved from http://escholarship.org/uc/item/13p2b72n. Accessed July 23, 2014). Grana, R., Benowitz, N., & Glantz, S.A. (2014). E-cigarettes: A scientific review. Circulation, 129(19), 1972–1986. http://dx.doi.org/10.1161/CIRCULATIONAHA.114.007667. Grana, R.A., & Ling, P.M. (2014). “Smoking revolution”: A content analysis of electronic cigarette retail websites. American Journal of Preventive Medicine, 46(4), 395–403. http://dx.doi.org/10.1016/j.amepre.2013.12.010. King, B.A., Alam, S., Promoff, G., Arrazola, R., & Dube, S.R. (2013). Awareness and ever use of electronic cigarettes among U.S. adults, 2010–2011. Nicotine & Tobacco Research, 15 (9), 1623–1627. http://dx.doi.org/10.1093/ntr/ntt013. Lopes, M. (2013, December 11). E-cigarettes: A burning question for U.S. regulators. Retrieved from http://www.reuters.com/article/2013/12/11/us-usa-ecigarettesidUSBRE9BA0ZT20131211. Accessed November 2, 2014. Mangalindan, J. P. (2014, May 1). For e-cigarette makers, a $10 billion market at stake. Retrieved from http://fortune.com/2014/05/01/for-e-cigarette-makers-a-10-billionmarket-at-stake/. Accessed November 2, 2014. Noel, J.K., Rees, V.W., & Connolly, G.N. (2011). Electronic cigarettes: A new ‘tobacco’ industry? Tobacco Control, 20(1), 81. http://dx.doi.org/10.1136/tc.2010.038562. O'Neill, M. (2014, August 11). How China is lighting up the e-cigarette market. EJ Insight. Retrieved from http://www.ejinsight.com/20140811-china-e-cigartte/. Pearson, J.L., Richardson, A., Niaura, R.S., Vallone, D.M., & Abrams, D.B. (2012). E-cigarette awareness, use, and harm perceptions in US adults. American Journal of Public Health, 102(9), 1758–1766. http://dx.doi.org/10.2105/AJPH.2011.300526. Pepper, J.K., & Brewer, N.T. (2014). Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: A systematic review. Tobacco Control, 23(5), 375–384. http://dx.doi.org/10.1136/tobaccocontrol-2013-051122. Pepper, J.K., Emery, S.L., Ribisl, K.M., & Brewer, N.T. (2014). How U.S. adults find out about electronic cigarettes: Implications for public health messages. Nicotine & Tobacco Research, 16(8), 1140–1144. http://dx.doi.org/10.1093/ntr/ntu060. Pepper, J.K., Emery, S.L., Ribisl, K.M., Rini, C.M., & Brewer, N.T. (2014). How risky is it to use e-cigarettes? Smokers' beliefs about their health risks from using novel and traditional tobacco products. Journal of Behavioral Medicinehttp://dx.doi.org/10.1007/ s10865-014-9605-2 [Epub ahead of print]. Policy 21 Limited. (2014). About Policy 21: Background. Retrieved from http://www. policy21.org/about.html. Accessed July 15, 2015. Popova, L., & Ling, P.M. (2013). Alternative tobacco product use and smoking cessation: A national study. American Journal of Public Health, 103(5), 923–930. http://dx.doi.org/ 10.2105/AJPH.2012.301070. Regan, A.K., Promoff, G., Dube, S.R., & Arrazola, R. (2011). Electronic nicotine delivery systems: Adult use and awareness of the ‘e-cigarette’ in the USA. Tobacco Control, 22(1), 19–23. http://dx.doi.org/10.1136/tobaccocontrol-2011-050044. Southeast Asia Tobacco Control Alliance (2014). Electronic cigarettes in Asia: A review of promotions and availability. Retrieved from http://www.healthjustice.ph/wpcontent/uploads/2014/12/SEATCA_Ecig-Report_Final.pdf. Accessed January 5, 2015. The Economist (2014, May 17). E-cigarette patent wars: A case of the vapers. Retrieved from http://www.economist.com/blogs/schumpeter/2014/03/e-cigarette-patent-wars. Accessed December 16, 2014. The Government of the Hong Kong Special Administrative Region (2013a, January 28). Media corner: TCO committed to enforcing smoking ban in statutory no smoking areas. Retrieved from http://www.tco.gov.hk/english/infostation/infostation_ 28012013.html. Accessed July 28, 2014.
