The prevalence and predictors of vaping quit attempt among electronic cigarette users: findings from provincial version of Global Adult Tobacco Survey 2020 in Vietnam

Abstract

Background

Electronic cigarette (e-cigarette) quit attempts among users have been a topic of increasing focus in high-income countries, but limited research exists in low- and middle-income countries (LMICs). This study aimed to determine the prevalence of e-cigarette quit attempts and investigate associated factors among e-cigarette users in a sample of 34 provinces in Vietnam.

Methods

A country-specific provincial version of the Global Adult Tobacco Survey was conducted in 34 provinces of Vietnam in 2020 (n = 80,166). Among 557 current e-cigarette users (288 exclusive users and 269 dual users of e-cigarettes and conventional cigarettes) aged 15 years and above, sociodemographic characteristics, smoking-related variables, reasons for e-cigarette use, and motivations to quit e-cigarettes were assessed. Logistic regression models were employed to analyze the relationships between these factors and e-cigarette quit attempts.

Results

Among e-cigarette users, 46.1% had made a quit attempt within the past 12 months, with 50.0% among exclusive users and 41.8% among dual users of e-cigarettes and combustible cigarettes. Perceiving e-cigarette use as more harmful than smoking cigarettes was associated with a higher likelihood of making an e-cigarette cessation attempt. Notably, smokers who had previously been unsuccessful in quitting cigarette smoking using e-cigarettes had a higher likelihood of quitting e-cigarettes. Conversely, using e-cigarettes as an alternative tobacco product when unable to smoke cigarettes was associated with a lower likelihood of attempting to quit e-cigarettes. The most common reasons for wanting to quit e-cigarettes included perceiving e-cigarettes as more harmful than combustible cigarettes, their cost, and friends’ or family members’ disapproval of e-cigarettes.

Conclusion

This study provides novel information on the prevalence and factors associated with e-cigarette quit attempts among e-cigarette users in Vietnam. The findings highlight the importance of harm perception, cost, and social influence in motivating individuals to quit e-cigarettes.

Introduction

Electronic cigarette (e-cigarette) use (or vaping) has increased globally in recent years [1]. Marketed explicitly or implicitly as a reduced-harm nicotine alternative and as a smoking cessation aid, e-cigarettes have attracted considerable attention from youth and young adults, as well as adult smokers [2]. Whereas much research attention has been directed at the impact of e-cigarettes on smoking cessation [3], less attention has been given to factors associated with quitting e-cigarettes, despite a few recent studies suggesting that many users want to quit vaping [4, 5]. In the US, the data from the Population Assessment of Tobacco and Health (PATH) Wave 4 survey (December 2016 – January 2018) showed that 60.7% of adult e-cigarette users planned to eventually quit vaping and 15.2% had made a past-year quit attempt [4]. In Europe, 13.9% had tried to quit using e-cigarettes, and 25.2% were planning to quit in the near future [6]. Other studies focusing on adolescents and youth showed a higher prevalence of quit attempts, ranging from 43% to 67.4%, and intention to quit, ranging from 53.4% to 76% [5, 7,8,9]. These studies have also explored the underlying reasons and factors contributing to vaping cessation attempts. Perceived harm of e-cigarettes and reasons for e-cigarette use (i.e., including trying to quit other tobacco products, using them unnoticed at home or school and being curious about them) were related to cessation behaviors among adolescents [5]. Among current JUUL users (i.e., those who reported past- 30-day JUUL use), lower intensity of use (i.e., pod finished in ≥ 1 month) was associated with higher odds of short- and long-term quit attempts, but JUUL device owners were less likely to report short- and long-term quit attempts compared to those who did not own the device [9]. Investigation of the putative drivers of e-cigarette quitting can shed light on the motivations and obstacles surrounding vaping cessation and provide valuable insights for the development of effective cessation strategies and interventions.

Research on vaping cessation has been limited and primarily focused on high-income countries, leaving a significant gap in our understanding of vaping cessation in low- and middle-income countries (LMICs) where there is a coexistence of high combustible tobacco prevalence and a rising trend in the use of new tobacco and nicotine products [10]. The economic, cultural, and political contexts in these countries may differ from high-income countries, which may influence vaping cessation behaviors.

