Rabid Yahya Putradasa, Anshorulloh Abd Fath, Bernie Endyarni Medise, Eldesta Nisa Nabila, Hamzah Pratama Megantara, Muhammad Maulana Wildani, Mutiara Ramadhanty, Nadhira Anindita Ralena
Faculty of Medicine, Universitas Indonesia
E-cigarette poses a new threat to our country, and Indonesia is now in a double burden of tobacco epidemics. Teenagers are prime target of both electronic and conventional cigarette companies. E-cigarette, however, is uniquely tailored to be appealing to this age group, and many publications have demonstrated this. E-cigarettes are novel, and teenagers are novelty-seeking. E-cigarettes also come with teenage-friendly flavours (banana, honey, coffee, etc) in contrast to the bitter, initially unpleasant taste of conventional cigarette. These flavours are perceived to be less harmful by teenagers, while in fact they can be more addicting than the conventionally-flavoured tobacco products.
E-cigarette companies often market their products as safer alternatives than conventional cigarette. In their website, they even often shame cigarette companies and conventional smokers. Furthermore, healthcare providers have not been made aware of the dangers of this new product, and may not be well-equipped to give advice and education about e-cigarette. This inconsistency may confuse teenagers: their logical thinking is still developing, and they might think that because e-cigarettes are safer than tobacco, it is therefore safe to consume e-cigarette. Indeed, the Indonesian Pediatric Associations have deemed that e-cigarette is unsafe to be consumed by children and teenagers of any age.
Thus, this work aims to address several questions: are Indonesian teenagers less knowledgable about vape as compared to conventional cigarette, and how is their attitude towards smoking versus vaping?
The study was conducted in four high schools from East Jakarta, South Jakarta, and Kota Metro, Lampung. We used a validated questionnaire to measure the knowledge, attitude, and intention of high school students regarding smoking conventional and electronic cigarette.
4 and 7 questions assessed the level of knowledge about conventional cigarette and e-cigarete, respectively (Cronbach’s Alpha= 0,88). These questions were in “True/False” format. Students were given a score of 1 when they answered incorrectly, and 2 when the answers were correct.
Attitude was assessed using a 8-item Likert Scale (scale of 1-4) (Cronbach’s alpha= 0,910). Statistical analyses were performed using SPSS.
Firstly, we analyzed the participants’ knowledge about conventional cigarette smoking. In responding to the item “It is safe to smoke if the duration is less than one year”, 10% (28/270) of the participants answered “True”. 14,8% (40/270) teenagers agreed that “Smoking can be used to reduce long-term stress”. 98% (220/270) answered correctly in the item “Smoking can cause severe COVID-19”. 96,7% (261/270) of teenagers knew that “Passive smokers can suffer from lung cancer too”.
We also analyzed participants’ knowledge about e-cigarette. In response to the item “Compared to smoking, vaping is safer for teenagers”, 27% (73/270) of teenagers answered “True”. 26,7% (32/270) of teenagers thought that “E-cigarettes do not contain nicotine”. 9,25% (25/270) of students agreed that “Vaping can improve mental health”. 25,9% (70/270) of the participants answered “True” when asked whether “Vaping can help teenagers who want to stop smoking”. 17% (46/270) thought that “Vaping does not cause addiction”. 11,11% (30/270) of subjects thought that “E-cigarette fruit-flavored liquids are safe for consumption”. 18,14% (49/270) believed that “The smoke from e-cigarette is safe because it contains only water vapor”.
The mean score of conventional cigarette knowledge was 93,7% (7,54 out of the maximum score of 8), while it was 90% for e-cigarette (12,6 out of the maximum of 14). This difference is significant (using Mann-Whitney Test; P<0.0001).
We next analyzed participants’ attitude towards conventional smoking versus vaping. We asked whether they would be worried their parents being angry if they they were caught smoking/vaping. With conventional cigarette, 4,8% (13/270) answered “Strongly Disagree”, 3,7% (10/270) answered “Disagree”, 28,1% (76/270) answered “Agree”, and 63,3% (171/270) answered “Strongly Agree”. With e-cigarette, the responses were 2,96% “Strongly disagree”, 5,92% “Disagree”, 46,2% “Agree”, and 44,8% “Agree”. Taken together, our participants were more likely to be afraid of being caught smoking than vaping (median score: 4 for smoking versus 3 for vaping, with maximum score of 4; P value=0.0002 with Mann-Whitney Test).