38
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
The Government of the Hong Kong Special Administrative Region (2013b). Thematic Household Survey: Report no. 53. The Government of the Hong Kong Special Administrative Region, Census and Statistics Department. Hong Kong. Retrieved from http://www.statistics.gov.hk/pub/ B11302532013XXXXB0100.pdf. Accessed April 23, 2014. Tsang, E. (2015, April 8). In Hong Kong, e-cigarettes are as available to children as candy. South China Morning Post. Retrieved from http://www.scmp.com/news/hong-kong/ article/1759634/hong-kong-e-cigarettes-are-available-children-candy. Vickerman, K.A., Carpenter, K.M., Altman, T., Nash, C.M., & Zbikowski, S.M. (2013). Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine & Tobacco Research, 15(10), 1787–1791. http://dx.doi.org/10.1093/ntr/ntt061.
Wang, M.P., Ho, S.Y., Leung, L.T., & Lam, T.H. (2015). Electronic cigarette use and its association with smoking in Hong Kong Chinese adolescents. Addictive Behaviors, 50, 124–127. http://dx.doi.org/10.1016/j.addbeh.2015.06.037. Yao, T., Jiang, N., Grana, R., Ling, P.M., & Glantz, S.A. (2014). A content analysis of electronic cigarette manufacturer websites in China. Tobacco Controlhttp://dx.doi.org/10.1136/ tobaccocontrol-2014-051840 [Epub ahead of print]. Zhu, S. -H., Sun, J.Y., Bonnevie, E., Cummins, S.E., Gamst, A., Yin, L., et al. (2014). Four hundred and sixty brands of e-cigarettes and counting: Implications for product regulation. Tobacco Control, 23(Suppl. 3), iii3–iii9. http://dx.doi.org/10.1136/ tobaccocontrol-2014-051670.
Contents lists available at ScienceDirect
Addictive Behaviors
Short Communication
Electronic cigarette awareness and use among adults in Hong Kong Nan Jiang a, Jing Chen b, Man-Ping Wang b,⁎, Sarah M. McGhee a, Antonio C.S. Kwong c, Vienna W.Y. Lai c, Tai-Hing Lam a a b c
School of Public Health, The University of Hong Kong, 5/F William MW Mong Block, 21 Sassoon Road, Hong Kong School of Nursing, The University of Hong Kong, 4/F William MW Mong Block, 21 Sassoon Road, Hong Kong Hong Kong Council on Smoking and Health, Unit 4402-03, 44/F Hopewell Centre, 183 Queen's Road East, Wanchai, Hong Kong
H I G H L I G H T S • • • •
We reported the awareness and ever use of e-cigarettes among adults in Hong Kong. The awareness of e-cigarettes was widespread among both smokers and nonsmokers. E-cigarette use was associated with male gender, young age, and cigarette smoking. Main reasons for use were curiosity, the stylish design, and quitting smoking.
a r t i c l e
i n f o
Article history: Received 13 March 2015 Received in revised form 21 July 2015 Accepted 21 August 2015 Available online 29 August 2015 Keywords: Electronic cigarette Epidemiology Adult Hong Kong
a b s t r a c t Introduction: Electronic cigarettes (e-cigarettes) have gained popularity rapidly in the Western world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong. Methods: Cross-sectional data were collected in 2014 from Chinese adults aged 15–65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status. Results: 75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p = .03), younger adults (aged 15–29, 5.2%, p = .002), and current cigarette smokers (11.8%, p b .001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%). Conclusions: Awareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Electronic cigarettes (e-cigarettes) are battery-operated vaporizing devices that produce vapor by heating the liquid solution (usually containing nicotine, flavorings, glycerol, and propylene glycol) (Grana, Benowitz, & Glantz, 2013). Since their introduction to the market in China in 2005, e-cigarettes have rapidly gained popularity in the ⁎ Corresponding author at: School of Nursing, The University of Hong Kong, 4/F William MW Mong Block, 21 Sassoon Road, Hong Kong. E-mail address: [email protected] (M.-P. Wang).
