The use of e-cigarettes among university students in Malaysia

INTRODUCTION E-cigarette use is an emerging phenomenon with increasing recognition and acceptance globally. This study aims to create a profile of e-cigarette users among university students in Malaysia. METHODS The study was conducted using a cross-sectional research involving six universities in Malaysia. A semi-structured questionnaire was distributed to 1302 randomly selected students, who either smoked cigarettes and/or e-cigarettes. The 2011 version of Global Adult Tobacco Surveys (GATS) tool was used to record the respondents’ sociodemographic data. RESULTS The study revealed that 74.9% of the respondents smoked e-cigarettes; 40.3% used both cigarettes and e-cigarettes (dual users), and 34.5% were exclusive e-cigarette users. The exclusive use of e-cigarettes was related to gender (OR=0.18, 95% CI: 0.09–0.39). Also, male respondents were the majority users (95%). Of the respondents, 75.2 % were Malays, 98.0% single and most believed they have no health problems (92.1%). Further findings revealed the occurrence of adverse effects, dizziness 14.4%, cough 14.1%, and headaches 12.4%. Overall, 57.8% of the respondents used e-cigarettes as a smoking cessation tool, while others consider e-cigarettes a self-image enhancing tool or as part of social activities. CONCLUSIONS Further research on the use of e-cigarettes should be conducted on a large number of respondents in other settings to augment the findings of this study, and also guide policy making on and prevention practice of e-cigarette use, among the general student population in Malaysia.


INTRODUCTION
The electronic-cigarette (e-cigarette) is an electronic device, also known as vape, containing a cartridge filled with liquid nicotine and/or other chemicals, producing inhalable smoke. E-cigarette use has quickly gained popularity worldwide 1 , especially among current and former smokers [2][3][4][5][6] . E-cigarette manufacturers promote it as a safer, cheaper and an alternative product for smoking cessation. As the popularity and use increase, so is concern about public health. In 2009, Australia, Brazil, China, Uruguay 7 , Brunei, Cambodia, Indonesia, Singapore, Thailand, and Vietnam 8 completely banned the sale and marketing of e-cigarettes; while New Zealand, United Kingdom, and other European countries allowed marketing of e-cigarettes. South-East Asia is one of the regions in the world with the highest number of countries (6 out of 11 countries in the region) that banned the use of e-cigarettes 8 . However, some aspects of the banned regulations in these countries need improvement 9 . The International Tobacco Control Policy Evaluation Project (ITC Project) reports the use of e-cigarettes in 10 countries, through a survey conducted between 2009 and 2013. Malaysia was found to be the country with the highest prevalence of users, at 14%, while other countries like Republic of Korea and Australia had 7% each, United States 6%, United Kingdom 4%, Netherlands 3%, Canada 1%, and China 0.05% 1 . The 2015 Global Adult Tobacco Survey (GATS) conducted in the South-East Asian (SEAN) region, gave the following e-cigarette use prevalence for countries in the region: Indonesia 0.3% and Malaysia 0.8%, in 2011 10 ; Philippines 1.7% 11 and Vietnam 0.2% 12 . Also, the Global Youth Tobacco Survey (GYTS) of 2016 showed the prevalence of e-cigarette use among students (age 13-15 years) to be 2.3% in Cambodia 13 and 5.7% in Myanmar 14 . Noteworthy, the survey revealed a 3.2% prevalence rate for Malaysia 1,14,15 , which makes it the largest vaping market in the SEAN region 16 .
Wong et al. reported 39.9% of e-cigarette use among young students of higher institutions and 36% use among young professionals in their study conducted in the Selangor and Kuala Lumpur areas of Malaysia 17 .
In an attempt to check the menace of e-cigarette use, the Higher-Education Minister of Malaysia announced in November 2015 a ban on e-cigarette use and tobacco smoking in universities. The ban is in effect in several Malaysian universities 18,19 .
E-cigarette use prevalence is high among the young, and diverse reasons for the use have been reported in several studies. Some studies state that cigarette (tobacco) smoking is an important associated factor of e-cigarette use among young people [20][21][22][23] , while the older users consider it an alternative to tobacco smoking 24,25 . Other reasons for the use are: experimenting due to curiosity [26][27][28][29] , interesting flavours 30,31 , 'just for fun' 29,32 , popularity 33 and 'just experimenting' 34 . The risk associated with e-cigarette use is said to be much less than that of tobacco smoking. If the claim is right, the harms related to tobacco smoking would be substantially reduced, with benefits for cardiovascular health 35 . However, more research needs to be conducted to ascertain the effects of e-cigarette use compared with tobacco smoking.
Several aspects of e-cigarette use in Malaysia were reported in various studies, but none was on the users' profile. As such, this study aims to explore the factors associated with e-cigarette use, in order to create e-cigarette users' profile based on sociodemographic distribution, source of information and supply, gender, and adverse effects, amongst other features, in six Malaysian universities.

