Perceived Safety and Effectiveness of Electronic Cigarettes among Malaysian Adults and Public Support for Regulations.

CONTEXT: Electronic cigarettes have been used as a harm reduction method toward tobacco cessation. Malaysian government has enforced a strict policy to regulate the sale of electronic cigarette products because its liquid contains nicotine. AIMS: This study aimed to explore the general public's perception toward electronic cigarette use. Public support toward electronic cigarette regulation was also examined. SETTINGS AND
DESIGN: This was a Malaysian population-based survey.
MATERIALS AND METHODS: Data were obtained from the National E-Cigarette Survey (NECS) 2016, which used a multistage stratified cluster sampling household survey representing all Malaysian adults aged 18 years old. A cross-sectional survey was conducted among a total of 4288 adults. STATISTICAL ANALYSIS USED: Descriptive and logistic regression analysis.
RESULTS: Majority were aged 25-44 years old (44%), completed at least secondary education (69%), of Malay ethnicity (73%), and married (68%). Majority (88.1%) have never used electronic cigarette. A quarter (25.5%) perceived electronic cigarette helps people quit cigarette smoking, whereas 20.3% perceived electronic cigarette helps people to maintain cigarette abstinence. Approximately 85% believed that electronic cigarette use does not help in improving breathing and coughing. Majority (91.8%) disagreed that electronic cigarettes should be allowed in places where tobacco smoking is banned. Thus, 63.4% agreed that electronic cigarette should be banned completely rather than regulated.
CONCLUSION: Majority of general public had negative perception about electronic cigarette use. Copyright:

INTRODUCTION

Each year, tobacco smoking is responsible for 20,000 deaths among Malaysians. By the year 2030, annual deaths caused by tobacco smoking among Malaysians could be increased to up to 30,000.[1] Globally, the leading causes of death due to tobacco smoking are cardiovascular diseases (1.69 million deaths), chronic obstructive pulmonary disease (0.97 million deaths), and lung cancer (0.85 million deaths).[2] Although vast majority of Malaysian adults were aware of the harmful effects of tobacco smoking toward health, approximately one-quarter of them remained as active smokers.[1]

Tobacco smoking is a manifestation of nicotine addiction.[3] Although currently-marketed smoking cessation products do increase the chance for active smokers to stop smoking, these products have been reported to lack high levels of efficacy in the real life setting.[4]

The electronic cigarette (EC) is an electronic nicotine delivery device (ENDD) powered by battery. Its functions are similar to tobacco cigarettes, delivering nicotine to its user without tobacco combustion.[5] Studies reported that using EC could help to reduce tobacco cigarette use, to relieve tobacco withdrawal symptoms, and to quit smoking.[668] In Malaysia, the prevalence of current EC users was 3.2%, which represents more than 600,000 adults (based on 19 million adults in Malaysia).[9] Since the introduction of the EC into the global market, its use has increased rapidly around the world. A study found high awareness of EC but low levels of trial and usage (46.6% overall, with 73% USA) among adults.[10] A population survey of a British sample showed that current use of EC doubled between 2010 and 2012 from approximately 3% to 7%.[11]

The Global Adult Tobacco Survey (GATS), conducted in 2011 among 4250 Malaysians aged 15 years and above, revealed that 21% of Malaysian adults were aware of EC and 3.9% of them were current users.[12] Studies on awareness and factors associated with the use of ECs have found several similar associated factors. These factors include reduction in conventional cigarette (tobacco smoking), reduction in the number of cigarettes smoked, claims that EC helped smokers to quit, less costly, less hazardous to health, and curiosity about EC use.[1113]

Nicotine is classified as a Class C poison under the Poisons Act of 1952 and the Control of Drugs and Cosmetic Regulations of 1984 (Malaysia), which forbids the sale or supply of poisons to people under 18 years old.[14] Therefore, after considerable debate, in early 2016, Malaysian government enforced a policy on the sale of nicotine, tobacco products, and ECs by allowing only licensed pharmacies or registered medical practitioners to sell nicotine-containing EC liquids, and prohibiting unregulated premises from selling such products.[15]

Consequently, majority of the EC users (95.8%) in Malaysia were reported to be against the policy, and obtaining nicotine from pharmacies was the least preferred source of purchase (21.4%).[16]

Despite the controversial discussion on EC in the country, it is not known how the general public in the nation perceive the safety of ECs, as well as their perception on the efficacy of EC in smoking cessation. The perception on policies related to regulation on EC is also unknown.