In Vietnam, an increasing trend of e-cigarette use has been observed. According to the Vietnam Global Adult Tobacco Survey (GATS) conducted in 2015, the national prevalence of e-cigarette use was 0.1% [11]. Another previous study conducted in 2020 found the prevalence of e-cigarette use among Vietnamese youth was 2.4% [12]. However, another report in 2020 highlighted a significant increase in e-cigarette use, revealing a prevalence of 12.6% among adolescents in Hanoi (the capital city) in 10–12 grade students [13]. While curent data on e-cigarette use among adults in Vietnam is scarce, it suggests an upward trend. Additionally, there is qualitative evidence that dual use (i.e., the use of both combustible cigarettes and e-cigarettes) is becoming more common [14]. While a previous study demonstrated that 48% of young adults attempted to quit e-cigarettes [12], the data on the adult population is limited, particularly as around half of Vietnamese e-cigarette users are middle-aged, and no prior studies examine the difference between single use and dual use of e-cigarettes. Given the scarcity of data on vaping quit behaviors in LMICs, this study aimed to examine the prevalence of vaping quit attempts in both exclusive and dual users of e-cigarettes in a sample of 34 provinces in Vietnam. Additionally, we also aimed to investigate factors associated with vaping quit attempts, which has not been done in the previous study.

Methods

Study sample and data collection

A Vietnam country-specific provincial version of the GATS (Vietnam PGATS) was conducted from August to December 2020 in 34 out of 63 provinces/cities in Vietnam by the Vietnam Tobacco Control Fund—Ministry of Health and Hanoi University of Public Health, with technical support from WHO and 34 Provincial Centers for Disease Control. While the original plan was to collect data from all provinces, the COVID- 19 pandemic caused delays. The remaining provinces/cities conducted the PGATS survey in 2022. This cross-sectional survey followed standardized approaches for questionnaire design, data collection, data management, and ethical considerations, which were consistent with GATS guidelines. Study participants in this survey were Vietnamese male and female citizens aged 15 or older.

In each province/city, 2400 individuals (1200 males and 1200 females) were randomly selected (See the supplemental file for the description of the sample size calculation for this study). Administrative units were categorized based on economic status, and one city/town and two districts with medium and underdeveloped economic status were chosen using simple random sampling. Within each city/town, the survey team randomly selected two communes, with 600 households chosen from these communes (300 households each). For districts with medium and underdeveloped economic status, 900 households were randomly chosen from three communes using a simple random sampling method. The interviews were conducted by provincial and local CDC (Centers for Disease Control and Prevention) staff, who received comprehensive training in data collection and interview techniques. Interviewers visited each household in the sample frame, inviting one member aged 15 or older to participate in the survey. All interviews were conducted face-to-face in Vietnamese using Android tablets or smartphones with the REDCap (Research Electronic Data Capture) data entry form. More detailed information has been previously published [15]. Among a total of 80,166 Vietnamese individuals aged 15 and above participated in PGATS, our final analytic sample included 557 current e-cigarette users.

Measurement

Current e-cigarette use was defined as persons responding “daily” or “less than daily” to the question: “Do you currently vape e-cigarettes?” Vaping quit attempt was measured by the question “In the past 12 months, have you ever tried to quit vaping?” and the responses were “yes” or “no”.

Individuals who were smoking cigarettes either daily or less than daily at the time of the survey were categorized as current smokers, whereas those who had previously smoked cigarettes but were not currently smoking were classified as former smokers and those who had never smoked cigarettes were identified as never smokers. Among cigarette smokers, the heaviness of smoking index was calculated as the sum of the scores for two components: 1) time to the first cigarette upon waking (within 5 min: 3 points, 6–30 min: 2 points, 31–60 min: 1 point, and after 60 min: 0 points), and 2) number of cigarettes smoked in a day (10 or fewer: 0 points, 11–20: 1 point, 21–30: 2 points, and 31 or more: 3 points). The sum scores were categorized into three levels of nicotine dependence: low (0–2 points), medium (3–4), or high (5–6 points) [16].

Current users of e-cigarettes who also reported currently smoking combustible cigarettes were defined as dual users, whereas those who reported never or formerly smoking were classified as exclusive e-cigarette users.

Reasons for using e-cigarettes were assessed with a yes–no question that allowed e-cigarette users to select multiple reasons, including: (1) to quit smoking, (2) to avoid relapsing into smoking, (3) liking the product, (4) being addicted to the product, (5) using it as an alternative to tobacco when unable to smoke cigarettes, (6) perceiving it as less harmful than cigarette smoking, (7) enjoying the flavor, (8) friends and family members using it, (9) avoiding secondhand smoke exposure for others, and (10) finding it less smelly than combustible cigarettes. The expense of e-cigarettes within the last 30 days was assessed using the question, “In the last 30 days, how much did you spend on e-cigarette use (VND)?” and then categorized into quartile groups (Q1-lowest, Q2, Q3 and Q4-highest). Additionally, participants were asked about their perceptions of the relative harm of e-cigarettes compared to combustible cigarettes and could respond with options: e-cigarettes being less harmful, about the same, more harmful than combustible cigarettes, or ‘don’t know’. Sociodemographic characteristics were measured, including age group (15–24, 25–34, 35–44, or 45 + years old), sex (male or female), educational level (primary school or lower, secondary school, high school, or college/university or higher), residential area (rural or urban), and occupation status (employed, freelance, or not be employed including housewife/student/retired/unemployed).

