Perceptions, use and cessation of e-cigarettes among young people in urban Northern Thailand
Publication Date
July 23, 2025
Creator
Abstract
Electronic cigarettes (e-cigarettes) are devices that heat a liquid, often containing nicotine, to produce an aerosol for inhalation, a practice known as vaping. The prevalence of vaping among youth is rising globally. While it is generally perceived as less harmful than smoking, e-cigarettes are not without risks. Although they are increasingly viewed as a potential tool for smoking cessation, there is ongoing debate regarding their role as a possible gateway to traditional smoking, raising important questions about their overall impact on public health. Approximately 30 countries have implemented strict bans on e-cigarette sales, aiming to protect non-smokers and young individuals, but these measures may inadvertently overlook potential benefits for adult smokers seeking alternatives. Despite these prohibitions, e-cigarette usage among adolescents remains prevalent, exposing them to unregulated products that can have inconsistent nicotine levels and safety standards. Thailand exemplifies a nation with stringent regulations on e-cigarettes, prohibiting their sale and import while enforcing an age limit of 20 years for the sale of other tobacco products. Investigating how young individuals navigate and perceive e-cigarettes in such a restrictive context is essential to mitigating the risks posed by unregulated products. This thesis aims to explore the perceptions, use, and cessation related to e-cigarettes among youth in countries with strict regulations, with a particular focus on Thailand. The research comprises a systematic review and primary research utilising an explanatory sequential mixed-methods design.
The first study is a mixed-methods systematic review that aims to identify, appraise, and synthesise literature on e-cigarette use and views among young people (aged 19 and below) in 31 countries where e-cigarette sale and/or use is banned. Medline, EMBASE, Web of Science, APA PsycINFO, and PubMed were searched for studies published from 2006 to April 2023 that present findings coded to at least one of four key topics about e-cigarettes: 1) prevalence/trend/susceptibility, 2) patterns of use, 3) factors associated with use, and 4) views. No language restrictions were applied. A double screening of 14,983 records was conducted, and citation searching was performed on 1,442 citations. Critical appraisal was conducted using the Joanna Briggs Institute (JBI) Critical Appraisal tools based on different study designs. Data from quantitative and qualitative studies were synthesised separately, using narrative synthesis for quantitative studies and a meta-aggregative approach for qualitative studies. The synthesised qualitative data was primarily used to explain and complement the quantitative findings where relevant. In total, 34 studies met inclusion criteria, representing data from 17 countries between 2015 and 2023. Among these, 32 were quantitative studies, primarily cross-sectional surveys, and two were qualitative. The data suggests that many countries with restrictive regulations observe relatively low rates of youth e-cigarette use. However, a significant number of young people still encounter unregulated e-cigarettes, revealing gaps in regulations and law enforcement. Nevertheless, insufficient studies revealed the vaping trend in this context. Factors associated with increased use included male gender, lower academic performance, smoking, alcohol consumption, drug use, sensation-seeking behaviour, and exposure to online advertising. The predominance of cross-sectional studies, however, limited the ability to establish causal relationships. Harm perceptions of e-cigarettes among youths are mixed but tend to be unfavourable. This review highlights the importance of identifying regulatory gaps and enhancing law enforcement measures to mitigate unregulated e-cigarette use. Additionally, it calls for further research into trends, usage patterns, and perceptions surrounding e-cigarettes to inform effective policy development in this context.
