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Journal of Adolescent Health 49 (2011) 542–546

www.jahonline.org

Original article

Electronic-Cigarette Smoking Experience Among AdolescentsJun 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, 2011Keywords: 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), andto 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 hierarchicallogistic 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 amongadolescents 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 theInternet (249, 46.4%), friends (150, 27.9%), television (59, 11.0%), books (50, 9.3%), and others (29, 5.4%). Thefollowing factors were determined to be statistically significant predictors of e-cigarette experience: malegender, 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 onInternet sites to prevent adolescents from being exposed to unsupported claims about e-cigarettes and toprovide appropriate information on health effects.

� 2011 Society for Adolescent Health and Medicine. All rights reserved.

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Smoking is a major cause of adverse health effects in mostountries. In the United States alone, an estimated 443,000 peo-le die prematurely from smoking or from exposure to second-and smoke each year, and another 8.6 million have a seriousllness caused by smoking [1]. Especially, adolescent smoking islinically important. In earlier study, adolescent smoking wasssociated with mental health symptoms and substance use dis-rders. Therefore, information on adolescent tobacco use mayssist in identifying patients at risk for substance abuse andental problems [2]. To prevent the diseases and deaths causedy cigarette use, the researchers have suggested various tobaccoeplacements as alternatives to cigarettes, such as smokeless

* Address correspondence to: Sang-Sik Moon, Ph.D., M.P.H., Department ofHealth Administration, Hanyang Women’s University, 17 Haengdang-dongSeongdong-gu, Seoul 133–793, Republic of Korea.

E-mail address:mssok1@naver.com (S.S. Moon).The comments of this article are solely the responsibility of the authors and do

anot necessarily represent the official view of the Ministry of Health and Welfarein Korea.

1054-139X/$ - see front matter � 2011 Society for Adolescent Health and Medicine. Adoi:10.1016/j.jadohealth.2011.08.001

obacco (ST) and nicotine delivery systems. Electronic cigarettee-cigarette) is one popular type of electronic nicotine deliveryystem (ENDS), a battery-powered device that looks like a ciga-ette but does not involve smoke and which enables users tonhale vaporized nicotine (WHO, 2009) [3].

With respect to e-cigarettes, there is growing interest as wells concern among cigarette smokers, manufacturers, health pro-essionals, and policy managers. The World Health Organizationas urgedmarketers of e-cigarettes to halt their unproved claimsbout the therapeutic benefits of using e-cigarettes and has indi-ated that there is no reliable scientific evidence to confirm theroduct’s safety and efficacy [4]. As of 2009, there are someountries, including New Zealand, the United Kingdom, andembers of the European Union, that allow marketing of e-igarettes within their current regulatory framework, whereashere are other countries, including Australia, Brazil, China, Sin-apore, Thailand, and Uruguay, that have completely banned theale and marketing of ENDS [3]. In the United States, the Nework State Assembly prohibits the sale of e-cigarettes to minors,

nd also of items that are not defined as tobacco products or

ll rights reserved.

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J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546 543

approved by the Food and Drug Administration for tobacco usecessation or harm reduction [5]. Conversely, beginning in 2007,marketers in the Republic of Korea began to sell e-cigarettes tothe public, which includes adolescents, through various Internetsites. However, in November 2008, the Ministry of Strategy andFinance made an authoritative interpretation that regarded e-cigarettes as a type of cigarette, and therefore only allowedmarketing within the existing regulatory framework for tobacco[6]. After that judgment wasmade, themarketing of e-cigarettesthrough the Internetwas banned. In 2009, theUnited States Foodand Drug Association reported that tobacco-specific nitro-samines (TSNAs) and tobacco-specific impurities, such as dieth-ylene glycol, were detected in two e-cigarette products, albeit atvery low levels [7]. TSNAs are known to be carcinogenic [8].

