Exploring initiation process and cultural identity towards young adult vapers in China: a qualitative study

doi:10.21203/rs.3.rs-3203792/v1

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Exploring initiation process and cultural identity towards young adult vapers in China: a qualitative study

https://doi.org/10.21203/rs.3.rs-3203792/v1

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Background

E-cigarette(EC) communication with conflicting views significantly shapes young people's knowledge and attitudes, which are precursor predictors of their usage behavior. This study aims to explore the experiences and perspectives on ECs from young adult vapers in China, especially in terms of culture.

Methods

Based on narrative analysis approach, this paper conducted one-on-one interview and focus group with 43 young adult vapers from China to understand their EC usage behavior and cultural understanding. Combined with the narrative analysis framework of the problem-solving approach, data were analyzed using thematic analysis, to develop themes related to EC usage.

Results

Three themes about e-cigarette usage behavior among the youth were presented: (i)e-cigarette initiation process and use patterns, (ii) temporal orientations to risks and benefits, and (iii) self-construction of individuals and relationships. The latter two are about the young adult vapers’ cultural understanding of EC.

Conclusion

Single and dual users have similar initiation processes in general, but have different behavioral structures in detail. Factors such as motivation and experience with traditional cigarettes should be considered for both when tailoring health messages. The cultural factors regarding time orientation and self-construation will provide support for message tailoring and behavioral intervention to young adult vapers.

young vaper

E-cigarette

initiation process

cultural identity

E-cigarettes (ECs), as the low-risk alternative to traditional cigarettes, were promoted around the world, and their popularity is rapidly increasing.[1] Because of their easy concealment, high nicotine content, and availability of various flavors, Electronic Nicotine Delivery Systems (ENDS) products are particularly likely to attract young people for using.[2] In China, surveys by the Chinese Center for Disease Control and Prevention showed that 3.6% and 2.5% of middle school students and college students are using EC in 2021.[3, 4] Although ECs were an important smoking cessation aid in adults, concerns about their potentially negative consequences have been raised, such as encouraging youth to start smoking, and prolonging the use of tobacco products by smokers who want to quit.[5] This leads to the increase of young vapers, who are more likely to become dual users, thus prolonging nicotine addiction and increasing health risks.[6] Conflicting views about EC may shape ambiguous perceptions and attitudes about the use of e-cigarettes among the public, especially for young people, which are predictors of (dis)engaging in their health behaviors.[7]

Culture is a critical element that cannot be ignored and can shape an individual's understanding of health and illness by influencing health perceptions and health practices[8]. And it has been confirmed in studies related to diseases and health behaviors such as asthma[9], cancer[10], and life quality[11]. Meanwhile, narratives provide insight into the connections between micro-level stories of personal experience and macro-level cultural values and ideologies to uncover individual members' particular cultural understandings of illness and health issues.[12]

A premarket tobacco product application guidance of ENDS from the Food and Drug Administration (FDA) recommends that applications incorporate evaluations of use behavior among current ENDS users, nonusers, and other tobacco product users, such as intention, initiation, switching behavior, cessation, and dual-use [13]. Although the antecedents and consequences of youth e-cigarette use have been studied extensively and mostly in quantitative surveys[14–16], serving it as a developmental process has rarely been examined, particularly for Chinese youth. This study defines EC usage as an interactive process, examines the causes, contexts, and subsequent outcomes of young adult vapers, and depicts the entire process.

Therefore, this study aims to explore the (i) initiation process, and (ii) sense-making of ECs by different young vapers (single users vs. dual users), especially in terms of culture. Also, we specifically focused on the differences between single and dual users of e-cigarettes.

Recruitment and data collection

After obtaining review and approval from the institutional review board (IRB), the study recruited participants and data collection in two ways. Survey data were first obtained through one-on-one personal interviews with young adult vapers, and then focus groups were organized to discuss e-cigarettes and their use behavior to confirm the findings. By combining these two methods, data sources can be triangulated to explore the data in-depth, enhance understanding of the study population and context, and increase the credibility of the findings [17].

The participants in personal interviews were recruited on the Internet, and the focus group was commissioned by the tobacco control organization of a university in central China (JXUT) to recruit. Young vapers aged 18–25 who are currently using EC for more than 30 days are eligible and invited to participate in the interview. Interviews were conducted between March to April 2021. With the consent of the interviewees, the interviews were focused on topics: 1) smoking history and current smoking status, including the age of smoking and the number of cigarettes smoked; 2) history of e-cigarette and usage patterns, including frequency of use, situations, etc.; 3) perceptions of e-cigarettes, including health effects, etc.; 4) views of family members, friends, etc. about e-cigarettes; 5) access to information on e-cigarettes, including topics, channels, etc. and recorded and transcribed verbatim after the interviews.

