Electronic-Cigarette Smoking Experience Among Adolescents
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Journal of Adolescent Health 49 (2011) 542–546
www.jahonline.org
Original article
Electronic-Cigarette Smoking Experience Among Adolescents
Jun Ho Cho, Ph.D., M.P.H., Eunyoung Shin, Ph.D., M.P.H., and Sang-Sik Moon, Ph.D., M.P.H.*
Department of Health Administration, Hanyang Women’s University, Seoul, Republic of Korea
Article history: Received December 16, 2010; Accepted August 2, 2011
Keywords: Electronic cigarette; Adolescents; Awareness rates; Contact routes; Internet
A B S T R A C T
Objectives: To investigate the level of awareness and contact routes to electronic cigarette (e-cigarette), and
to identify significant factors that may affect adolescent use of e-cigarettes; this study explores the experi-
ence of e-cigarettes among adolescents.
Methods: Using the data from the 2008 Health Promotion Fund Project in Korea, we used a hierarchical
logistic regression analysis to evaluate gender, level of school, family smoking, perception of peer influence,
satisfaction in school life, and cigarette smoking experience as predictors of trying e-cigarettes among
adolescents in five schools in Korea.
Results: Overall, 444 (10.2%) students responded as having seen or heard of e-cigarettes. Twenty-two (.5%)
students reported as having used an e-cigarette. The contact routes of information on e-cigarettes were the
Internet (249, 46.4%), friends (150, 27.9%), television (59, 11.0%), books (50, 9.3%), and others (29, 5.4%). The
following factors were determined to be statistically significant predictors of e-cigarette experience: male
gender, perception of peer influence, satisfaction in school life, and cigarette smoking experience.
Conclusions: In light of this fact, continuous attention needs to be paid on the marketing of e-cigarettes on
Internet sites to prevent adolescents from being exposed to unsupported claims about e-cigarettes and to
provide appropriate information on health effects.
䉷 2011 Society for Adolescent Health and Medicine. All rights reserved.
Smoking is a major cause of adverse health effects in most tobacco (ST) and nicotine delivery systems. Electronic cigarette
countries. In the United States alone, an estimated 443,000 peo- (e-cigarette) is one popular type of electronic nicotine delivery
ple die prematurely from smoking or from exposure to second- system (ENDS), a battery-powered device that looks like a ciga-
hand smoke each year, and another 8.6 million have a serious rette but does not involve smoke and which enables users to
illness caused by smoking [1]. Especially, adolescent smoking is inhale vaporized nicotine (WHO, 2009) [3].
clinically important. In earlier study, adolescent smoking was With respect to e-cigarettes, there is growing interest as well
associated with mental health symptoms and substance use dis- as concern among cigarette smokers, manufacturers, health pro-
orders. Therefore, information on adolescent tobacco use may fessionals, and policy managers. The World Health Organization
assist in identifying patients at risk for substance abuse and has urged marketers of e-cigarettes to halt their unproved claims
mental problems [2]. To prevent the diseases and deaths caused about the therapeutic benefits of using e-cigarettes and has indi-
by cigarette use, the researchers have suggested various tobacco cated that there is no reliable scientific evidence to confirm the
replacements as alternatives to cigarettes, such as smokeless product’s safety and efficacy [4]. As of 2009, there are some
countries, including New Zealand, the United Kingdom, and
members of the European Union, that allow marketing of e-
* Address correspondence to: Sang-Sik Moon, Ph.D., M.P.H., Department of cigarettes within their current regulatory framework, whereas
Health Administration, Hanyang Women’s University, 17 Haengdang-dong there are other countries, including Australia, Brazil, China, Sin-
Seongdong-gu, Seoul 133–793, Republic of Korea. gapore, Thailand, and Uruguay, that have completely banned the
E-mail address: mssok1@naver.com (S.S. Moon).
sale and marketing of ENDS [3]. In the United States, the New
The comments of this article are solely the responsibility of the authors and do
not necessarily represent the official view of the Ministry of Health and Welfare York State Assembly prohibits the sale of e-cigarettes to minors,
in Korea. and also of items that are not defined as tobacco products or
1054-139X/$ - see front matter 䉷 2011 Society for Adolescent Health and Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2011.08.001J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546 543
approved by the Food and Drug Administration for tobacco use asked, “Have you ever smoked an e-cigarette, even one or two
cessation or harm reduction [5]. Conversely, beginning in 2007, puffs?” If they answered in the affirmative, they were classified as
marketers in the Republic of Korea began to sell e-cigarettes to having had the experience of e-cigarette use.