http://dx.doi.org/10.1016/j.addbeh.2015.08.008 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
Western world (Adkison et al., 2013; Dockrell, Morrison, Bauld, & McNeill, 2013; Grana, Benowitz, & Glantz, 2014; Pepper & Brewer, 2014). Today, over 200 companies worldwide manufacture ecigarettes (Southeast Asia Tobacco Control Alliance, 2014) with more than 466 brands on the market (Zhu et al., 2014). Big tobacco companies (e.g., Lorillard, R. J. Reynolds, Altria, British American Tobacco, and Imperial Tobacco) have entered the e-cigarette market since 2012 (Pepper & Brewer, 2014; The Economist, 2014). The world's largest ecigarette producer and exporter, China, launched its own e-cigarette lines in 2014 (O'Neill, 2014). The rapidly growing business of ecigarettes represented a $2 billion (US dollar) global market in 2013,
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
and the revenue is estimated to rise to $10 billion by 2017 (Lopes, 2013; Mangalindan, 2014). E-cigarette manufacturers and retailers often marketed the products as healthier alternatives to conventional cigarettes and a smoking cessation device (Grana & Ling, 2014; Yao, Jiang, Grana, Ling, & Glantz, 2014). These marketing claims have been successfully transmitted to consumers as the most common reasons for smokers' initiating ecigarette use were to reduce the harm of traditional cigarettes or to help quit cigarette smoking (Adkison et al., 2013; Dawkinns, Turner, Roberts, & Soar, 2013; Etter, 2010; Etter & Bullen, 2011; Goniewicz, Lingas, & Hajek, 2013; Pepper, Emery, Ribisl, Rini, & Brewer, 2014). However, recent studies showed that e-cigarette users were less likely to quit smoking (Vickerman, Carpenter, Altman, Nash, & Zbikowski, 2013), or there was no difference in cessation between e-cigarette users and non-users (Adkison et al., 2013) or nicotine patch users (Bullen et al., 2013). Little is known about e-cigarette use in Asian countries. China produces 90% of the world's e-cigarettes (Barboza, 2014), but the Chinese government has no regulation on the device (O'Neill, 2014). Hong Kong, a special administration region of China, has no law targeting ecigarettes, but e-cigarettes containing nicotine are regulated as pharmaceutical products. As of August 2015, no one has applied for a license to sell e-cigarettes with nicotine in Hong Kong. E-cigarette use is banned in smoke-free venues in Hong Kong as the clean indoor air law bans smoking without specifying what is being smoked (The Government of the Hong Kong Special Administrative Region, 2013a). However people, including children, can easily get e-cigarettes (many claimed to be nicotine-free) in shopping malls, local stores, or through the Internet (Tsang, 2015). E-cigarettes containing nicotine are available from websites for online shopping, such as taobao.com, the largest online shopping destination in China. In 2012/13, 1.1% of secondary school students in Hong Kong reported current (past 30-day) e-cigarette use, and e-cigarette use is associated with smoking intention and nicotine dependence in adolescents in Hong Kong (Wang, Ho, Leung, & Lam, 2015). The government is now considering a total ban on e-cigarettes, including sales, advertising, distribution, sponsorship and manufacturing (Chan, 2015; Tsang, 2015). This study examined the awareness and use of e-cigarettes in a probability sample of Chinese adults in Hong Kong. We compared the responses among three subgroups, including never smokes, former cigarette smokers, and current cigarette smokers, and described their reasons for using e-cigarettes. Findings may help understand the potential need to regulate e-cigarette marketing in Hong Kong.
35
current cigarette smokers) who were randomly selected to answer the questions about e-cigarettes.
2.2. Main measures The awareness of e-cigarettes was assessed by a question “Have you ever heard of e-cigarettes? (E-cigarette is a battery-powered device that looks like cigarettes and delivers aerosol to a user while heating the cartridges.)” Respondents who answered “Yes” were asked “Have you ever tried an e-cigarette?” E-cigarette users were asked “Why do you use ecigarettes?” Multiple answers could be selected from 17 response options, including “I like the taste,” “It looks stylish and cool,” “It is novelty,” “It helps quit smoking,” “It helps reduce cigarette consumption,” “It is a gift from others,” “It is less harmful,” “No secondhand smoke, so it does not bother others,” “I can use it in smokefree areas,” “It is cheaper than traditional cigarettes,” “It is green, good for the environment,” “It is safer than traditional cigarettes,” “It is clean,” “I am curious about it,” “It is convenient to use,” “I saw friends using the device, so want to have a try,” and “other reasons”. Demographic characteristics such as gender, age, and education attainment were recorded.