Data Analysis

The data were analyzed using thematic analysis for coding. The codes were generated deductively by examining the data with reference to areas of interest raised in the topic guide, combing with the narrative analysis framework of the problem-solving approach. During the coding process, the stages were continuously compared and integrated until no new concepts, categories, and themes relevant to the purpose of the study emerged to reach a saturation point.

Sample

Table 1 shows the details of all participants (N = 43) who provided qualitative data in this study. Among them, there are more males (N = 26) than females (N = 17). More than half had more than 6 months of experience with e-cigarettes, 11.6% are new vapers (1 month of use), and 24.9% of the sample are heavy vapers (all-day use). 65.1% (N = 28) dual users with experience of traditional cigarettes.

Table 1

Participants information (n = 43)
Characteristics of the participants		N(%)
Gender	Male	26(60.5%)
Gender	Female	17(39.5%)
Age	18–22	28(65.1%)
Age	23–25	15(34.9%)
Education	Bachelor	33(76.7%)
	Master	6(14.0%)
	Other	4(9.3%)
Duration use	1 months	5(11.6%)
	2–6 months	8(18.6%)
	7–12 months	12(27.9%)
	1–3 years	13(30.2%)
	More than 3 years	5(11.7%)
Frequency of daily use	A few times a week	3(7.0%)
	A few times a day	12(27.9%)
	Certain times of the day	13(30.2%)
	All the day	15(24.9%)
Investment in e-cigarette consumption	Less than ¥100	4(9.3%)
	¥101–300	8(18.6%)
	¥301–500	12(27.9%)
	¥501–1000	12(27.9%)
	More than ¥1000	7(16.3%)
Use traditional cigarettes	Yes	28(65.1%)
Use traditional cigarettes	No	15(23.9%)

The 3 themes were the EC initiation process, temporal orientation to risk and benefit, and self-construction of individual and relationship (Table 2). The latter two are about the young adult vapers’ cultural understanding of e-cigarettes. These themes are described below and illustrated using verbatim participant quotations.

Table 2

Summary of themes and subthemes
Theme	Subtheme	Number	Representative quotes
1. E-cigarette initiation process and use pattern	1.1 Characters	18	“I only use e-cigarettes, it's a personal thing for me.” (P01-S) “In my daily life, I smoke traditional cigarettes significantly more often than I smoke e-cigarettes. E-cigarettes can only be a substitute.” (G02-3D)
	1.2 Setting	12	“A classmate who smokes e-cigarettes recommended it to me, and I tried a few puffs with him in the bathroom.” (G02-5S) “People around me have switched from traditional cigarettes to e-cigarettes, so I followed suit.” (P09-D)
	1.3 Problem	9	“My roommate brought a new gadget that didn't smell like smoke, it is novel.” (G03-4D) “Traditional cigarette users use e-cigarettes as an aid to quit smoking.” (G02-6D)
	1.4 Actions	15	“I feel tight and bloated in my chest after smoking e-cigarettes.” (P14-D) “I smoke e-cigarettes a lot because it's convenient. I can take it out anytime and anywhere and take a few puffs.” (G04-5D) “It tends to 'plug the smoke'. Oil leaks are also a nuisance.” (G03-5D)
	1.5 Resolution	6	“The first time I tried smoking after feeling quite fun, and then I bought one myself. Gradually I began to smoke electronic cigarettes every day.” (G02-5S)
2. Temporal orientations to risk and benefit	2.1 Future-oriented risk avoidance	13	“E-cigarettes, as a new thing, still have many potential risks with the addition of many artificial chemical ingredients.” (P06-D)
2. Temporal orientations to risk and benefit	2.2 Present-focused benefit acquisition	10	“Now after using it, I find it is convenient, environmentally friendly and now most people can accept it.” (P15-S)
3. Self-construction of individual and relationship	3.1 Self-satisfaction dominated by personal needs	22	“Smoking e-cigarettes not only because it feels cool, but also feel very 'comfortable'.” (G02-5S)
3. Self-construction of individual and relationship	3.2 Compliance with norms dominated by social relationships	19	“When I'm going to use an e-cigarette, I usually ask people if they mind. After all, I don't want to be disliked by others.” (G01-1D)

Themes 1: E-cigarette initiation process

Although youth are the primary group of vapers, the initiation processes of EC between single users and dual users are different. Two maps(Fig. 1–2) were drawn to show the process of acceptance and use of e-cigarettes for each of the two characters.