the public, which includes adolescents, through various Internet
sites. However, in November 2008, the Ministry of Strategy and Other variables. With respect to family smoking, students were
Finance made an authoritative interpretation that regarded e- asked, “Do you have smoking persons among family members?”
cigarettes as a type of cigarette, and therefore only allowed If they answered none, they were classified into the “No” cate-
marketing within the existing regulatory framework for tobacco gory, whereas if they answered one or more of the following
[6]. After that judgment was made, the marketing of e-cigarettes options: father, mother, grandfather, grandmother, brother, sis-
through the Internet was banned. In 2009, the United States Food ter, or others, they were classified into the “Yes” category. With
and Drug Association reported that tobacco-specific nitro- respect to perception of peer influence, students were asked, “Do
samines (TSNAs) and tobacco-specific impurities, such as dieth- you think your smoking behaviors are easily affected by
ylene glycol, were detected in two e-cigarette products, albeit at friends?” Response options were as follows: definitely yes, prob-
very low levels [7]. TSNAs are known to be carcinogenic [8]. ably yes, probably not, and definitely not. The definitely yes and
Despite the fact that e-cigarette use is now a worldwide probably yes responses were merged into the “Yes” category, and
phenomenon, very little is known regarding its use within the the probably not and definitely not were merged into the “No”
adolescent community [9,10]. This study was conducted to as- category. With respect to satisfaction in school life, students
sess the level of awareness and contact routes to e-cigarette were asked, “Are you satisfied with school life?” Response op-
among adolescents, and to test the following specific hypothe- tions were as follows: definitely yes, probably yes, indifferent,
ses: Variables, such as male gender, older age, smoking in the probably not, and definitely not. The definitely yes and probably
family, perception of peer influence, dissatisfaction with school yes responses were merged into the “Satisfaction” category, the
life, and previous experience with cigarette smoking, increase indifferent responses were classified into the “Indifferent” cate-
the likelihood of trying e-cigarettes for the first time. gory, and probably not and definitely not responses were merged
into the “Dissatisfaction” category. With respect to traditional
Methods cigarettes’ experience, students were asked, “Have you ever
smoked a cigarette, even one or two puffs?” If they answered in
Data were collected during the course of a 2008 project titled the affirmative, they were classified into “Ever” category, as hav-
“Primary study for appropriate policies to regulate smokeless ing had the experience of traditional cigarette use.
tobacco products in Korea” financed by the Health Promotion
Fund of the Ministry of Health and Welfare in Korea [11]. Data
Statistical analysis
were collected on sociodemographic characteristics (age, gen-
der, level of school [middle and high school, university], residen-
Frequency analyses were conducted to assess the rates of
tial district), current cigarette use, ST use, e-cigarette use, ciga-
e-cigarette awareness and experience, and to classify contact
rette availability, knowledge and behavior with regard to
routes of information on e-cigarette use among adolescents. In
tobacco products, family smoking history, perception of peer
addition, to assess the predictors of e-cigarette smoking, we
influence, attempts to quit smoking, and school life (satisfaction
performed 2 and multiple hierarchical logistic regression anal-
and their school record). Of these, only the data pertaining to
yses for e-cigarette experience by gender, level of school, ciga-
e-cigarette use among adolescents were used to test the study
rette smoking family, perception of peer influence, satisfaction in
hypotheses.
school life, and cigarette smoking experience. Additionally,
The survey adopted a cluster probability sample design. First,
Fisher exact test was applied to compensate 2 analyses if the
to distribute the districts evenly, following five schools were
expected values in contingency table were small. SPSS software
chosen based on their geographic locations: one school was
package (version 12.0; SPSS Institute, Inc, Cary, NC) was used for
selected from southern Seoul area, two from northern Seoul area,
the statistical analyses.