Despite the fact that e-cigarette use is now a worldwidehenomenon, very little is known regarding its use within thedolescent community [9,10]. This study was conducted to as-ess the level of awareness and contact routes to e-cigarettemong adolescents, and to test the following specific hypothe-es: Variables, such as male gender, older age, smoking in theamily, perception of peer influence, dissatisfaction with schoolife, and previous experience with cigarette smoking, increasehe likelihood of trying e-cigarettes for the first time.

ethods

Data were collected during the course of a 2008 project titledPrimary study for appropriate policies to regulate smokelessobacco products in Korea” financed by the Health Promotionund of the Ministry of Health and Welfare in Korea [11]. Dataere collected on sociodemographic characteristics (age, gen-er, level of school [middle and high school, university], residen-ial district), current cigarette use, ST use, e-cigarette use, ciga-ette availability, knowledge and behavior with regard toobacco products, family smoking history, perception of peernfluence, attempts to quit smoking, and school life (satisfactionnd their school record). Of these, only the data pertaining to-cigarette use among adolescents were used to test the studyypotheses.The survey adopted a cluster probability sample design. First,

o distribute the districts evenly, following five schools werehosen based on their geographic locations: one school waselected fromsouthern Seoul area, two fromnorthern Seoul area,ne from near Seoul area (the Satellite Cities of the Seoul Metro-olitan), and one from a province of the country. Second, withinach selected school, most of the classrooms were sampled, andtudents in those classrooms were invited to participate in theurvey. Instead of names, identification codes were used to en-ure confidentiality. All survey instruments used for data collec-ion were reviewed and approved by the Institutional Reviewoard of the Hanyang Women’s University.

easures

-cigarette questions. For assessing the level of awareness andontact routes among the test subjects regarding e-cigarettes, thetudentswereasked, “Haveyouever seenorheardof e-cigarettes?”f students answered in the negative, they were classified into theNo” category. If they answered in the affirmative, they were clas-ified into the “Yes” category, and their contact sources, such asriends, television, books (including journals), Internet, and others,

ere recorded. With respect to e-cigarette use, students were f

sked, “Have you ever smoked an e-cigarette, even one or twouffs?” If they answered in the affirmative, they were classified asaving had the experience of e-cigarette use.

ther variables. With respect to family smoking, students weresked, “Do you have smoking persons among family members?”f they answered none, they were classified into the “No” cate-ory, whereas if they answered one or more of the followingptions: father, mother, grandfather, grandmother, brother, sis-er, or others, they were classified into the “Yes” category. Withespect to perception of peer influence, studentswere asked, “Doou think your smoking behaviors are easily affected byriends?” Response optionswere as follows: definitely yes, prob-bly yes, probably not, and definitely not. The definitely yes androbably yes responsesweremerged into the “Yes” category, andhe probably not and definitely not were merged into the “No”ategory. With respect to satisfaction in school life, studentsere asked, “Are you satisfied with school life?” Response op-ions were as follows: definitely yes, probably yes, indifferent,robably not, and definitely not. The definitely yes and probablyes responses were merged into the “Satisfaction” category, thendifferent responses were classified into the “Indifferent” cate-ory, andprobably not anddefinitely not responsesweremergednto the “Dissatisfaction” category. With respect to traditionaligarettes’ experience, students were asked, “Have you evermoked a cigarette, even one or two puffs?” If they answered inhe affirmative, they were classified into “Ever” category, as hav-ng had the experience of traditional cigarette use.

tatistical analysis

Frequency analyses were conducted to assess the rates of-cigarette awareness and experience, and to classify contactoutes of information on e-cigarette use among adolescents. Inddition, to assess the predictors of e-cigarette smoking, weerformed �2 and multiple hierarchical logistic regression anal-ses for e-cigarette experience by gender, level of school, ciga-ette smoking family, perception of peer influence, satisfaction inchool life, and cigarette smoking experience. Additionally,isher exact test was applied to compensate �2 analyses if thexpected values in contingency table were small. SPSS softwareackage (version 12.0; SPSS Institute, Inc, Cary, NC) was used forhe statistical analyses.

esults

A total of 4,341 students (70.5% participation) responded tohe questionnaire. Two thousand three hundred sixty-nine mid-le school students and 1,874 high school students from fivechools participated in the survey; 1,988 of them were boys and,245 of them were girls. The mean age of students in middlechools was 14.0 years (standard deviation: .87) and that oftudents in high schoolswas 16.5 years (standard deviation: .77).

