Predicting susceptibility to e-cigarette (EC) initiation among adolescents is crucial to optimize preventive measures before the health risk behavior persists through adulthood. The identification of susceptible groups is needed in response to the surge of EC use. This study aimed to determine the prevalence and determinants associated with EC susceptibility among tobacco product naïve (never users of any single tobacco product) school-going adolescents in Malaysia.

Data were derived from the Tobacco and EC Survey among Malaysians (TECMA), which recruited a total of 13162 school-going adolescents aged 10– 19 years from 138 randomly selected schools via a two-stage stratified cluster sampling design. A validated self-administered questionnaire adapted from the Global Youth Tobacco Survey was utilized as the study instrument. The data were analyzed using SPSS version 22.0 descriptively and with multivariable logistic regression to determine the associated factors of EC susceptibility.

About 15.7% of the tobacco naïve adolescents were susceptible to EC initiation, with the proportion of susceptibility significantly higher among males, mid-adolescents, rural adolescents, those reporting exposure to tobacco advertisement and those not taught in school about the danger of tobacco use. Multivariable logistic regression revealed that the male students (AOR=2.20; 95% CI: 1.86–2.59) from a rural locality (AOR=1.45; 95% CI: 1.23–1.71), those reporting no lessons on the danger of tobacco use at school (AOR=1.66; 95% CI: 1.39–1.99) and those exposed to tobacco advertisement (AOR=1.67; 95% CI: 1.07–2.61), were more susceptible to EC initiation, while no significant association was found between secondhand smoke exposure and EC susceptibility.

Comprehensive EC preventive strategies are critically needed together with the implementation of targeted, gender, and culturally impressionable interventions. In addition, future studies should focus on the evaluation of the impacts of the preventive and control efforts to ensure their effectiveness in preventing EC initiation among Malaysian adolescents.

We thank the Director-General of Health Malaysia for the permission to publish this article. We also thank all authorities involved in the survey, as well as the Department of Community Health, Faculty of Medicine, National University of Malaysia, for their support.
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. F. Daud reports receiving funding from Universiti Kebangsaan Malaysia, and that the Malaysian Ministry of Health allowed the data collection and presentation.
The research was funded by the Ministry of Health Malaysia and the Universiti Kebangsaan Malaysia.
Ethical approval was obtained from the Ministry of Health Malaysia, Medical Research Ethics Committee (Approval: NMRR-20-3149-57296 IIR; 6 May 2021); and from the Universiti Kebangsaan Malaysia, Ministry of Education (Approval: FF-2021-210 (UKM PPI/111/8/JEP-2021-367); 24 May 2021). Written informed consent was obtained from the participants and their parents/guardians before recruitment.
The data supporting this research are available from the authors on reasonable request.
FD coordinated the study and performed the quality assurance. MFMY designed the research. PPH wrote the manuscript. PPH and KHL were involved in data management and statistical analysis. All authors were involved in the interpretation and implications of the data, reviewed the draft manuscript and agreed upon the final version.
Not commissioned; externally peer reviewed.
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