Figure 1 shows the initiation process of EC by single users. As shown in the figure, single users are usually introduced to EC by peers and driven by popularity. They view EC as a cool, novel, and trendy product, and begin to be aware of and use based on their curiosity. They are more concerned about the benefits in terms of self-regulation and entertainment, and the barriers due to product quality problems. After a comprehensive assessment of EC in terms of risk perceptions, benefits, and barriers, they make the decision to accept and continue using it.

Figure 2 shows the initiation process for dual users. As shown in the figure, dual users are introduced to EC in the same setting as single users. However, dual users sever e-cigarettes as an aid to replace traditional cigarettes to quit smoking. Of the participants, 78.1% (N = 25) are traditional cigarette users who turn to dual users. Due to their experience with traditional cigarettes, they consistently made comparisons and references to traditional cigarettes in their assessment of EC. As a result, they are more concerned with the perceived benefits of smoking cessation and health improvement, and more concerned with the perceived barriers to negative e-cigarette experiences and health consequences. Similarly, dual users decide to continue to use e-cigarettes or use them as an alternative to traditional cigarettes in their daily lives after a comprehensive evaluation.

Themes2: Temporal orientation of risk and benefit

As health behaviors typically involve immediate and delayed cost and benefit issues, temporal orientation has become an important temporal perspective for health decision-making research. Cultural understanding related to temporal orientation also is associated with young adults' experiences of EC, specifically in terms of (i) future-oriented risk avoidance, and (ii) present-focused benefit acquisition.

Future-oriented risk avoidance

Individual differences in the extent to which individuals consider the short or long-term consequences of health behaviors represent not only a future orientation but also a cognitive mindset, which is defined as consideration of future consequences (CFC).[18] Future-oriented risk avoidance was found in responses of young adults for EC risk. As noted earlier, ECs remain controversial in health communication as a new tobacco product. As a result, a strategic tendency to avoid the potential future risks of EC is adopted by young adults, which affects their long-term use of EC. For example, dual users compared the hazards of e-cigarettes with traditional cigarettes.

"EC is a new thing with many potential risks. I don't want to be a daredevil and try something I can't foresee what the consequences will be....there are no worse outcomes about using cigarettes like father's generation."(G02-4D)

Dual users, in particular, have a clearer understanding of the hazards of traditional cigarettes due to their experience, and they have a higher baseline for risk perceptions of traditional cigarettes. Thus, compared to traditional cigarettes, an avoidance strategy was in consideration of the future consequences of e-cigarettes. The reason is that dual users are uncertain about the risks of e-cigarettes and are unwilling to assume the potential risks.

Present-focused benefit acquisition

Such a psychological phenomenon in which an individual's assessment of the value of an event decreases with time is called temporal discounting,[19] and it is frequently found in judgments and decisions about health behaviors. Young adult vapers are also engaged in temporal discounting of benefits in e-cigarette use, specifically focusing on present benefit acquisition. Through interviews, many attributes about EC that attracted youth were we identified, particularly the benefits. These benefits include sensory gratification, concealed smoking, low cost, and convenience. Most of these are the immediate consequences of e-cigarettes, which satisfy various needs of young adult vapers, and somewhat promote their e-cigarette usage. For example, a single user described his reasons for using e-cigarettes.

"The smoke of EC will not be rejected by all. Some people even like the light flavor. I can take a puff at any time on many occasions, so convenient ..... So many boys and girls are vaping and feel cool."(G04-3S)

Single users, especially, place a high value on temporary needs and gratification as they have just tried smoking and do not have negative experiences with smoking. Coupled with the popularity of EC in the neighborhood, their discounting of the immediate benefits of EC is more pronounced and potentially amplifies it.

Themes 3: Self-construction of individual and relationship

Self-construction is viewed as a cultural orientation and variable at the individual level and is used to understand cultural influences on social behavior.[20] It is viewed as cultural orientation and variable at the individual level and used to understand cultural influences on social behavior.[20] Corresponding to individualism and collectivism, there are two different ways of self-construction, namely independent self-construction and interdependent self-construction.[21] Different self-construction regarding EC usage among young adult vapers resulted in their behavior, which was specified as (i) self-satisfaction dominated by personal need, and (ii) compliance with norms dominated by social relationship.