one from near Seoul area (the Satellite Cities of the Seoul Metro-
politan), and one from a province of the country. Second, within
each selected school, most of the classrooms were sampled, and Results
students in those classrooms were invited to participate in the
survey. Instead of names, identification codes were used to en- A total of 4,341 students (70.5% participation) responded to
sure confidentiality. All survey instruments used for data collec- the questionnaire. Two thousand three hundred sixty-nine mid-
tion were reviewed and approved by the Institutional Review dle school students and 1,874 high school students from five
Board of the Hanyang Women’s University. schools participated in the survey; 1,988 of them were boys and
2,245 of them were girls. The mean age of students in middle
Measures schools was 14.0 years (standard deviation: .87) and that of
students in high schools was 16.5 years (standard deviation: .77).
E-cigarette questions. For assessing the level of awareness and Overall, 444 (10.2%) students responded as having seen or
contact routes among the test subjects regarding e-cigarettes, the heard of e-cigarettes. Twenty-two (.5%) students reported as
students were asked, “Have you ever seen or heard of e-cigarettes?” having used an e-cigarette. The frequencies and percentages
If students answered in the negative, they were classified into the were determined by contact routes of information on e-
“No” category. If they answered in the affirmative, they were clas- cigarettes among adolescents in multiple response approach.
sified into the “Yes” category, and their contact sources, such as The highest contact route of information on e-cigarettes was the
friends, television, books (including journals), Internet, and others, Internet (249, 46.4%). The second highest contact route was
were recorded. With respect to e-cigarette use, students were friends (150, 27.9%), followed by television (59, 11.0%), books544 J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546
Table 1 for those having cigarette smoking in their families, for those
Results of 2 analyses of electronic-cigarette experience among adolescents in with lower satisfaction in school life, and for those who had
five schools in Korea
previously smoked. Contrary to expectations, however, statisti-
Independent variables Students 2 p cally significant associations were not found for school level
number (%) (significantly)
(middle vs. high school) and for the perception of peer influence.
Gender 10.64 .001* Results from the multiple hierarchical logistic regression
Girls (n ⫽ 2,221) 4 (.18) analyses are indicated in Table 2. Model 1, which included demo-
Boys (n ⫽ 1985) 18 (.91) graphic variables, such as gender and level of school as predictors
Level of school .90 .343
of e-cigarette use, produced a good fit to the data according to the
Middle school (n ⫽ 2,341) 10 (.43)
High school (n ⫽ 1,857) 12 (.65) Hosmer–Lemeshow 2 test (22 ⫽ .7; p ⫽ .7). A statistically
Cigarette smoking family 5.27 .022** significant difference was found between adolescent boys and
No (n ⫽ 1,845) 4 (.22) girls (p ⬍ .01). Adolescent boys were 6.3 times more likely than
Yes (n ⫽ 2,363) 17 (.72)
female students to use e-cigarettes. Thus, the data support part of
Propensity to be easily affected 2.65 .104
by friends the hypothesis, with the rates of e-cigarette use being higher
Yes (n ⫽ 1,605) 5 (.31) among male students.
No (n ⫽ 2,442) 17 (.70) Model 2, which also includes cigarette smoking in the family
School life 10.90 .004***
and the perception of peer influence as predictors of e-cigarette
Satisfaction (n ⫽ 1,876) 9 (.48)
Indifference (n ⫽ 1,664) 4 (.24) use, produced a good fit to the data according to the Hosmer–
Dissatisfaction (n ⫽ 685) 9 (1.31) Lemeshow 2 test (26 ⫽ 5.7; p ⫽ .5). Same as in model 1,
Cigarette smoking experience 44.08 .000* adolescent boys were 6.4 times more likely than female students
Never (n ⫽ 3,402) 5 (.15)
to use e-cigarettes. Accordingly, students in middle schools were
Ever (n ⫽ 810) 16 (2.0)
more likely to use e-cigarettes than those in high schools, al-
* p ⬍ .001.
