1Department of Mass Communication, Universiti Tunku Abdul Rahman, 31900 Kampar Perak, Malaysia
2Department of Media, Universiti Tunku Abdul Rahman, 31900 Kampar Perak, Malaysia
3Pusat Pengajian Citra Universiti, Universiti Kebangsaan, 43600 Bangi, Selangor, Malaysia
4Department of Community Health, Hospital Universiti Kebangsaan Malaysia, 56000 Cheras, Malaysia
*Corresponding Author’s Email: santhidran@utar.edu.my
Smoking electronic cigarettes (e-cigarettes) is currently a common social behaviour worldwide. Malaysia has the second highest smoking rate in the world after the United States. Some countries have positively embraced e-cigarettes to combat traditional cigarettes. However, most Asian countries, including Malaysia, are not sure whether to endorse or ban e-cigarette smoking. Therefore, this study aims to investigate the prevailing meanings and motives for e-cigarette smoking. An interpretive phenomenological approach was used to understand the lived experiences and underlying perceptions of e-cigarette smoking. A total 45 participants from the young adult age group (18-25) were selected and interviewed individually with open-ended questions until saturation was reached. Seven themes emerged from the analysis, namely public acceptance, social status and peer influence, healthy alternatives, smoking cessation tools, individual empowerment, flavourful attractions, and ease of availability. The themes identified provide a good understanding of this phenomenon for effective management of e-cigarette sales and general public health policy planning.
Keywords: E-Cigarette; Harm Reduction; Empowerment; Cessation Tool
The World Health Organization stated in its 2018 report that there are 41 million e-cigarette smokers worldwide. The United States is the world's leading market for e-cigarettes, with over nine million smokers spending $3.7 billion on related products (Yunus, 2021). The United States, the United Kingdom, and France lead the Western world in vaping, and in Asia, Malaysia is the leading nation in vaping with a prevalence of 5% or about 1.12 million vapers and a market value estimated at RM2.27 billion ($529.16 million) and is the world's largest producer of e-liquid currently (Yunus, 2021; Mat Salleh et al., 2023; Chin & Tay, 2023).
Most of the e-cigarette literature focuses on the United States and Europe and very little on the Asian population. Most studies use a quantitative approach, and there is a need for more qualitative research to uncover the profound experiences of this new e-cigarette or vaping phenomenon. The popularity of vaping in Malaysia and around the world is not merely in the technical or the safety it affords users. Vaping which is comparable to smoking behaviour is embedded in human history which dates back to thousands of years. This nurtured behaviour has its roots in personal desires and the social environment. Understanding these deeper personal and social experiences is extremely important. This study therefore investigates the meaning and lived experiences of e-cigarette smoking behaviour. Electronic cigarettes or electronic nicotine delivery systems (ENDS) are popular among smokers, former smokers, and non-smokers, and especially among young adults worldwide (Beard et al., 2015). Research suggests that tobacco smokers are addicted to nicotine on the one hand and to the sensory stimuli and rituals associated with smoking on the other (Fagestrom & Bridgman, 2014). Hence, Quit Clinic’s of nicotine replacement therapies was ineffective because it did not mimic the rituals of tobacco smoking. Nearly 80% of smokers who quit traditional cigarettes return to smoking within one month of quitting (Hughes, Keely & Naud, 2004). A large majority of the smoking public was made aware of the toxicity of conventional cigarettes through the aggressive, fear-themed, “
The purpose of this study is to understand the lived experiences at the personal, social, and community levels, as well as the life circumstances of young adults in Malaysia who smoke e-cigarettes. A multivariate statistical study with large samples was deemed insufficient to understand the deep meanings embedded in the vaping phenomenon, thus requiring interpretive phenomenological analysis (IPA) (Larkin, Watts & Clifton, 2006 and Smith, 2011). According to Larkin, Watts and Clifton (2006), IPA allows researchers to understand the lived experiences of participants in order to describe and interpret a particular topic in a personal, social, cultural, and theoretical context. Smith (2011) recommends the following three guidelines for assessing the quality of IPA studies. First, there must be a clear focus that provides detail on a particular topic. Second, the analysis should be descriptive and interpretive, showing both convergence and divergence in themes; third, manuscripts should be carefully prepared to reflect these principles. The underlying assumption of this research is that not all factors related to e- cigarette smoking have been fully uncovered or conceptually understood.