Self-satisfaction dominated by personal need

Individuals with independent self-construction are characterized by supporting internal attributes and value personal goals and interests.[22] They differentiate themselves from others and place greater emphasis on their unique personal attributes when expressing themselves in public.[23] Youth vapers presented an independent self-construction in EC usage to satisfy their respective individual needs. Specifically, they were more concerned with the immediate benefits, such as relieving sudden smoking cravings and emphasizing the cool feeling of EC. However, they are influenced by the social norms of family and friends, even if the influence is limited, and tend to continue using ECs despite family opposition. A single user described his feelings about using ECs.

" ......after vaping, like floating in the clouds...... When the craving comes, you can take a puff at any time and place, such as when playing games, going to the toilet, bed ...... Although my parents have reprimanded me several times for it, I still use them secretly."(P10-S).

Significantly, independent self-construction is more evident in the usage of EC by single users. Due to the higher social acceptance of EC flavors, single users can pay less attention to the limitations and implications of the surroundings regarding their use of ECs and focus on satisfying their personal needs.

Compliance with norms dominated by social relationship

Individuals with interdependent self-construction usually maintain harmony among group members by developing intimate relationships.[22] They pay more attention to each other's views and opinions and adopt appropriate behaviors.[23] Young adult vapers similarly value social relationships and conform to social norms when vaping to fit in with the group, presenting a self-construction characterized by collectivism. Specifically, they placed more importance on long-termly, collective interests and emphasized rational cognition and judgment about EC. Meanwhile, they are more influenced by social norms and prioritize the issue of secondhand smoke and EC acceptance. A dual user explained some of his concerns about using EC.

"I usually ask people nearby if they would be bothered. Especially when there are women and children present ...... some scientific information believes that long-term use of ECs can also be harmful to the body, but less than traditional cigarettes."(P16-D).

Thus, it is apparent that young adults are consciously concerned with social relationship during their use of the EC, especially dual users. As noted above, dual users consistently compare and refer to traditional cigarettes when using EC. As a result, dual users have to consider the taboos and norms related to traditional cigarette use to better integrate into the group and maintain rapport.

This study analyzed young adult vapers' views related to EC and examined "how they accept and use EC". Analysis of this study revealed that young adult vapers in different characters (single user or dual user) have different initiation processes, and that present specific cultural identities in terms of temporal orientation and self-construction.

Specifically, single user and dual user have similar usage patterns in general but have different behavioral structures in the EC initiation process in detail. First, in terms of use patterns, both are exposed to ECs through peer recommendations or influenced by popular trends; subsequently, they make resolutions after a comprehensive assessment of the perceived risks, benefits, and barriers. However, single users and dual users have different biases in their motivations for use: the former is motivated by curiosity, while the latter is motivated by quitting smoking. Significantly, since dual users have experience with traditional cigarettes, comparison with traditional cigarettes was in their comprehensive evaluation of ECs constantly. Factors associated with the use of e-cigarettes have been examined, which refer to the individual level, the interpersonal level, and the social and policy level.[24] Findings in this study regarding the reasons and scenarios of EC use among young adult vapers largely cover those that have emerged from established relevant surveys and literature. [25, 26]

Furthermore, single users and dual users have different biases in their motivations for use: the former is motivated by curiosity to engage with e-cigarettes, while the latter is motivated by quitting smoking. As a result, they differ in the outcome and degree of need satisfaction of e-cigarettes, which in turn leads to different biases in risk perception, benefit perception, and barrier perception. Previous studies have shown that dual users have less positive attitudes toward e-cigarettes than single users [27] and fewer risk perceptions towards e-cigarettes [28], which is consistent with the findings of this paper.

Significantly, since dual users have experience with traditional cigarettes, comparison with traditional cigarettes was in their comprehensive evaluation of e-cigarettes constantly. When the experience of e-cigarettes meets the dual users' motivational expectations for quitting smoking, they will continuously use e-cigarettes as an aid to quit smoking; when it does not, e-cigarettes are treated as a substitute for traditional cigarettes and used when traditional cigarettes are restricted. Therefore, it is clear that motivation and experience with traditional cigarettes may be important factors to consider when tailoring information to e-cigarette users.