2.3. Statistical analysis Data were analyzed using Stata version 13.0. Analyses were adjusted with sample weight according to Hong Kong 2014 census data (Government of Hong Kong Special Administrative Region, 2012; The Government of the Hong Kong Special Administrative Region, 2013b) and accounted for oversampling of former and current cigarette smokers according to the prevalence of former and current smoking for the entire adult population (aged 15–65 years) in Hong Kong (The Government of the Hong Kong Special Administrative Region, 2013b). Sample demographics, weighted prevalence of e-cigarette awareness and use, and reasons for using e-cigarettes were summarized using descriptive statistics. We conducted chi-square tests to compare ecigarette awareness and ever use by demographics and cigarette smoking status. We then conducted multivariable logistic regression to examine if e-cigarette awareness was associated with gender, age, education and cigarette smoking status with mutual adjustment. Table 1 The awareness and ever use of e-cigarettes among Chinese adults in Hong Kong. N
Awareness
2. Material and methods n
2.1. Data source We analyzed data from the 2014 Hong Kong Tobacco Control Policyrelated Survey (thereafter referred as “the Survey”) commissioned by the Hong Kong Council on Smoking and Health. This cross-sectional probability survey was conducted annually via computer-assisted telephone interviews among Chinese adults aged 15–65 years in Hong Kong since 2013. Households with a landline telephone (about 70% of the total population in Hong Kong) were covered by the Survey. Data for this study were collected in May–September 2014 by the Policy 21 Limited, a local renowned survey company (Policy 21 Limited, 2014). The questionnaire was anonymous, including core questions (responded by all participants) and random questions (responded by a random subset of participants). A total of 2419 respondents (including 819 never smokers who had never smoked cigarettes, 800 former smokers who smoked cigarettes before but did not smoke now, and 800 current smokers who smoked cigarettes in the past 30 days) completed the interviews with a response rate of 73.8%. The analysis was limited to a subset of 809 respondents (including 357 never smokers, 269 former cigarette smokers, and 183
Total Gender Male Female Age 15–29 30–49 50–65 Education Primary Secondary Post-secondary Cigarette smoking status Never smokers Former smokers Current smokers
%
Ever use p-Value for χ2
809 575 75.4
n
%
41
2.3
29 12
3.6 1.3
20 12 9
5.2 1.8 1.0
1 20 18
1.2 2.0 2.9
.04 416 317 80.4 393 258 71.2
.03
.20 248 186 83.1 224 161 73.7 327 220 72.5
.002
.39a
.06 86 49 57.5 436 305 74.8 267 208 79.4
b.001b
.51 357 268 76.3 269 180 70.1 183 127 71.2
p-Value for χ2
4 1.0 13 4.3 24 11.8
a Due to small cell size, we combined respondents with primary and secondary education levels into one group. Chi-square test examined the difference between the combined group and those with post-secondary education level. b Due to small cell size, we combined never smokers and former cigarette smokers into one group as non-cigarette smokers. Chi-square test examined the difference between non-cigarette smokers and current cigarette smokers.
36
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
3. Results Table 1 shows the frequency and weighted prevalence of e-cigarette awareness and ever use by demographics and cigarette smoking status. About 75.4% of the respondents had heard of e-cigarettes. Males were more aware than females (80.4% vs. 71.2%, p = .04). E-cigarette awareness marginally increased with education level (p = .06). The awareness was similar across age (p = .20) and cigarette smoking subgroups (p = .51). The multivariable logistic regression model confirmed that greater awareness was associated with male gender (Adjusted odds ratio [AOR] = 1.9, 95% confidence interval [CI] = 1.0–3.6, p = .04), and found that respondents with secondary (AOR = 2.0, 95% CI = 1.0–3.7, p = .04) or post-secondary education levels (AOR = 2.2, 95% CI = 1.0–4.6, p = .04) reported higher adjusted odds of e-cigarette awareness than those with primary education level (data not shown in tables). About 2.3% of respondents reported having tried e-cigarettes. The users were more likely to be male (3.6%, p = .03) and younger (aged 15–29) adults (5.2%, p = .002). Cigarette smoking status was related to e-cigarette use (p b .001), with current smokers reporting the highest rate of having tried e-cigarettes (11.8%), and never smokers reported the lowest rate (1.0%). Education was not related to e-cigarette use (p = .39). Table 2 lists the reasons for e-cigarette use by cigarette smoking status. Of the 17 answer options, 8 were selected by e-cigarette users. Ecigarettes were used mainly because of curiosity (e.g., “I saw friends using the device, so want to have a try” 41.0%; “I am curious about it” 6.4%), the stylish design (25.8%), and the perception that e-cigarettes can help quit smoking (13.6%). Former cigarette smokers (23.0%) reported that e-cigarettes were less harmful or did not bother other people. 4. Discussion This is the first study that examined the awareness and ever use of ecigarettes in a probability sample of Chinese adults in Hong Kong. In 2014, 75% of adults had heard of e-cigarettes, and over 2% reported having used e-cigarettes. These rates were low comparing to US adults (awareness: 86%; ever use: 6%) (King, Alam, Promoff, Arrazola, & Dube, 2013; Pepper, Emery, Ribisl, & Brewer, 2014). However, there was a high awareness rate in never smokers (76%). A study in the UK found that 38% of never smokers were aware of e-cigarettes in 2012 (Dockrell et al., 2013), but awareness could have increased rapidly since then. For ecigarette use, 12% of current cigarette smokers and 4% of former cigarette smokers had used e-cigarettes. These rates were much lower than those reported by smokers in the US (20% in 2011) and UK (52% in 2014), but were higher than cigarette smokers in Canada (4% in 2010–2011) and Australia (2% in 2010–2011) (Action on Smoking and Health, 2014; Adkison et al., 2013; Popova & Ling, 2013). Table 2 Reasons for using e-cigarettes among ever users in Hong Kong.