Overall, 444 (10.2%) students responded as having seen oreard of e-cigarettes. Twenty-two (.5%) students reported asaving used an e-cigarette. The frequencies and percentagesere determined by contact routes of information on e-igarettes among adolescents in multiple response approach.he highest contact route of information on e-cigarettes was thenternet (249, 46.4%). The second highest contact route was

riends (150, 27.9%), followed by television (59, 11.0%), books

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J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546544

(50, 9.3%), and others (29, 5.4%). Other routes included teachers,athletes, fathers, mothers, and newspapers.

Through �2 analyses, the differences in e-cigarette experienceamong adolescents are shown in Table 1. Fisher exact test wasapplied to compensate �2 analyses when the values in contin-gency table were less than five. Statistically significantly higherrates of e-cigarette experience were found for adolescent boys,

Table 1Results of �2 analyses of electronic-cigarette experience among adolescents inve schools in Korea

Independent variables Studentsnumber (%)

�2 p(significantly)

Gender 10.64 .001*Girls (n � 2,221) 4 (.18)Boys (n � 1985) 18 (.91)

Level of school .90 .343Middle school (n � 2,341) 10 (.43)High school (n � 1,857) 12 (.65)

Cigarette smoking family 5.27 .022**No (n � 1,845) 4 (.22)Yes (n � 2,363) 17 (.72)

Propensity to be easily affectedby friends

2.65 .104

Yes (n � 1,605) 5 (.31)No (n � 2,442) 17 (.70)

School life 10.90 .004***Satisfaction (n � 1,876) 9 (.48)Indifference (n � 1,664) 4 (.24)Dissatisfaction (n � 685) 9 (1.31)

Cigarette smoking experience 44.08 .000*Never (n � 3,402) 5 (.15)Ever (n � 810) 16 (2.0)

* p � .001.** p � .05.*** p � .01.

Table 2Results of multiple logistic regression analyses of dependadolescents

Independent variables Model 1a

OR (95% CI

GenderGirls 1.0Boys 6.3* (2.0–2

Level of schoolMiddle school 1.0High school .7 (.3–1.6

Cigarette smoking familyNoYes

Propensity to be easily affected by friendsYesNo

School lifeSatisfactionIndifferenceDissatisfaction

Cigarette smoking experienceNeverEver

Sample size was n � 4,173.CI � confidence interval; OR � odds ratio.

a Model significant at p � .05.* p � .01.

** p � .05.*** p � .001.

for those having cigarette smoking in their families, for thosewith lower satisfaction in school life, and for those who hadpreviously smoked. Contrary to expectations, however, statisti-cally significant associations were not found for school level(middle vs. high school) and for the perception of peer influence.

Results from the multiple hierarchical logistic regressionanalyses are indicated in Table 2.Model 1,which included demo-graphic variables, such as gender and level of school as predictorsof e-cigarette use, produced a goodfit to the data according to theHosmer–Lemeshow �2 test (�2

2 � .7; p � .7). A statisticallysignificant difference was found between adolescent boys andgirls (p � .01). Adolescent boys were 6.3 times more likely thanfemale students to use e-cigarettes. Thus, the data support part ofthe hypothesis, with the rates of e-cigarette use being higheramong male students.