though there remained no significant difference (p ⫽ .123). Sta-
** p ⬍ .05.
*** p ⬍ .01. tistically significant differences were found for cigarette smok-
ing in the family—the students who had smoking persons among
family members were 3.4 times more likely to use e-cigarettes
(50, 9.3%), and others (29, 5.4%). Other routes included teachers, than those who did not have smoking persons (5 ⬍ .05). As for
athletes, fathers, mothers, and newspapers. perception of peer influence, interestingly, the students who
Through 2 analyses, the differences in e-cigarette experience perceived to be not easily influenced by their friends were 3.0
among adolescents are shown in Table 1. Fisher exact test was times more likely (5 ⬍ .05) to use e-cigarettes than those who
applied to compensate 2 analyses when the values in contin- perceived to be easily affected by their friends.
gency table were less than five. Statistically significantly higher In model 3, we added satisfaction in school life to model 2 as
rates of e-cigarette experience were found for adolescent boys, one of the predictors of e-cigarette use. Model 3 produced a good
Table 2
Results of multiple logistic regression analyses of dependent variables with electronic-cigarette experience among
adolescents
Independent variables Model 1a Model 2a Model 3a Model 4a
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Gender
Girls 1.0 1.0 1.0 1.0
Boys 6.3* (2.0–20.6) 6.4* (1.9–20.9) 5.8* (1.8–19.1) 3.5** (1.0–11.8)
Level of school
Middle school 1.0 1.0 1.0 1.0
High school .7 (.3–1.6) .6 (.2–1.4) .6 (.2–1.4) .5 (.2–1.2)
Cigarette smoking family
No 1.0 1.0 1.0
Yes 3.4** (1.1–10.0) 3.4** (1.1–10.1) 2.8 (.9–8.5)
Propensity to be easily affected by friends
Yes 1.0 1.0 1.0
No 3.0** (1.0–9.0) 2.9 (.99–8.8) 3.9** (1.3–12.0)
School life
Satisfaction 1.0 1.0
Indifference .6 (.2–1.9) .4 (.1–1.4)
Dissatisfaction 2.8** (1.1–7.3) 1.9 (.7–5.0)
Cigarette smoking experience
Never 1.0
Ever 11.2*** (3.9–32.3)
Sample size was n ⫽ 4,173.
CI ⫽ confidence interval; OR ⫽ odds ratio.
a
Model significant at p ⬍ .05.
* p ⬍ .01.
** p ⬍ .05.
*** p ⬍ .001.J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546 545
fit to the data according to the Hosmer–Lemeshow 2 test (28 ⫽ isfaction of school life changed from being a significant to a
7.8; p ⫽ .5). After we added satisfaction in school life, variables, nonsignificant predictor when adding cigarette smoking experi-
such as gender, level of school, and cigarette smoking in the ence to the statistical model. According to earlier reports, the
family, continued to be similar to the ORs and significance levels prevalence rates of tobacco product use, such as cigarette, ST, and
observed in model 2, except for perception of peer influence. water pipe cigarette, among older students and students with
More specifically, model 3 showed that boys were 5.8 times more smoking persons in their families were higher than among the
likely than girls to use e-cigarettes (p ⬍ .01), and students who younger students and those without smoking persons in their
had smoking persons among family members were 3.4 times families [12]. In detail, when earlier researchers examined male
more likely to use e-cigarettes than those who had no smoking ST users by grade, they reported 7% of 5th graders, 22% of 8th
persons (p ⬍ .05). Consistent with models 1 and 2, there was no graders, and 32% of 11th graders to be ST users [13]. Also, 4% of
significant difference in e-cigarette use when comparing middle middle school students and 11% of high school students reported
school students with high school students (p ⫽ .207). However, ever having used a water pipe cigarette, and 3.6% of middle
there was no statistically significant difference in e-cigarette use
school students and 9.9% of high school students reported as
when comparing students who perceived to be not easily af-
current cigarette users [14].
fected by friends with those who perceived to be easily affected
In the case of cigarettes, ST, and water pipe cigarettes, adoles-
by friends (p ⫽ .053). With respect to satisfaction in school life,
cent smoking behaviors were known to be largely affected by
students who were dissatisfied with their school life were 2.8
friends [15,16]. The current study results indicated that preva-
times more likely (p ⬍ .05) to use e-cigarettes than those who
lence rates of e-cigarette use among students who perceived to
were satisfied with their school life.