All ever users (n = 41)
Former Never cigarette smokers smokers (n = 4) (n = 13)
Current cigarette smokers (n = 24)
%
%
%
%
47.2
49.3
36.1
26.4 0 26.4 0 0 0
1.8 24.0 0 13.4 0 23.0
29.0 20.2 0 9.1 6.5 0
0
23.0
0
I saw friends using it, so want to have 41.0 a try It looks stylish and cool 25.8 It helps quit smoking 13.6 It is novelty 9.0 I am curious about it 6.4 It is convenient to use 3.7 It is less harmful 2.0 No secondhand smoke, so it does not 2.0 bother others Note. Multiple response, not add up to 100%.
Although e-cigarette awareness was lower than many western countries, and e-cigarettes had not been widely used in Hong Kong, the prevalence of use may increase substantially in a short time like the US and UK (Action on Smoking and Health, 2014; King et al., 2013; Pepper & Brewer, 2014). The current low prevalence of use in Hong Kong might be related to the less aggressive marketing promotions than western countries, the regulations that ban e-cigarette use in smokefree venues, and the laws that restricted nicotine sale. However, there are loopholes in the current laws in Hong Kong as the laws cannot ban the promotion of smoking devices containing no nicotine. E-cigarette awareness in Hong Kong has increased from 66% in 2013 (Chen et al., 2015) to 75% in 2014. The trend of e-cigarette use remains unknown. Health surveillance systems must incorporate e-cigarette utilization into the surveys and monitor the trend to inform public policies and interventions. Consistent with previous studies, e-cigarette awareness was associated with male gender and higher education (Adkison et al., 2013; Choi & Forster, 2013; Pepper, Emery, Ribisl, & Brewer, 2014; Regan, Promoff, Dube, & Arrazola, 2011), but the relationship with age (King et al., 2013; Pearson, Richardson, Niaura, Vallone, & Abrams, 2012; Pepper, Emery, Ribisl, & Brewer, 2014; Regan et al., 2011) was not observed in our sample. One explanation might be that e-cigarette marketing in the US targets youth. The e-cigarette retail websites in the US often show images of young people and claim youthful lifestyle appeals (e.g., increase socialization and romance) (Grana & Ling, 2014). E-cigarettes are aggressively advertised via youth-dominated channels in the US such as Facebook and YouTube.com (Noel, Rees, & Connolly, 2011). In Hong Kong, the target of e-cigarette marketing might be different. One study examining e-cigarette marketing found that Chinese e-cigarette manufacturers seldom claimed youthful lifestyle appeals (Yao et al., 2014). Notably, cigarette smoking was unrelated to e-cigarette awareness. This finding is different from the western studies which found that current cigarette smokers were more likely to report e-cigarette awareness than never smokers (Choi & Forster, 2013; Dockrell et al., 2013; King et al., 2013; Pearson et al., 2012; Pepper, Emery, Ribisl, & Brewer, 2014; Regan et al., 2011) and former smokers (Dockrell et al., 2013; King et al., 2013; Pearson et al., 2012; Regan et al., 2011). Our finding might be explained by the different e-cigarette marketing strategies in Hong Kong and the western countries. Further studies are warranted to examine how e-cigarettes are promoted in Hong Kong, and the sources of e-cigarettes for different smoking subgroups. Although the three smoking subgroups exhibited the similar awareness level, current cigarette smokers were more likely to report ecigarette ever use than never and former cigarette smokers. This result is consistent with the findings from western populations (Choi & Forster, 2013; Dockrell et al., 2013; King et al., 2013; Regan et al., 2011). It indicated that e-cigarettes appealed mostly to current cigarette smokers. While exploring what motivated the users to choose ecigarettes, the most common reasons cited by all subgroups were related to curiosity and the stylish design of e-cigarettes. Current and former smokers also stated that e-cigarettes could help quit smoking. The high rate of ever use among current smokers might be associated with the perception of cessation efficacy as noted in previous studies (Choi & Forster, 2013; Choi & Forster, 2014). Interventions should educate the public about the unclear relationship between e-cigarette use and smoking cessation. Very few users stated that e-cigarettes were less harmful or did not bother others. The perception that e-cigarettes are less toxic than conventional cigarettes is widespread in western countries (Adkison et al., 2013; Choi & Forster, 2013; Etter, 2010; Etter & Bullen, 2011; Goniewicz et al., 2013; Pearson et al., 2012; Pepper, Emery, Ribisl, Rini, et al., 2014). The difference in such perception between our sample and the western population might be explained by the underreporting. Some respondents might believe that e-cigarettes were less harmful and did not bother others, but did not report while replying to the question why they used the products via phone interviews,