Statistical analysis

Quit attempt prevalence was assessed by weighted percentages by user groups (dual users and exclusive users) and personal characteristics. Chi-square tests were employed to evaluate sociodemographic differences between user groups. A multiple logistic regression model was utilized to evaluate the association between sociodemographic factors and quit attempts. Multiple logistic regression analyses, adjusted for sociodemographic characteristics, were conducted to examine the association between reasons for e-cigarette use, smoking-related variables, e-cigarette expense, and quit attempts. Participants with missing data on vaping quit attempt were excluded from analysis. We used cross-sectional sampling weights to account for uneven representation in given age groups and regions. The data analysis was performed using STATA software (Version 17). p < 0.05, two-tailed, was considered to be statistically significant.

Ethics

The study obtained ethical approval from the Institutional Ethical Review Board at Hanoi University of Public Health (Approval number 318/2020/YTCC-HD3). Informed consent was obtained from all participants, and measures were taken to ensure the confidentiality and anonymity of the participants when reporting the results. For youth aged 15 to < 18 years old, parental informed consent was obtained, and interviews were conducted at their homes.

Results

Table 1 presents the sociodemographic characteristics of the study population. The majority of e-cigarette users were males (88.8%). Most were aged 34 years and below (81.5%), resided in urban areas (60.6%), had attained a high school education or higher (56.0%), and worked as freelancers (65.3%). In comparison to dual users of combustible cigarettes and e-cigarettes, exclusive e-cigarette users were more likely to have a higher educational level (p = 0.01). Among e-cigarette users, 46.1% had made a vaping quit attempt within the past 12 months, with 50.0% for exclusive users and 41.8% for dual users (p = 0.33).

Table 1 Participant sociodemographic characteristics, overall and by dual-use status

As shown in Table 2, none of the sociodemographic factors were significantly associated with quit attempts. Table 3 displays the results of logistic regression models for vaping quit attempts separately for exclusive users and dual users. In both dual users and exclusive users, the perceived harmfulness of e-cigarettes relative to cigarettes was significantly associated with making a quit attempt. In particular, e-cigarette users, regardless of smoking status, who perceived e-cigarettes as either more harmful or equally harmful compared to combustible cigarettes had 2 to 3 times higher odds of making a quit attempt, compared to those who perceived e-cigarettes as less harmful. For dual users, using e-cigarettes to quit smoking was positively associated with vaping quit attempts while liking e-cigarettes, using e-cigarettes as an alternative, and perceiving e-cigarettes as less harmful than cigarettes were negatively associated with vaping quit attempts. Supplemental Table 1 shows the predictors of vaping quit attempts among exclusive users by smoking status. For exclusive e-cigarette users who formerly smoked, using e-cigarettes to quit smoking, and being addicted to e-cigarettes was positively associated with vaping quit attempts while liking e-cigarettes, and perceiving them as less harmful than conventional cigarettes were negatively associated with vaping quit attempts. The wide confidence interval suggests that few former cigarette smokers used e-cigarettes to quit smoking (n = 30). Whereas no factors significantly associated with vaping quit attempts among exclusive users who never smoked.

Table 2 Sociodemographic factors associated with vaping quit attempts

Table 3 Smoking and e-cigarette factors as predictors of vaping quit attempt by dual-use status

Table 4 presents the motivations to quit vaping among e-cigarette users who made a quit attempt. The findings indicated that the most prevalent reasons for quitting e-cigarettes were the cost of e-cigarettes (52.0%) and their perceived harm (44.3%), followed by opposition from friends and family members towards vaping (24.2%).

Table 4 Motivations for quitting vaping among e-cigarette users who made quit attempts

Discussion

Limited research has been conducted on vaping cessation attempts among e-cigarette users, and the existing studies have primarily focused on high-income countries [4,5,6,7,8,9, 17,18,19]. This study provided insight into the prevalence of e-cigarette cessation attempts and its associated factors in LMICs. Our findings indicate that among our sample, nearly half of Vietnamese current e-cigarette users attempted to quit vaping within the last year, which was higher than the rates reported in previous studies on Western populations. For instance, a study by Hobkrik et al. conducted in the United States among 301 JUUL users reported that only 22.6% had made a lifetime quit attempt [18]. Another study by Palmer et al. found that 15.2% of adult e-cigarette users in the US reported making past-year quit attempts [4]. In studies conducted in European countries, less than 15% of e-cigarette users had attempted to stop vaping [6, 19]. Further investigation of vaping quit attempts, including situational and contextual factors influencing vaping cessation, among Vietnamese adolescents is urgently needed to guide the development of tailored prevention and cessation programs.