Model 2, which also includes cigarette smoking in the familyand the perception of peer influence as predictors of e-cigaretteuse, produced a good fit to the data according to the Hosmer–Lemeshow �2 test (�2

6 � 5.7; p � .5). Same as in model 1,dolescent boyswere 6.4 timesmore likely than female studentso use e-cigarettes. Accordingly, students inmiddle schoolswereore likely to use e-cigarettes than those in high schools, al-

hough there remained no significant difference (p � .123). Sta-istically significant differences were found for cigarette smok-ng in the family—the studentswho had smoking persons amongamily members were 3.4 times more likely to use e-cigaretteshan those who did not have smoking persons (5 � .05). As forerception of peer influence, interestingly, the students whoerceived to be not easily influenced by their friends were 3.0imes more likely (5 � .05) to use e-cigarettes than those whoerceived to be easily affected by their friends.In model 3, we added satisfaction in school life to model 2 as

ne of the predictors of e-cigarette use.Model 3 produced a good

ariables with electronic-cigarette experience among

Model 2a Model 3a Model 4a

OR (95% CI) OR (95% CI) OR (95% CI)

1.0 1.0 1.06.4* (1.9–20.9) 5.8* (1.8–19.1) 3.5** (1.0–11.8)

1.0 1.0 1.0.6 (.2–1.4) .6 (.2–1.4) .5 (.2–1.2)

1.0 1.0 1.03.4** (1.1–10.0) 3.4** (1.1–10.1) 2.8 (.9–8.5)

1.0 1.0 1.03.0** (1.0–9.0) 2.9 (.99–8.8) 3.9** (1.3–12.0)

1.0 1.0.6 (.2–1.9) .4 (.1–1.4)

2.8** (1.1–7.3) 1.9 (.7–5.0)

1.011.2*** (3.9–32.3)

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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 �

7.8; p � .5). After we added satisfaction in school life, variables,such as gender, level of school, and cigarette smoking in thefamily, continued to be similar to the ORs and significance levelsobserved in model 2, except for perception of peer influence.More specifically,model 3 showed that boyswere 5.8 timesmorelikely than girls to use e-cigarettes (p � .01), and students whohad smoking persons among family members were 3.4 timesmore likely to use e-cigarettes than those who had no smokingpersons (p � .05). Consistent with models 1 and 2, there was nosignificant difference in e-cigarette use when comparing middleschool students with high school students (p � .207). However,there was no statistically significant difference in e-cigarette usewhen comparing students who perceived to be not easily af-fected by friends with those who perceived to be easily affectedby friends (p � .053). With respect to satisfaction in school life,students who were dissatisfied with their school life were 2.8times more likely (p � .05) to use e-cigarettes than those whowere satisfied with their school life.

With cigarette smoking experience, model 4 included all thepredictive variables. Model 4 produced a good fit to the dataaccording to the Hosmer–Lemeshow �2 test (�2

7 � 12.7; p �.120). After controlling for cigarette smoking experience, boyswere 3.5 timesmore likely than girls to use e-cigarettes (p� .05),and the students who perceived to be not easily affected byfriends were 3.9 times more likely to use e-cigarettes than thosewho perceived to be easily affected by friends (p � .016), al-though the difference was not significant in the previous model3. In addition, students with experience in cigarette smokingwere 10.8 times more likely to use e-cigarettes than those withno experience in using e-cigarettes (p � .001). However, previ-ously significant differences in e-cigarette use based on cigarettesmoking in the family were not significant in this model (p �.074). Thus, most of the hypotheses were supported by thesedata, with the exception of the perception of peer influence as apredictive factor for e-cigarette use.

Discussion

The results of this study suggest that e-cigarette advertise-ments and related promotion activities are spreading to adoles-cents, and internationally through the Internet [3]. Within acouple of years after companies began tomarket e-cigarettes, theawareness rate among adolescents participating in this surveywas 11%. This result provides statistical evidence for the opinionthatmarket penetration of unregulated ENDS has expanded rap-idly tomostWorld Health Organization regions [3]. However, anissue of concern is that the information provided by the sellers toadolescents do not contain risk-related data, despite the fact thatcarcinogenic-ingredients, such as TSNAs, were detected in e-cig-arette products [7,8].