Temporal orientation can be used as an individual characteristic to predict a variety of health-related beliefs, attitudes, and intentional behaviors. Single users focused more on EC access to their present benefits, while dual users placed more emphasis on future risk avoidance. Established research demonstrates that individuals with low CFC will focus more on immediate needs and concerns; whereas high CFC will focus more on the future impact of their behavior and act accordingly.[29] This is consistent with our investigation that dual users have a higher level of consideration for future negative consequences compared to single users. The reason for this may be that dual users have experience with traditional cigarettes and already have a baseline of the harms of smoking. Meanwhile, their experience with ECs does not meet demand expectations. As a new tobacco product, ECs also have multiple uncertainties and are associated with unnatural factors, leading to EC becoming an alternative to traditional cigarettes for them. Thus, persuasive messages for dual users should place more emphasis on the potential uncertainty of e-cigarette risks; while, for single users should weaken the temporary benefits of EC and strengthen the immediate risks, such as e-cigarettes are not fashionable and may bring safety hazards. Therefore, health communication for dual users should make clear that EC have the same restrictions on use scenarios as traditional cigarettes, and emphasize their impact and harm to others and the surroundings.

Scholars argued that independent and interdependent self-constructions coexist within the same culture and individual [30] and varied across individuals and contexts.[31] Young adult vapers with independent self-construction will have higher self-efficacy and are more likely to resist smoking compared to others, which is consistent with the findings of this paper. Single users were more concerned with personal need satisfaction than with the impacts of the behavior on others and the harms of long-term EC usage; the opposite consideration was true for dual users. Social norms regarding traditional cigarettes were transferred to ECs for dual users compared to single users. As a result, the dual users had a biased interdependent self-construction. They are group-integration oriented and more concerned about their surroundings and collective interests.

The validity of message tailoring is moderated and constrained by factors such as context and requires formative research [32] or relies on the researcher's cultural prior knowledge of the target group [33]. While the antecedents and consequences of EC behavior have been explored, this study unified these factors and defined EC usage as an interactive process that analyzed the causes, contexts, and consequences of young adult vapers’ behavior. It also depicted the initiation process of young adult EC usage and compared the similarities and differences in patterns and behavioral structures between single and dual users. This study also identified cultural identities in young adult vapers’ EC usage in terms of temporal orientation and self-construction. These cultural factors will facilitate group distinction and message tailoring in persuasion campaigns and improve the effectiveness of health education and interventions.

Limitations and future research

There are, of course, some limitations to this study. The sample for this study was primarily drawn from young adults, and the results do not include the voices of adolescent vaper groups regarding EC. To some extent, this limits the generalization of the study's findings, and it is only appropriate for health practices with tobacco control messages tailored to young adults. In addition, the impact of focus groups can lead to and result in potential bias in the results. While focus groups have their advantages, participants may share more or feel more comfortable if a traditional interview is used.

The finding of different initiation processes for single and dual users among young adult vapers of ECs highlighted the importance of understanding differentiated behavioral structures. Factors such as motivation and experience with traditional cigarettes should be considered for both when tailoring health messages. Moreover, the cultural factors regarding time orientation and self-construation that were detected in this paper, deepened the understanding of the behavior of e-cigarette use among young adults, particularly the cultural aspects. This will provide support for incorporating these cultural factors into behavioral intervention.

EC: E-cigarettes; ENDS: Electronic Nicotine Delivery Systems; CFC: Consideration of Future Consequences

Acknowledgments

I would like to express my great appreciation to the anonymous reviewers for their constructive feedback in the peer review process, and all participants interviewed by the authors.

Authors’ Contributions

All work for this study was completed by JZ. The author has read and approved the final manuscript。

Funding

This work was supported by the Fundamental Research Funds for the Central Universities, Zhongnan University of Economics and Law [Grant number:2722023BQ040].

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was approved by the ethical review board of Wuhan University. All participants provided written informed consent prior to participation.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All work for this study was completed by JZ. The author has read and approved the final manuscript。

Author details

^1*School of Journalism and Culture Communication, Zhongnan University of Economics and Law, 182# Nanhu Avenue, Wuhan, China, 430073

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No competing interests reported.

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Exploring initiation process and cultural identity towards young adult vapers in China: a qualitative study

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Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Recruitment and data collection

Data Analysis

Results

Sample

Themes 1: E-cigarette initiation process

Themes2: Temporal orientation of risk and benefit

Future-oriented risk avoidance

Present-focused benefit acquisition

Themes 3: Self-construction of individual and relationship

Self-satisfaction dominated by personal need

Compliance with norms dominated by social relationship

Discussion

Limitations and future research

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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