The second study aimed to quantitatively assess e-cigarette use, cessation, and perceptions among young people aged 13-19 in Thailand. The results from a systematic review informed the adjustment of the survey questionnaire. Data were collected using an in-class survey conducted via the online platform JISC, with the researcher administering the survey to students in grades 7-12 from 12 public secondary schools located in the most urban areas of northern Thailand. The fieldwork took place between August and November 2022. Data were analysed using descriptive statistics and multivariable logistic regression. Of the 2,284 respondents, 8.1% were current e-cigarette users, 14.2% had tried e-cigarettes, 6.9% were current cigarette smokers, and 3.5% were dual users. While one-third of non-users were susceptible to e-cigarettes, one-fifth of non-smokers were susceptible to smoking. Most current e-cigarette users vaped infrequently, primarily used pods, tanks, or mods, vaped with friends, and did so at home. Curiosity, stress relief, and flavour enjoyment were the most common reasons for initiating vaping. Half of the current e-cigarette users had attempted to quit, while one-third had no intention to do so. Those who had used e-cigarettes cited perceived harm, legal regulations, and unenjoyable flavours as reasons for quitting. These products were also perceived as accessible similarly among different young groups, with most users accessing products online. Overall, most respondents had unfavourable perceptions of e-cigarettes. However, susceptible, current, and former e-cigarette users were more likely than non-susceptible non-users to perceive e-cigarettes and second-hand aerosol as harmless/ little harmful, helpful for quitting smoking, and either equally or more harmful and addictive than cigarettes. Current users without the intention to quit were also more likely to perceive e-cigarettes as harmless/ little harmful and as aids for quitting smoking. This study indicates the importance of reinforcing law enforcement to limit youth e-cigarette access. While regulations on e-cigarettes may shape youth perceptions in ways that differ from existing evidence, this study highlights that addressing certain beliefs about the harms and benefits of e-cigarettes may help discourage initiation, reduce continued use, and promote cessation.
The third study qualitatively explored e-cigarette use, cessation, and perceptions to help explain the findings of the quantitative study. An interview guide was designed and navigated by the initial findings of the quantitative study. Online semi-structured interviews were conducted with 25 current and former e-cigarette users, drawn from the survey participants, between November and December 2022. The data were analysed using the framework and thematic analysis, identifying five key themes: e-cigarette initiation, patterns of use, cessation and reduction, intentions for future use, and perceptions of e-cigarettes. The findings suggest that although e-cigarettes are illegal in Thailand, enforcement is lax, making access easy and possibly easier than cigarettes. Most participants were first offered e-cigarettes by friends, with online shops being the primary commercial source. Peer influence played a significant role in the initiation, access, continuation, and relapse of e-cigarette use, while perceptual, parental, social, and legal factors influenced patterns of use, such as concealing behaviour and motivations for quitting. Barriers to successful cessation included socialisation, stress, heavy dependence, and appealing flavours. Most participants perceived the harmfulness of e-cigarettes, particularly to the respiratory and nervous systems, and perceived them as equally or more harmful and addictive than cigarettes. However, despite knowing that their e-liquids contained nicotine, many were unaware of its addictive properties. This study reinforces the importance of strengthening law enforcement to limit youth access to e-cigarettes, particularly online. Consistent and uniform enforcement of e-cigarette bans and minimum age sales laws for tobacco products should be ensured to minimise unintended consequences related to product accessibility. It also emphasises the need to consider perceptions of harm and benefits, along with social and environmental factors, when designing prevention and cessation interventions.
Overall, these findings suggest that while regulatory bans may have a certain effect on youth e-cigarette use to some extent, bans alone are relatively ineffective without robust enforcement and a wide range of prevention efforts addressing perceptual and social factors. Furthermore, with the ban being weakly enforced, the illegal market of e-cigarettes is widely accessible to young people. It is still unclear whether the benefits of reducing youth e-cigarette use through bans outweigh the negative impacts associated with the lack of regulation in the illegal e-cigarette market. It is also unclear what role e-cigarettes play in smoking patterns among youth and their overall nicotine consumption in this context. Future longitudinal research on the public health impact of e-cigarette use on smoking is required.
Item Type
ethesis
Thesis Type
PhD
Subjects (LC)
Associated Schools / Departments
School of Medicine
eprints ID
81018
UoN Repository URI
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Examined. This is the revised thesis with minor corrections addressed.
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