Previous studies have also reported relatively high rates of unsuccessful attempts to quit vaping [17, 19], indicating the challenges in the vaping cessation process. Previous evidence suggests that e-cigarette users often make multiple quit attempts in the process of quitting vaping [4, 7]. This aligns with the common observation that most smokers often need multiple quit attempts before achieving long-term smoking abstinence [20]. Further research with a longitudinal design is necessary to gain a comprehensive understanding of the nature of these quit attempts, the effectiveness of different cessation methods, and the success rate of vaping cessation.

Our study found that perceiving e-cigarette use as equally or more harmful than cigarettes was associated with a higher likelihood of attempting to quit vaping. This perception was also a motivating factor for over half of e-cigarette users to quit vaping, which is consistent with findings from previous studies from other countries [17, 21, 22]. Related, we found that using e-cigarettes because of perceiving e-cigarettes as less harmful than combustible cigarettes could discourage smokers from quitting vaping. Other research has been conflicted on this association [5, 9]. In Vietnam, recent media coverage, including newsletters from the Ministry of Health and national television broadcasts, have highlighted the adverse effects of using e-cigarettes and emphasized that they are not free from hazards, posing risks such as nicotine addiction, respiratory injury, cardiovascular diseases, metabolic syndrome, and other tobacco-related illnesses [23]. Furthermore, the Ministry of Health in Vietnam does not recognize e-cigarettes as less harmful products with low health risks and has proposed a ban on all emerging tobacco products, including e-cigarettes [24]. These factors may contribute to increased perceptions of harm among e-cigarette users and potentially lead to a higher prevalence of vaping quit attempts than Western populations.

Interestingly, our study found that dual users who were using e-cigarettes to quit smoking were more likely to attempt to quit vaping than dual users who were using e-cigarettes for other reasons. This might be attributed to the fact that e-cigarettes have not achieved the desired results in quitting smoking, leading them to attempt to quit vaping. This hypothesis is supported by findings from the 2016 ITC four-country smoking and vaping survey, which revealed that many smokers started using e-cigarettes with the expectation that they would help in cutting down or quitting smoking, but ultimately discontinued their uses due to their unhelpfulness in reducing cravings and quitting smoking [25]. However, in another study among youth in the US, attempting to quit using other tobacco products, such as cigarettes, by using e-cigarettes was not associated with an e-cigarette quit attempt [5]. It might be the aforementioned messaging by the Vietnamese government regarding the relative harms of e-cigarettes in comparison to cigarettes combined with smokers’ dissatisfaction with e-cigarettes as a smoking cessation aide that explains our finding and its contrast to the US study. On the other hand, exclusive e-cigarette users who formerly smoked were more likely to attempt to quit vaping if they had used e-cigarettes to quit smoking. This may be because they successfully quit smoking with the help of e-cigarettes and no longer feel the need to use them. The wide confidence interval suggests that few former cigarette smokers used e-cigarettes to quit smoking.

Additionally, our study showed that using e-cigarettes as an alternative tobacco product when in situations or places unable to smoke cigarettes decreased the likelihood of attempting to quit vaping. Similar findings were observed in another study where youth reported using e-cigarettes unnoticed at homes or schools, which was associated with lower odds of attempting to quit vaping [5]. Therefore, to promote quitting vaping, smoke-free policies should encompass all types of tobacco products, not just tobacco smoking products.

The expense of e-cigarettes is another motivating factor for e-cigarette users to quit vaping, which is consistent with previous studies [17, 21]. This is particularly relevant in LMICs like Vietnam, where the price of e-cigarettes (ranging from VND 100,000—300,000, equivalent to US$ 4.3–13) is significantly higher than combustible cigarettes (VND 11,800 per pack, equivalent to US$ 0.54) [11], making them less affordable. In our study, the average monthly amount of money spent on e-cigarettes was VND 216,000.

The study has certain limitations. We lacked information on the specific cessation methods employed during quit attempts, the timing or frequency of attempts, e-cigarette dependence, and participants’ future intentions to quit vaping. Another limitation is that the measurement of quit attempts relied on self-report and retrospective recall, which introduces the potential for recall bias. Additionally, the study’s findings are cross-sectional, and therefore, temporal relationships and causal inference are limited. Lastly, the small sample size of exclusive users who formerly smoked and exclusive users who never smoked likely did not provide sufficient power in subgroup analysis.

Conclusion

Vaping cessation attempts were highly prevalent among Vietnamese e-cigarette users. We found that the perceived harm of e-cigarettes and the high cost of e-cigarettes were strong motivators for users to quit vaping. Additionally, unsuccessful smoking cessation attempts using e-cigarettes were associated with a higher likelihood of quitting vaping. These findings highlight the importance of harm perception, affordability, and the need for tailored interventions to support individuals in their efforts to quit vaping.