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
despite these answer options were present in the questionnaire. Another reason might be related to the marketing strategies. The ecigarette marketing claims in Hong Kong may be different from the western countries, and the products may be mostly promoted as a cessation aid among Chinese residents in Hong Kong. It would be useful to know the e-cigarette marketing in Hong Kong, and how the marketing affects the initiation of e-cigarette use, the usage patterns, and the selection of smoking cessation aids. E-cigarette use was related to male gender and younger age. Previous findings on the relationship between e-cigarette use and demographic variables were mixed (Pepper & Brewer, 2014). Regan et al. (2011) found that males were more likely to report e-cigarette use, whereas others found no relationship with gender (Dockrell et al., 2013; King et al., 2013; Pearson et al., 2012). Two studies reported that e-cigarette use was inversely associated with age (Dockrell et al., 2013; Pearson et al., 2012), while other reports showed no relationship (King et al., 2013; Regan et al., 2011). Future studies need to confirm these demographic relationships to e-cigarette use. This study has several limitations. First, current and former cigarette smokers were oversampled. However, analyses were weighted to account for sampling design and census data so that our estimates should be representative. Second, the small sample size limited our ability to generalize the findings, and the small number of e-cigarette users in our sample (n = 41) did not allow multivariable analysis of factors associated with e-cigarette use. Third, data of e-cigarette use were selfreported, and the validity was uncertain. 5. Conclusions The awareness of e-cigarettes was widespread in Hong Kong. Though e-cigarette use was relatively low, its relationship to younger age and cigarette smoking is of concern. Health surveillance of e-cigarette use is urgently needed. Tobacco control efforts should address the marketing claims of e-cigarettes, especially the messages regarding the effect of ecigarettes on smoking cessation. Interventions should target young adults and cigarette smokers. Role of funding sources The Hong Kong Tobacco Control Policy-related Survey was sponsored by Hong Kong Council on Smoking and Health. Hong Kong Council on Smoking and Health played no role in the selection of the research questions, conduct of the research, or data analysis and interpretation. Contributors NJ and JC designed the study. JC conducted the statistical analysis. NJ wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript. Conflict of interest The authors declare no conflict of interest. Acknowledgments We would like to thank Dr. Lai-Ming Ho and Ms. Xin Wang from the University of Hong Kong for their advice on statistical analysis.
References Action on Smoking and Health (2014). ASH briefing: Electronic cigarettes. Retrieved from http://www.ash.org.uk/files/documents/ASH_715.pdf. Accessed January 16, 2015. Adkison, S.E., O'Connor, R.J., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H. -H., et al. (2013). Electronic nicotine delivery systems: International tobacco control fourcountry survey. American Journal of Preventive Medicine, 44(3), 207–215. http://dx. doi.org/10.1016/j.amepre.2012.10.018. Barboza, D. (2014, December 13). China's e-cigarette boom lacks oversight for safety. Retrieved from http://www.nytimes.com/2014/12/14/business/international/chinas-ecigarette-boom-lacks-oversight-for-safety-.html?_r=0. Accessed December 25, 2014. Bullen, C., Howe, C., Laugesen, M., McRobbie, H., Parag, V., Williman, J., et al. (2013). Electronic cigarettes for smoking cessation: A randomised controlled trial. Lancet, 382 (9905), 1629–1637. http://dx.doi.org/10.1016/S0140-6736(13)61842-5.