Participants and procedure
The study was conducted through a cross-sectional field survey research approach, from August 2016 to December 2016. Six out of sixteen universities situated in Klang Valley, Malaysia, were randomly selected; three public and three private universities. As prevalence for e-cigarette users among adults in Malaysia was 14% 1 , and the total population was estimated at 204000 students, a sample size of n=185 (95% Confidence Interval (CI) and 5% significant level) from each of the selected universities was obtained using the Leslie Kish formula. A total of 1302 participants were chosen through a box-model random sampling technique.
Inclusion criteria of this study were: 1) university student, 2) age 18 years and older, and 3) student currently smoking a conventional cigarette or use of e-cigarette at the time of the study. Exclusion criteria were: 1) student on leave and/or not attending classes for three months, 2) student suspended by university, 3) student did not wish to participate in the study, and 4) student with cognitive disorders due to diseases like dementia, Parkinson's disease or schizophrenia.

Measurements
The questionnaire, in English and Malay, contained both closed and open-ended questions, divided into three sections: 1) sociodemographic background and current health status; 2) smoking history; and 3) e-cigarette use. The sociodemographic section included age, gender, race/ethnicity, educational levels, nationality, marital status, total household income and health problems. Questionnaires were distributed to the participants by the lead researcher and a trained research assistant. Ethical approval for the study was granted by the Secretariat of Research and Innovation, Universiti Kebangsaan Malaysia Medical Centre (Code: FF-2016-301) and the administrative board of each participating university. Information sheets and consent forms were distributed to all students, and active consent was received from the participants. The respondents were duly informed that participation in the study was voluntary, and that their identity will remain anonymous. They were also informed that a response to a question was neither 'right' nor 'wrong'.
Questions on smoking history were adapted from the GATS 2011 with slight modification to suit the study. Participants were asked if they had ever smoked a cigarette, smoking habits of their immediate family members, age at smoking initiation, amount of smoking and type of cigarette used, among other questions. Questions on the reasons for e-cigarette use were based on 28 items and a 5-point Likert scale (1=totally disagree, 2=disagree, 3=unsure, 4=agree, 5=totally agree). Responses were coded in two categories: low (total score lower than mean score) and high (total score higher than mean score).

Statistical analysis
The collected data were analyzed using SPSS version 23.0, using frequencies (n), percentages (%), chisquare tests and multivariable binary logistic regression models. Level of significance was set at p<0.05 and regression results are presented as Adjusted Odds Ratios (AOR) with 95% Confidence Interval (CI).

Participants' background
The respondents were between the ages of 18 to 40 years: males n=1234 (94.8%) and females n=68 (5.2%); mean age and standard deviation of 21.15 ± 2.55 years; ethnic Malay 75.2%, Malaysian nationals 97.9%, and single 98.0%. Distribution based on education level was PhD/DrPH 0.6% and undergraduate 65.2%. The household mean monthly income was MYR 5760.89 ± 7411.14, and the propotion of participants with a self-perception of being healthy was 92.1% (Table 1). This study showed that over 67% of the respondents did not report any health impact and were not certain if they suffered any adverse effects from the use of e-cigarettes. Among the adverse effects experienced by the users were: dizziness 14.4%, cough 14.1%, headache 12.4%, addiction to e-cigarette use 9.5%, chest pain 6.9%, and shortness of breath 5.7%. Other adverse effects, experienced by less than 5% of the respondents, were: vomiting 4.5%, decreased appetite 4.1%, insomnia 4.0%, weight loss 1.9%, depression 1.6%, and anxiety 1.1%. Dual users had significantly experienced more adverse effects compared to exclusive e-cigarette users (Table 3). Figure 2 depicts the feelings of respondents towards Smoking and e-cigarette use profile Within our sample population of students, 34.5% were exclusive e-cigarette users, and 40.3% were dual users, indicating that 74.8% of the respondents were current e-cigarette users ( Figure 1). Moreover, 18.7% were current smokers and 6.4% neither smoked nor used e-cigarettes. Among current e-cigarette users, 40.3% used cigarettes and e-cigarettes simultaneously. In all, 57.5% (749) of the respondents were introduced to e-cigarettes by colleagues in the university, 37.5% (488) by friends outside the university, 36.6% through the internet (websites, social networking sites, blogs, and e-mails) and 28.8% through the communication media (television, radio, mail, print, billboards and outdoor advertisement). A propotion of 37.9% of the respondents bought e-cigarette products from retailers, 17.6% from their fellow university students, and 14.8% online. Findings in this study revealed that most of the e-cigarette users preferred locally produced e-liquid With regards to the reason for e-cigarette use provided by dual users (n=975), 64.6% of the respondents use e-cigarette due to their own desire, personal beliefs 64.6%, social influence 54.8%, emotional factors (boredom, loneliness and stress) 62.6%, current trends 62.7%, while 57.8% claimed to use e-cigarettes as a means for quitting smoking.
The study found that majority of the respondents were dual users, the high-risk group (involved in tobacco/nicotine use). The bivariate analysis revealed