The results also indicate that gender, propensity to be affectedby friends, satisfaction in school life, and previous experiencewith cigarette smoking may be predictors of e-cigarette use.After controlling for the variables described, it was possible toassess the relationship between e-cigarette use and the vari-ables. Specifically, in the final model (model 4), it was found thatboys (compared with girls), propensity to not be affected byfriends, dissatisfaction in school life, and previous cigarettesmoking experience are important predictors of e-cigarette use.The variable of school level remained as an insignificant factor,

and the variables of cigarette smoking in the family and dissat- c

isfaction of school life changed from being a significant to anonsignificant predictor when adding cigarette smoking experi-ence to the statistical model. According to earlier reports, theprevalence rates of tobaccoproduct use, such as cigarette, ST, andwater pipe cigarette, among older students and students withsmoking persons in their families were higher than among theyounger students and those without smoking persons in theirfamilies [12]. In detail, when earlier researchers examined maleST users by grade, they reported 7% of 5th graders, 22% of 8thgraders, and 32% of 11th graders to be ST users [13]. Also, 4% ofmiddle school students and 11% of high school students reportedever having used a water pipe cigarette, and 3.6% of middleschool students and 9.9% of high school students reported ascurrent cigarette users [14].

In the case of cigarettes, ST, andwater pipe cigarettes, adoles-cent smoking behaviors were known to be largely affected byfriends [15,16]. The current study results indicated that preva-lence rates of e-cigarette use among students who perceived tobe not easily affected by friends were higher than those whoperceived to be easily affected by friends. However, this resulthas limitationwhen considering the perception of peer influenceto be the peer pressure. The type of question, such as askingadolescents whether they think their smoking behaviors areeasily affected by friends, is likely to generate response biasbecause of social desirability. Thus, the peer pressure related toe-cigarette use among adolescents needs to be assessed in afuture project.

This study indicates that continuous attention needs to bepaid on themarketing of e-cigarettes on Internet sites to preventadolescents from being exposed to unsupported claims aboute-cigarettes. The students taking part in the surveywouldmainlyobtain information on e-cigarettes through the Internet. Addi-tionally, the adolescents could purchase e-cigarettes through theInternet during the period of the survey. The sale of e-cigaretteson Internet siteswas banned later, in November 2008. It is noted,however, that according to a previous report, only 25.5% of theInternet sites sampled prohibited purchases byminors, althoughit was illegal for minors to buy cigars [17].

This study did not investigate whether adolescents were cur-ently using e-cigarettes on a periodic basis, but rather assessedhether they had ever used an e-cigarette. Further researcheeds to assess the rates of current use of e-cigarettes amongdolescents. Also, because the study was cross-sectional, itould not establish the direction of the association betweenhe various predictive variables and e-cigarette use amongdolescents. Accordingly, further research indicating the di-ection of the associations should be performed. Moreover,lthough large numbers of students participated in this study,he prevalence rates of e-cigarette use were determined rela-ively low among adolescents. The most likely explanationsre that e-cigarette use is still in its infancy and, as in otherountries, current numbers of e-cigarette users are very smalln Korea. Therefore, this point may be acceptable. Further-ore, the health risks because of e-cigarette use need to bessessed in a future project, in terms of both acute and chronicffects, including nicotine addiction. To our knowledge, noopulation-based studies have estimated the awareness andxperience of e-cigarette among adolescents. Therefore, theesults of this study may provide useful evidence for adoles-

ent behaviors on e-cigarette use.

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J.H. Cho et al. / Journal of Adolescent Health 49 (2011) 542–546546

Acknowledgments

The authors thank NamWon Paik, Professor of Seoul NationalUniversity in Korea, for the thoughtful comments on the article,andDr. Samuel Y. Paik, Senior Specialist of Abbott Laboratories inthe United States, for his highly valuable reviewing and editing.This study was funded by the 2008 Health Promotion Fund ofMinistry of Health and Welfare in Korea, and additional supportwas provided by the Hanyang Women’s University.

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