be not easily affected by friends were higher than those who
With cigarette smoking experience, model 4 included all the
predictive variables. Model 4 produced a good fit to the data perceived to be easily affected by friends. However, this result
according to the Hosmer–Lemeshow 2 test (27 ⫽ 12.7; p ⫽ has limitation when considering the perception of peer influence
.120). After controlling for cigarette smoking experience, boys to be the peer pressure. The type of question, such as asking
were 3.5 times more likely than girls to use e-cigarettes (p ⬍ .05), adolescents whether they think their smoking behaviors are
and the students who perceived to be not easily affected by easily affected by friends, is likely to generate response bias
friends were 3.9 times more likely to use e-cigarettes than those because of social desirability. Thus, the peer pressure related to
who perceived to be easily affected by friends (p ⫽ .016), al- e-cigarette use among adolescents needs to be assessed in a
though the difference was not significant in the previous model future project.
3. In addition, students with experience in cigarette smoking This study indicates that continuous attention needs to be
were 10.8 times more likely to use e-cigarettes than those with paid on the marketing of e-cigarettes on Internet sites to prevent
no experience in using e-cigarettes (p ⬍ .001). However, previ- adolescents from being exposed to unsupported claims about
ously significant differences in e-cigarette use based on cigarette e-cigarettes. The students taking part in the survey would mainly
smoking in the family were not significant in this model (p ⫽ obtain information on e-cigarettes through the Internet. Addi-
.074). Thus, most of the hypotheses were supported by these tionally, the adolescents could purchase e-cigarettes through the
data, with the exception of the perception of peer influence as a Internet during the period of the survey. The sale of e-cigarettes
predictive factor for e-cigarette use. on Internet sites was banned later, in November 2008. It is noted,
however, that according to a previous report, only 25.5% of the
Discussion Internet sites sampled prohibited purchases by minors, although
it was illegal for minors to buy cigars [17].
The results of this study suggest that e-cigarette advertise- This study did not investigate whether adolescents were cur-
ments and related promotion activities are spreading to adoles- rently using e-cigarettes on a periodic basis, but rather assessed
cents, and internationally through the Internet [3]. Within a whether they had ever used an e-cigarette. Further research
couple of years after companies began to market e-cigarettes, the needs to assess the rates of current use of e-cigarettes among
awareness rate among adolescents participating in this survey
adolescents. Also, because the study was cross-sectional, it
was 11%. This result provides statistical evidence for the opinion
could not establish the direction of the association between
that market penetration of unregulated ENDS has expanded rap-
the various predictive variables and e-cigarette use among
idly to most World Health Organization regions [3]. However, an
adolescents. Accordingly, further research indicating the di-
issue of concern is that the information provided by the sellers to
rection of the associations should be performed. Moreover,
adolescents do not contain risk-related data, despite the fact that
although large numbers of students participated in this study,
carcinogenic-ingredients, such as TSNAs, were detected in e-cig-
the prevalence rates of e-cigarette use were determined rela-
arette products [7,8].
The results also indicate that gender, propensity to be affected tively low among adolescents. The most likely explanations
by friends, satisfaction in school life, and previous experience are that e-cigarette use is still in its infancy and, as in other
with cigarette smoking may be predictors of e-cigarette use. countries, current numbers of e-cigarette users are very small
After controlling for the variables described, it was possible to in Korea. Therefore, this point may be acceptable. Further-
assess the relationship between e-cigarette use and the vari- more, the health risks because of e-cigarette use need to be
ables. Specifically, in the final model (model 4), it was found that assessed in a future project, in terms of both acute and chronic
boys (compared with girls), propensity to not be affected by affects, including nicotine addiction. To our knowledge, no
friends, dissatisfaction in school life, and previous cigarette population-based studies have estimated the awareness and
smoking experience are important predictors of e-cigarette use. experience of e-cigarette among adolescents. Therefore, the
The variable of school level remained as an insignificant factor, results of this study may provide useful evidence for adoles-
and the variables of cigarette smoking in the family and dissat- cent behaviors on e-cigarette use.546 J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546
Acknowledgments [6] Authentic interpretations for government legislations (2nd, 2008). Do elec-
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The authors thank Nam Won Paik, Professor of Seoul National islation of Republic of Korea, 08-0339, November 10, 2008.
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University in Korea, for the thoughtful comments on the article,
Health & Human Services, US Food and Drug Administration, 2009.
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