DISCUSSION
The study assessed factors related to e-cigarette use through which user profiles were created. The study revealed that male respondents were the majority e-cigarette users, most of them young and residing in urban areas. The respondents smoked cigarettes alongside their family members, colleagues and peers who either smoked tobacco, used an e-cigarette, or both. This finding is similar to the e-cigarette user profile reported by Jun et al. 20 and Joan-Carles et al. 21 . In Malaysia, smoking among females is culturally unacceptable, which affirms the low number of female e-cigarette users found in the study. Young people have strong desires to try something new; living in an urban settings allows easy access to e-cigarette sources and living in proximity to a smoking environment enhances smoking interest. Involvement with e-cigarette use exposes the users to various health risks, particularly those who use it as an alternative to quitting cigarette smoking. The implication here is the possible lack of knowledge about smoking quitting methods, despite the availability of alternative means for quitting cigarette smoking, such as nicotine lozenges, support group, counselling, nicotine patch, nicotine replacement drug and traditional medicine. The listed methods are safe and subsidized by the government, but were only used by 25% of the respondents.
In this study, about 74.8% of the respondents were e-cigarette users, the finding is augmented by the Saddleson et al. 36 assertion that most university/ college students use e-cigarettes for pleasure. However, a study conducted in France found that 70% of college students in two major campuses never used Continued Data exclude non-e-cigarette user with analysis using logistic regression. E-cigarette user refers to exclusive e-cigarette user. AOR: adjusted odds ratio, CI: confidence interval. *p<0.05 indicates significant difference does exist. e-cigarette 37 . Also, some studies in the United States and other countries show that e-cigarette users may as well use conventional cigarettes 38,39 and drugs 40 in the future. It is also worrying that e-cigarette use among ex-smokers may cause a return to cigarette smoking 41 .
Over three-quarters of the respondents were involved in smoking, including ex-smokers. Of them, 54.9% started smoking at the age of 16-20 years, when they were in high school or just entering university. This situation clearly indicates that strategic prevention planning should target this age group and younger. Rigotti 42 stated that university students should be targeted for behavior change advocacy, because adolescents were the main marketing target group of the tobacco industry. It was further revealed that 34.5% of the respondents were exclusive e-cigarette users, with preference to e-juice without nicotine (only flavors) and lower level of nicotine (≤ 6 mg of nicotine) 41 .
Health effects of smoking are well known due to the existence of evidence-based research outcomes and established linkage to cancer, heart disease, and stroke. Information on smoking hazards are available and easily accessible through various media outlets (e.g. posters, advertisements on buildings and vehicles, video, radio and television ads etc.). Despite this development for a conventional cigarette, information on e-cigarette adverse effects are relatively new and emerging, and in need of more research. In this study, adverse effects like dizziness, cough, headache, addiction and chest pain were reported. Findings by Hua et al. 43 posit that there are over 405 different health-related effects experienced by users. Additionally, most common health-related effects occurred in the respiratory, neurological, sensory and digestive systems, while direct health effects occurred solely in the respiratory system 43 .
E-cigarette marketers often advertise it as a safe and healthier alternative to conventional smoking and that it aids smoking cessation [44][45][46][47][48] . The study found that e-cigarettes were used by the respondents for various reasons: own desire, personal beliefs, selfemotion, and as a current smoking trend. Using it as a means for quitting smoking is popular among dual users (59.4%). Chapman et al. 49 stated that e-cigarette use is not consistent with attempting to quit tobacco smoking among young adults, as adults most often report e-cigarette use as a substitute for tobacco and not as a means for quitting 24,25,49 .
The effectiveness of e-cigarette use as a smoking cessation tool is unclear 1,4,20 , and subject for further research. Moreover, e-cigarette use is not without risk, but much less dangerous than tobacco, as it has less carcinogenic chemicals (e.g. acetone, acroline, benzene, cadmium, carbon monoxide, toluene, etc.) 46,48 . Lynn et al. 50 suggested that the mistaken perception of lesser risk may be the influencing factor for e-cigarette use as a substitute for tobacco smoking. Further research on the health effects of e-cigarette use should be conducted, to ascertain its severity on human health.
The main limitation of this study is that the data were only collected in one of the States in Malaysia within a certain time duration. Therefore, the samples do not represent a national proportion and hence have limited generalizability. Also, the self-reporting mechanism used in data collection could result in a biased response. Despite these limitations, the findings present a good profile of e-cigarette users and a framework with which to guide decision making and future research on e-cigarette use. Additionally, e-cigarette use was more popular among young people in this study, larger studies in diverse locations and populations might address the challenges of this study.

CONCLUSIONS
The study provides evidence-based information for a behaviour change campaign on e-cigarette use among university students. Both cigarettes, as well as e-cigarette use among students, for whatever reason, need to be discouraged. Achieving meaningful mitigation of the use of tobacco products needs the combined efforts of academics, civil society, government, industry and communities to find effective means for a solution to the tobacco epidemic.