Another item in our questionnaire examined their confidence to resist peer pressure to smoke/vape (“If my good friend ask me to smoke/vape, I am sure I can say ‘No’”). In response to this question in relation to conventional smoking, 1,48% (4/270) answered “Strongly disagree”, 7% (19/270) answered “Disagree”, 30,4% (82/270) answered “Agree”, and 61,1% (165/270) answered “Strongly Agree”. With regards to e-cigarette, 2,59% (7/270) answered “Strongly Disagree”, 7,78% (21/270) answered “Disagree”, 34,4% (93/270) answered “Agree”, and 55,18% (149/270) answered “Strongly Agree. The average score of this question is higher in that of conventional cigarette as compared to e-cigarette (P Value= 0.0006 with Mann-Whitney Test). In other words, participants felt more confident to resist peer pressure to consume conventional cigarette as compared to e-cigarette.
The next question in our survey examined how teenagers perceive smoking and vaping as normative adolescent behaviors. The statement was “I think that it is normal for teenagers my age to smoke/vape due to curiosity”. In regards to conventional smoking, 31,85% (86/270) answered “Strongly Disagree”, 21,85% (59/270) responded “Disagree”, 41,48% (112/270) answered “Agree”, and 4,8% (13/270) answered “Strongly Agree). In regards to vaping, 31,1% (84/270) answered “Strongly Disagree”, 20% (54/270) answered “Disagree”, 43,3% (117/270) answered “Agree”, and 5,18% (14/270) answered “Strongly agree”. There was no significant difference in the scores between conventional versus e-cigarette for these questions (P value= 0,61).
The last question in the survey examined whether teenagers think smokers and vapers are cool. In response to the item “Smokers are cooler than non-smokers”, 72,9% (197/270) of participants answered “Strongly disagree”, 20,3% (55/270) answered “Disagree”, 5,2% (14/270) responded “Agree”, and 1,5% (4/270) answered “Strongly agree”. In response to the item “Vapers are coolers than smokers”, 41,85% (113/270) answered “Strongly disagree”, 39,6% (107/270) answered “Disagree”, 17,4% (47/270) answered “Agree”, and 1,1% (3/270) answered “Strongly Agree”.
Taken together, comparing the total score of attitude towards conventional smoking versus vaping, there was a significant difference between the two, with the total score of conventional smoking being higher than that of e-cigarette (P value: <0.0001 with Mann-Whitney test; median: 14 versus 13).
Teenagers in our sample were significantly more knowledgeable about conventional cigarette (mean score 93,7%) than they were about e-cigarette (mean score 90%; p-value <0.0001). Interpretation of these percentages should be done judiciously; although these scores appear to be high, we used True/False questions instead of multiple-choice format. Furthermore, the number of items were few (only four questions for conventional cigarette and seven for e-cigarettes). They were relatively easy: a perfect score should be possible for an individual with adequate knowledge. Furthermore, a breakdown of each question showed several concerning responses (e.g. 27% of the teenagers agreed that vaping is safer than smoking, while it is crucial for them to understand that both are hazardous for them).
Our finding suggests that teenagers may be more afraid to be caught smoking conventional cigarettes than e-cigarette. Although adolescents rely more on their peers than their parents as role models, parental guidance still matters to them. Lack of parental supervision is associated with an increased risk of substance abuse initiation. This difference might be explained by the fact that it is easier to hide e-cigarettes from parents: they are often shaped like a USB drive, or a small bottle of perfume.
Teenagers in our population was less confident in resisting peer pressure to vape than to smoke, and the difference was statistically significant. This might be related to the novelty and the appeal of e-cigarette.
46,3% and 48,5% of our participants viewed that it is normal for teenagers their age to smoke and to vape, respectively, and there was no significant difference in score between conventional versus e-cigarette for this question. The percentage of students seeing smoking/vaping as the norm is alarming. Normative belief about smoking and vaping (i.e. the belief that smoking and vaping are the norm, and that many teenagers in this world are smoking and vaping) is a risk factor for smoking and vaping initiation. Future studies should examine the relationship between knowledge, attitude, intention, and the smoking/vaping behavior itself.
E-cigarette, Cigarette, Knowledge, Attitude