Following the Society for Adolescent Health and Medicine's definition of young adults, participants between the ages of 18 and 25 were selected for this study. This age range is appropriate given the prevalence of e-cigarette use in this age group, as indicated by the 2020 National Health and Morbidity Survey (NHMS) and several local surveys (Sumisha, 2015; Nurasyikin, Leelavathi & Tohid, 2019; Beard et al., 2015). Purposive selection was used for this study. Participants were selected based on a predetermined criterion that they must be current e-cigarette smokers, defined as having smoked once in the past 30 days, and aged between 18 and 25. Initially participants known to the researchers were interviewed first; following this, a snowball sampling technique was used to recruit more participants from the Klang Valley, Malaysia, which is the nation’s e-cigarette smoking hub. Forty-five respondents were selected for this study. Participants were compensated RM100.00 (approximately US$24.00) for participating in this study. The UTAR Scientific and Ethical Review Committee (SERC) granted ethical clearance for this study (U/SERC/39/2019). A semi-structured interview protocol was used to guide the interview. The protocol questions were divided into five groups: (1) basic demographics, (2) personal involvement in smoking, reasons, and expectations, (3) e-cigarette device, content, cost, and effects, (4) social interactions and public viewpoints, and (5) rules, regulations, and controls. On average, interviews lasted between 45 minutes and an hour. Interviews were conducted face-to-face. Two researchers conducted the interviews. One researcher focused on the conversation, and the other took notes on the interviewees' emotional expressions and interesting remarks. Participants' narratives were audio-recorded, and informed consent was obtained from participants before the in-depth interview began.
Data analysis was conducted using Colaizzi's phenomenological method to understand e-cigarette enthusiasts' personal experiences, perceptions, and beliefs, which differ from theoretical explanations (Colaizzi, 1978). The transcribed verbatim responses of 45 respondents were read multiple times by the researchers to gain a comprehensive understanding of the respondents' lived experiences. Significant phrases, reflecting the essence of the lived experiences, were clustered into common< themes among participants. Methodological robustness was established by applying the verification, validation, and validity emphasized by the qualitative approach (Creswell & Poth, 2016). The process of extracting categories and linking it to themes in the code book was done separately by two teams of researchers and later compared, discussed and significant themes confirmed. Multiple readings, references to field notes, team checks, and verification on the clusters, categories and themes were triangulated to ensure validity and reliability of the findings.
A total of 20% of participants (n=9) reported using e-cigarettes exclusively. Dual use of conventional and e-cigarettes was 80% (n=36). Years of e-cigarette smoking were as follows: under 1 year, 19.6% of respondents, one year 24.2%, two years 17.0%, and three years or more 39.2%. The sample was 87% male, and the mean age was 23.5 years. The main reason for dual use was to reduce and eventually quit smoking tobacco for health reasons (n=34 or 76%). A minority cited social interaction, reducing the overall cost of smoking, and pleasure (n=11 or 24.4%). On average, RM102.00 ($24.40 USD) was spent monthly on purchasing flavoured juices for e-cigarettes.
All participants indicated that they were influenced by their peers and described vaping as a social trend (n= 45 or 100%). A total of three respondents succeeded in quitting tobacco smoking (n=3 or 7%) and six of the respondents had no intention of quitting tobacco smoking (n=13 or 13%). From 45 verbatim transcripts, 398 significant statements were extracted to create the formulated meanings. These formulated meanings were arranged into clusters, resulting in seven themes.
Those who smoked e-cigarettes exclusively (n=9) indicated that the general public had no concerns about vaping compared to smoking conventional cigarettes and this gave them a sense of respect and confidence in the public domain. Participants expressed that when smoking conventional cigarettes people tend to move away or exhibit negative facial gestures of disapproval, especially with the offensive smelling smoke. The following responses substantiated the above theme.
"Because it has many different tastes. It’s good for taste; there's no second-hand smoke problem" (CSC28/ L13). Unlike traditional cigs, the public doesn’t like the smoke; vaping has no problems; it smells good; the public accepts it (CSC12)". "Also, I can just vape anywhere, in public places too; so far, the public has never shown disapproval of vaping (CSC01)".
