Cigarettes smoking and e-cigarettes using among university students: a cross-section survey in Guangzhou, China, 2021

Despite numerous efforts to stop the tobacco epidemic, tobacco smoking is recognized as a major preventable cause of disease worldwide [1]. The 2021 Global Report on trends in the prevalence of tobacco use 2000–2025, published by the World Health Organization (WHO), states that tobacco use in any form kills and sickens millions of people every year and over 8 million people died from a tobacco-related disease in 2019 [2]. Smoking and passive smoke (exposure to second-hand smoke) are the key contributors to the mortality of specialization chronic diseases, namely, cardiovascular disease, chronic respiratory disease, and cancer [3]. The prevalence of current (at least 1 of the last 30 days) cigarettes smoking among Chinese adults reached 27.7% in 2015, making it one of the highest smoking rates in the world [4]. The health risks of smoking have attracted more and more attention, and smoking on campus has become a serious school and social problem [2, 5].

Customers are getting more worried about the physical harm as their awareness of cigarettes' dangers is increased, and they are more encouraged to choose e-cigarettes which are claimed as less harmful and can meet their needs of risk reduction [6]. Many researches have shown that e-cigarettes, although they cannot be considered safe [7], may cause less harm to the body than cigarettes [8‐11]. Some cigarettes smokers are converting to e-cigarettes to avoid the effects of smoking [12].

E-cigarettes are electronic devices that deliver nicotine to the respiratory system by atomizing an aerosol of smoke containing glycerin, propylene glycol, nicotine and other additives through an electric heating element [13]. Since e-cigarettes produce much less tar, carbon monoxide, and carcinogenic ingredients such as aldehydes, acids, and phenols, the exclusive use of e-cigarettes among smokers may reduce the number of diseases caused by such ingredients [14‐16]. Studies have shown that cigarettes and e-cigarettes are the most frequently used nicotine products in youth adults in the USA [17‐20] and probably China. China is the world’s largest consumer of tobacco products and contributes substantially to the global burden of smoking-related diseases [21]. It is noteworthy that the use of e-cigarettes in China is far less frequent than in some European countries and the United States [22‐27].

However, the health risks of e-cigarettes have not been adequately studied, data on their effects and risks on human body are limited [15, 28]. Despite the fact that using e-cigarettes is a worldwide phenomenon [29, 30], there is a paucity of data regarding the knowledge and attitude of e-cigarettes users particularly among the young adults in China [31]. Studies of cigarettes and e-cigarettes use among e-cigarettes consumers are still in their infancy, with most of them being questionnaires about basic consumer information, consumption behavior and preferences. Most survey respondents are European and American e-cigarettes consumers, and there are limited reports on Chinese e-cigarettes consumers' vaping behavior. There is an urgent need to investigate the status quo and influence factors of smoking and using e-cigarettes [32].

Therefore, we conducted a cross-sectional survey of using cigarettes and e-cigarettes to investigate the smoking behaviors among university students in Guangzhou. One of our research interests was the use of cigarettes and e-cigarettes among university students. Another focus was on the factors that influence the use of cigarettes and e-cigarettes by university students.

Our findings were consistent with some prior prevalence studies in which males were more likely to smoke than females (males: females = 37.2:7.5) [10, 36‐38]. However, the gender difference in e-cigarettes were smaller than in cigarettes, which is also consistent with previous research studies [39‐41].

The gender differences in smoking may be attributed to traditional sociocultural influences [31, 32, 42‐44]. Habitual thinking suggests that female's smoking is associated with an inappropriate social image. The social circumstances put more pressure on female smokers, whereas, for male smokers, social opinion has a much smaller negative impact than for females, suggesting that the socio-cultural context have an intervening role in smoking.