37
Chan, S. (2015, March 30). Hong Kong anti-smoking watchdog calls for ban on electronic cigarettes. South China Morning Post. Retrieved from http://www.scmp.com/news/ hong-kong/article/1751034/hong-kong-anti-smoking-watchdog-urges-ban-ecigarettes?page=all. Chen, J., Wang, M.P., McGhee, S., Kwong, A., Lai, V., & Lam, T.H. (2015). Awareness and perceived harmfulness of e-cigarettes and their associations with smokers' intention to quit in Hong Kong. Paper presented at the 16th World Conference on Tobacco or Health, Abu Dahbi, United Arab Emirates. Choi, K., & Forster, J. (2013). Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young US Midwestern adults. American Journal of Public Health, 103(3), 556–561. http://dx.doi.org/10.2105/AJPH. 2012.300947. Choi, K., & Forster, J.L. (2014). Beliefs and experimentation with electronic cigarettes: A prospective analysis among young adults. American Journal of Preventive Medicine, 46(2), 175–178. http://dx.doi.org/10.1016/j.amepre.2013.10.007. Dawkinns, L., Turner, J., Roberts, A., & Soar, K. (2013). ‘Vaping’ profiles and preferences: an online survey of electronic cigarette users. Addiction, 108(6), 1115–1125. http://dx. doi.org/10.1111/add.12150. Dockrell, M., Morrison, R., Bauld, L., & McNeill, A. (2013). E-cigarettes: Prevalence and attitudes in Great Britain. Nicotine & Tobacco Research, 15(10), 1737–1744. Etter, J. -F. (2010). Electronic cigarettes: A survey of users. BMC Public Health, 10(231) http://dx.doi.org/10.1186/1471-2458-10-231. Etter, J. -F., & Bullen, C. (2011). Electronic cigarette: Users profile, utilization, satisfaction and perceived efficacy. Addiction, 106(11), 2017–2028. http://dx.doi.org/10.1111/j. 1360-0443.2011.03505.x. Goniewicz, M.L., Lingas, E.O., & Hajek, P. (2013). Patterns of electronic cigarette use and user beliefs about their safety and benefits: An internet survey. Drug and Alcohol Review, 32(2), 133–140. http://dx.doi.org/10.1111/j.1465-3362.2012. 00512.x. Government of Hong Kong Special Administrative Region (2012). Hong Kong population projections 2012–2041. Hong Kong: Government of Hong Kong Special Administrative Region, Census and Statistics Department (retrieved from http://www.statistics.gov. hk/pub/B1120015052012XXXXB0100.pdf. Accessed September 17, 2014). Grana, R., Benowitz, N., & Glantz, S.A. (2013). Background paper on e-cigarettes (electronic nicotine delivery systems). Center for Tobacco Control Research and Education, University of California, San Francisco, WHO Collaborating Center on Tobacco Control (retrieved from http://escholarship.org/uc/item/13p2b72n. Accessed July 23, 2014). Grana, R., Benowitz, N., & Glantz, S.A. (2014). E-cigarettes: A scientific review. Circulation, 129(19), 1972–1986. http://dx.doi.org/10.1161/CIRCULATIONAHA.114.007667. Grana, R.A., & Ling, P.M. (2014). “Smoking revolution”: A content analysis of electronic cigarette retail websites. American Journal of Preventive Medicine, 46(4), 395–403. http://dx.doi.org/10.1016/j.amepre.2013.12.010. King, B.A., Alam, S., Promoff, G., Arrazola, R., & Dube, S.R. (2013). Awareness and ever use of electronic cigarettes among U.S. adults, 2010–2011. Nicotine & Tobacco Research, 15 (9), 1623–1627. http://dx.doi.org/10.1093/ntr/ntt013. Lopes, M. (2013, December 11). E-cigarettes: A burning question for U.S. regulators. Retrieved from http://www.reuters.com/article/2013/12/11/us-usa-ecigarettesidUSBRE9BA0ZT20131211. Accessed November 2, 2014. Mangalindan, J. P. (2014, May 1). For e-cigarette makers, a $10 billion market at stake. Retrieved from http://fortune.com/2014/05/01/for-e-cigarette-makers-a-10-billionmarket-at-stake/. Accessed November 2, 2014. Noel, J.K., Rees, V.W., & Connolly, G.N. (2011). Electronic cigarettes: A new ‘tobacco’ industry? Tobacco Control, 20(1), 81. http://dx.doi.org/10.1136/tc.2010.038562. O'Neill, M. (2014, August 11). How China is lighting up the e-cigarette market. EJ Insight. Retrieved from http://www.ejinsight.com/20140811-china-e-cigartte/. Pearson, J.L., Richardson, A., Niaura, R.S., Vallone, D.M., & Abrams, D.B. (2012). E-cigarette awareness, use, and harm perceptions in US adults. American Journal of Public Health, 102(9), 1758–1766. http://dx.doi.org/10.2105/AJPH.2011.300526. Pepper, J.K., & Brewer, N.T. (2014). Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: A systematic review. Tobacco Control, 23(5), 375–384. http://dx.doi.org/10.1136/tobaccocontrol-2013-051122. Pepper, J.K., Emery, S.L., Ribisl, K.M., & Brewer, N.T. (2014). How U.S. adults find out about electronic cigarettes: Implications for public health messages. Nicotine & Tobacco Research, 16(8), 1140–1144. http://dx.doi.org/10.1093/ntr/ntu060. Pepper, J.K., Emery, S.L., Ribisl, K.M., Rini, C.M., & Brewer, N.T. (2014). How risky is it to use e-cigarettes? Smokers' beliefs about their health risks from using novel and traditional tobacco products. Journal of Behavioral Medicinehttp://dx.doi.org/10.1007/ s10865-014-9605-2 [Epub ahead of print]. Policy 21 Limited. (2014). About Policy 21: Background. Retrieved from http://www. policy21.org/about.html. Accessed July 15, 2015. Popova, L., & Ling, P.M. (2013). Alternative tobacco product use and smoking cessation: A national study. American Journal of Public Health, 103(5), 923–930. http://dx.doi.org/ 10.2105/AJPH.2012.301070. Regan, A.K., Promoff, G., Dube, S.R., & Arrazola, R. (2011). Electronic nicotine delivery systems: Adult use and awareness of the ‘e-cigarette’ in the USA. Tobacco Control, 22(1), 19–23. http://dx.doi.org/10.1136/tobaccocontrol-2011-050044. Southeast Asia Tobacco Control Alliance (2014). Electronic cigarettes in Asia: A review of promotions and availability. Retrieved from http://www.healthjustice.ph/wpcontent/uploads/2014/12/SEATCA_Ecig-Report_Final.pdf. Accessed January 5, 2015. The Economist (2014, May 17). E-cigarette patent wars: A case of the vapers. Retrieved from http://www.economist.com/blogs/schumpeter/2014/03/e-cigarette-patent-wars. Accessed December 16, 2014. The Government of the Hong Kong Special Administrative Region (2013a, January 28). Media corner: TCO committed to enforcing smoking ban in statutory no smoking areas. Retrieved from http://www.tco.gov.hk/english/infostation/infostation_ 28012013.html. Accessed July 28, 2014.
38
N. Jiang et al. / Addictive Behaviors 52 (2016) 34–38
The Government of the Hong Kong Special Administrative Region (2013b). Thematic Household Survey: Report no. 53. The Government of the Hong Kong Special Administrative Region, Census and Statistics Department. Hong Kong. Retrieved from http://www.statistics.gov.hk/pub/ B11302532013XXXXB0100.pdf. Accessed April 23, 2014. Tsang, E. (2015, April 8). In Hong Kong, e-cigarettes are as available to children as candy. South China Morning Post. Retrieved from http://www.scmp.com/news/hong-kong/ article/1759634/hong-kong-e-cigarettes-are-available-children-candy. Vickerman, K.A., Carpenter, K.M., Altman, T., Nash, C.M., & Zbikowski, S.M. (2013). Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine & Tobacco Research, 15(10), 1787–1791. http://dx.doi.org/10.1093/ntr/ntt061.
Wang, M.P., Ho, S.Y., Leung, L.T., & Lam, T.H. (2015). Electronic cigarette use and its association with smoking in Hong Kong Chinese adolescents. Addictive Behaviors, 50, 124–127. http://dx.doi.org/10.1016/j.addbeh.2015.06.037. Yao, T., Jiang, N., Grana, R., Ling, P.M., & Glantz, S.A. (2014). A content analysis of electronic cigarette manufacturer websites in China. Tobacco Controlhttp://dx.doi.org/10.1136/ tobaccocontrol-2014-051840 [Epub ahead of print]. Zhu, S. -H., Sun, J.Y., Bonnevie, E., Cummins, S.E., Gamst, A., Yin, L., et al. (2014). Four hundred and sixty brands of e-cigarettes and counting: Implications for product regulation. Tobacco Control, 23(Suppl. 3), iii3–iii9. http://dx.doi.org/10.1136/ tobaccocontrol-2014-051670.