Participants perceived vaping and the social interactions associated with smoking e-cigarettes as extremely "cool" and trendy. Dual-mode smokers (n=36) indicated that they perceived a pleasant smell when vaping, and this was readily accepted, especially by their female friends during social activities. Overall, the aromatic and socially accepted smells were unanimously cited (n=45). Many said that it helped them connect with and align with the current trend among their peers. Many could show their prowess in vaping tricks, which enabled them to gain social capital and achieve camaraderie among peers. The following responses substantiated the above theme:
"I am the one who influenced my friends, not they. It is actually a trend because most of my friends who are not smoking traditional cigarettes went to smoke e-cigarettes, so it is sort of a trend (CSC04 /L 44 & 56)". "Yes, a lot of people are using it as a socializing mechanism (LSL06/L56)." Maybe some of them wanted to like..erm..play around like..erm..you know they are making loops.(CSC07)".
Both e-cigarette and conventional cigarette smoking can be conceptualized as social acts or practices (Gravely et al., 2014). Social practice is described as a set of interrelated behaviours rather than a single activity, which explains why it is so difficult to quit smoking. Therefore, people will continue to seek safer alternatives to smoking, such as e-cigarettes. All respondents (n=45) were aware of the health hazards of conventional cigarettes through the "TakNak" campaign, and one specifically mentioned the existence of 7,000 chemicals (ITC Malaysia Wave 1-4 National Report (2005-2009), 2012). The following responses substantiated the above theme.
"Because traditional cigarette is more harmful than e-cigarette and it will left very strong taste, strong smell on you (CSC09)". "Because traditional cigarette is more harmful than e-cigarette (CSC12)". "Of course I want to quit traditional cigarette because it’s very very bad for health and that's a lot of the chemical that are negative inside cigarette compared to the vape so yea (LSL01)".
All dual smokers (n= 36) confirmed that they used vaping as a smoking cessation aid. This was primarily because vaping mimics traditional cigarette smoking without the dangerous chemicals. Respondents were also hoping that by smoking e-cigarettes they could gradually reduce tobacco smoking and also control the amount of nicotine they would like to vape, and this was viewed as a way to moderate their consumption of nicotine. The following responses substantiated the above theme. "Because to reduce my traditional cigarette, initially I starting with traditional cigarette and then I pick up e-cigarette because trying to reduce traditional cigarette (LSL04)"."Yes I have the desires to quit the traditional cigarette because I don't want to make it into a habit and that is why I vape.Yes, currently I'm lowering down a bit just smoke one or 2 puff of traditional cigs only (LSL05)".
The fourth theme is individual empowerment. Several respondents felt that, unlike traditional cigarettes, with e-cigarettes they have full control over how long they smoke and how much nicotine they want to consume (n=29). They can also create their own blend of flavours by mixing the vape juices. This idea of having control over vaping is a new experience, especially for dual smokers. The following responses substantiated the above theme:
"I am free to choose the flavors and is much more attractive than traditional cigarettes CSC20/L47)’."E- cigarette is more flexible compare to tobacco. Can choose nicotine level, 8mg, 32, 16mg. Can choose flavor or mix flavor, this part I like most (CSC19/L57)". "Interestingly you can vape and stop and even continue later unlike the tobacco cigarettes where once light up need to finish it. E-cig helps in the nicotine intake, in terms of balancing (LSL06/L72)".
Many respondents specifically mentioned the distasteful smell of traditional cigarettes, which made a majority of them take up e-cigarettes, which have a wide range of exciting and interesting flavours to choose from (n= 34). This feature of the e-cigarette is one of the most significant attractions for former smokers, dual-mode smokers, and e-cigarette only smokers. Most of the flavours are from food derivatives, particularly fruits, coffee, caramel, cola, tea, and others. The following responses substantiated the above theme: "Like I say they when we hang around every time, they also smoke e- cigarettes then you know the flavour is smell good that’s why I start to begin of it (LSL05)"."Choose e- cigarette because firstly is my friend intro me to use the e-cigarette and I found out is like a totally a very special taste and compare with the traditional (LSL07)"."I choose e- cigarettes because there are many flavours to pick (LSL11)".
The easy availability of the equipment and juices. The availability of the e-cigarette smoking device and juices enables the attainment of tangible and intangible benefits. Most respondents confirmed that ease of availability was one of the main reasons for smoking e-cigarettes (n= 33). The e-cigarette smokers mentioned that there are many vape shops online and offline that they can easily choose from and purchase their supply from at any time. The following responses substantiated the above theme: "Oh Yeah of course because the availability in Malaysia and it’s super convenient to get it right so yah I think is kind of influence me (LSL10/L66)"."For my electronic device. I get it at the shop. And for the flavour actually can get it everywhere, shop and online, no restrictions (CSC04/ L83)".