In addition, we found that the rate of using cigarettes and e-cigarettes was the highest among undergraduates, followed by Ph.D. students, and the lowest was among master students, both for cigarettes, e-cigarettes, and dual use. It indicates that cigarettes and e-cigarettes use was shown as a non-linear relationship with education level, which is consistent with other studies [45]. This may be due to the fact that undergraduates have less academic stress and more social activities [46], which are susceptibility factors for cigarettes and e-cigarettes use. A number of studies have shown that there is a significant correlation between smoking and the education level of the smoker, the higher the education level is, the lower the smoking rate is [47, 48]. This is because people with a higher level of education level have a higher level of health awareness, and a relatively higher level of awareness of the diseases caused by smoking and harmful results [49, 50], and thus have a lower smoking rate, which explains the relatively lower rate of cigarettes and e-cigarettes use among master student s and Ph.D. students. Undergraduate students were more likely to use e-cigarettes, in contrast to master students and Ph.D. students, who had the lowest rates of cigarettes and e-cigarettes use and a greater preference for cigarettes. It has been established that e-cigarettes use shows a non-linear relationship with education level, but the exact reasons for this are unclear and warrant further study [51]. Our findings displayed that the use of both e-cigarettes and cigarettes was lower in prestigious Chinese universities perhaps due to the widely different circumstances, different management, and different type of student in different universities. In addition, we found that the cigarettes use rate of Ph.D. students is much higher than the e-cigarettes use rate, which is different from the situation of undergraduates and vocational school students. The reasons for this may be that Ph.D. students are older than others and e-cigarettes are emerging products, so many Ph.D. students are used to using cigarettes and are not familiar or are not willing to try e-cigarettes.

Similar to previous surveys, we found that non-medical students have higher rates of cigarettes and e-cigarettes use than medical students [52]. This may be due to the fact that medical students are more aware of the effects of nicotine on the body after learning extensive knowledge of physiology and pathology [16, 30, 43]. It is noteworthy that, the highest rate of using cigarettes and e-cigarettes was law students. The considerable pressure placed on them in academic performance can explain this result [53].

A growing body of research indicates that emotion is also one of the influencing factors of smoking and negative emotions can induce smoking [54, 55]. Our findings found that the majority of dual users will use cigarettes rather than e-cigarettes when they are depressed. This result may be due to the different experiences of smoking and vaping while there is no related data to illustrate that smoking cigarettes will provide more pleasure in the present.

We also discovered that among all the future choices, dual use is becoming increasingly popular, as the previous study reported [56]. 51.2% of the dual users started as cigarettes only users, indicating a huge shift of nicotine products using pattern in young adults. Consistent with our findings above, some studies [30, 41, 57] also indicated that cigarettes only users are more likely to try e-cigarettes than non-smokers. However, a study by Sean Esteban McCabe et al. indicated that dual users had the greatest risk for engaging in risk behaviors (including truancy, grade point average <  = C + , binge drinking, alcohol use, marijuana use, illicit drug use and nonmedical Rx drug use) followed by cigarettes only users, e-cigarettes only users, and non-nicotine products users [5].

The present study reveals the use rate of cigarettes and e-cigarettes among university students in Guangzhou, China. This study also provides the possible future choices of cigarettes or e-cigarettes users among university students. Our investigation shows that 29.8% of participants reports that they used cigarettes or e-cigarettes. Among them, 16.7% were e-cigarettes only users, 35.0% were cigarettes only users and 48.3%were dual users. 51.2% of the dual users were developed from cigarette only users.

Additionally, this study investigated influencing factors to cigarettes and e-cigarettes use, showing that gender, school, education level, specialization, and lifestyles all had impacts on the use of cigarettes and e-cigarettes among university students in Guangzhou. Students who were male, had low education levels, from non-prestigious Chinese universities or vocational schools, had non-medical specialization, and the presence of inappropriate lifestyles such as drinking and playing video games excessively were more likely to use cigarettes and e-cigarettes. Besides, emotion also can have significant effects on the choice of using cigarettes or e-cigarettes for dual users.

This study elucidates the characteristics of cigarettes and e-cigarettes use and related influencing factors among university students in Guangzhou, providing more information to better understand young people's preferences for cigarettes and e-cigarettes. This cross-section survey offers a perspective for policy makers to develop more guiding industry rules of young adult's cigarettes and e-cigarettes using.

In our future work, further investigations, which take more variables related to cigarettes and e-cigarettes using into account, will need to be undertaken, and more reliable analytical methods must be required.