The majority were not in favor of banning e-cigarettes but were in favor of regulating the e-cigarette business (n= 29) to ensure the e-liquids are of good quality, control nicotine content, prevent drug abuse through vaping, and disallow the underage population to consume them. The concern was to safeguard this new way of smoking by making sure there was no compromise in quality, safety, or possible drug abuse The following responses substantiated the above theme." Yes. Because now, I see that many young people below than 18, they use the e-cigarette when they are yumcha with their friends. So, also, they can bring to school or what (CSC14)"."Because e- cigarettes actually can do a lot of illegal stuff. (CSC01)".
The results of this study, especially the influence of peers, are consistent with the findings of previous studies here and in other countries (Pokhrel et al., 2015; Keane et al., 2016). One study showed that the main reason for experimenting with an e-cigarette was peer influence, while other reasons were curiosity and flavours (Wong et al., 2016; Elkalmi et al., 2016; van der Eijk et al., 2022). In another study, statistically significant predictors of e-cigarette smoking were peer support, dissatisfaction with school life, and experience with traditional cigarette smoking (Kong et al., 2015; Cho et al., 2011).
One of the predominant new themes that emerged among our dual-smoking participants (n=36) is individual empowerment. The e-cigarette gives them control over how often they smoke, where they smoke, how long they smoke, and the freedom to choose flavours and nicotine strengths which are not available with traditional cigarettes. Other dominant and new themes also emerged, namely public acceptance, healthy alternatives, flavourful attractions, and ease of availability. The theme of flavourful attractions has been mentioned before in studies outside Malaysia, but here for the first time (van der Eijk et al., 2022). In summary, out of the seven themes, peer influence and cessation tools have been mentioned in previous Malaysian research.
These positive narratives imply that young adults' lived experiences, perceptions, and motivations are strongly associated with e-cigarette use. It is also important to note that there are currently no major negative narratives or barriers to e-cigarette smoking behaviour. A majority (n=25) wanted e-juices to be regulated to ensure the quality and safety of e-juices, while others (n=17) opposed any form of control, believing them to be harmless and helpful in tobacco cessation.
The Malaysian government is currently debating the Tobacco Product Control and Smoking Act, also known as the Generation Change Act, which would ban the sale of cigarettes, tobacco, and vape products to people born in 2007 or later. The ban on cigarettes and vape products can fuel the existing illegal cigarette market. According to a news report, Malaysia is the world's largest tobacco black market, accounting for 65% of the local tobacco market (New Straits Times, 2020, October 19).
In a recent survey published in a leading online newspaper, 49% of current smokers said they use e- cigarettes to reduce or quit using traditional cigarettes, 52% believe e-cigarettes are less harmful, and 90% believe e-cigarettes should be actively promoted to reduce or quit using traditional cigarettes (New Straits Times, 2020, June 3). Perhaps the government can use e-cigarettes to allow current smokers of conventional cigarettes to switch to e-cigarettes to reduce harm. The United Kingdom adopted a harm reduction approach for e-cigarettes (Notley et al., 2018). Risk-based regulation is an appropriate way to achieve this balance by imposing the right controls, as it has the potential to reduce the prevalence of traditional cigarette smoking.
It is important to note that the purpose of this study is not to generalize but to describe and interpret the phenomenon. Nonetheless, the research findings contribute to future policy decisions on whether an end-game approach or a risk-appropriate strategy is more appropriate for a phenomenon that will always exist and which, as the study shows, is deeply embedded in the lifestyles of young Malaysians. Another limitation of this study is the dominant participation of male e-cigarette smokers. A gender balance would have further enriched the analysis; future research may seek to achieve this balance.
Given the seven strong positive themes that combine to form an irresistible social and hedonistic benefits of e-cigarette smoking, and the current lack of evidence of serious health consequences, perhaps the relevant government agencies can take an end-game approach to conventional cigarettes and a risk-adjusted approach to e-cigarette control.
The authors of this article declared no conflicts of interest.
This study was funded by the Ministry of Higher Education, Malaysia under the Fundamental Research Grant Scheme (FRGS/1/20/18/SKK01/UTAR/02/1).
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