The aim of this study was to investigate the perception of the general public toward the safety, perceived effectiveness for smoking cessation, and related policy regarding EC use.

SUBJECTS AND METHODS

A cross-sectional study, known as the Malaysian National E-Cigarette Survey (NECS) 2016, was conducted between May and June in 2016 among Malaysian adults in the entire Malaysia. Approval for the research ethics of this study was obtained from the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR-16-171-28819 (IIR)). This study represents one part of the NECS 2016: Prevalence, Pattern and Perception Regarding E-Cigarette and Vape Use Among Malaysian Adults.

Participant

The inclusion criteria were all Malaysians above the age of 18 years who had lived in the selected residences for at least 6 months in the past 1 year, understood Bahasa Malaysia or English, and agreed to participate. Exclusion criteria were institutional populations such as those staying in hotels, hostels, and hospitals. The survey form was distributed to 5722 participants who fulfilled the inclusion criteria. Both verbal and written consent were obtained from subjects who fulfilled the criteria.

In this paper, a current EC user refers to one who has smoked at least a puff of EC and has been using it in the last 30 days; a current tobacco smoker is one who has smoked at least 100 cigarettes in their lifetime and who has smoked at least one cigarette in the past 30 days; a dual user is one who is currently smoking both tobacco cigarettes and EC during the period of the study.

Procedure

A NECS Questionnaire Survey Form was designed and developed from the inputs of experts in tobacco control and smoking cessation from the Ministry of Health and academics. The questionnaire underwent face and content validation processes before it was then piloted. Nevertheless this questionnaire had been used by two major published studies in Malaysia: the GATS Malaysia 2011 and Tobacco and E-cigarette Use among Adolescents (TECMA) survey.

Sample size was calculated to be 5722, based on the prevalence (p) of 5% with the precision (d) of 1.5%, 2 strata (s), and design effect (DEFF) of 2.0 at 95% confidence interval.

The primary sampling unit was the administrative district. The secondary sampling unit was the enumeration blocks within the selected districts. The final sampling unit was the living quarters within the selected enumeration blocks. The study population was divided into six zones according to the map of Malaysia for data collection––north, central, south, east coast, Sabah, and Sarawak. All data were collected at the respective zone level, before being posted to the coordination center in International Islamic University Malaysia (IIUM), Kuantan campus. In IIUM, the data were entered into the NECS Database twice (double data entry) to ensure the data were keyed in correctly.

Data were analyzed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY, USA) and Stata Statistical Software: Release 13 (StataCorp LP, College Station, TX, USA). All information obtained in this survey was kept and handled in a confidential manner. Identity of the subjects will not be revealed during publishing or presenting of the survey results.

RESULTS

Data from 4288 subjects, corresponding to 19 million Malaysian adults nationally, were assessed. Table 1 shows the sociodemographic characteristics of the study’s subjects. Majority (88.1%, n = 3874) have never used EC. Less than one-third (28.0%, n = 1140) were current cigarette users. Only a small number of them were using EC (3.2%, n = 110) and using both ECs and tobacco cigarettes (2.3%, n = 77). There were 4.6% (n = 183) former cigarette smokers.

Table 1

Sociodemographic profile of subjects

Age group	n (%)	N
18–24	693 (19.4)	3,676,358
25–44	1684 (43.6)	8,268,976
45–64	1437 (25.9)	5,280,969
65 and above	464 (9.1)	1,728,000
Gender
Male	1984 (50.2)	9,533,557
Female	2298 (49.8)	9,444,650
Education
No formal education	429 (7.1)	1,351,823
Completed primary	1163 (23.6)	4,472,862
Completed secondary	1820 (44.3)	8,402,672
Completed college/ university	871 (25.0)	4,753,257
Occupation
Government	384 (10.2)	1,945,052
Nongovernment	958 (26.3)	5,002,612
Self-employed	928 (20.2)	3,830,211
Student	267 (7.5)	1,427,397
Homemaker	1106 (21.7)	4,114,501
Retiree	208 (4.9)	931,590
Not working	436 (9.2)	1,751,746
Race
Malay	3215 (72.6)	13,783,021
Chinese	419 (12.2)	2,323,697
Indian	188 (5.9)	1,126,055
Iban	49 (0.9)	169,998
Kadazan	51 (0.9)	175,889
Other Bumiputra	348 (7.1)	1,351,770
Others	13 (0.2)	44,064
Religion
Islam	3483 (78.9)	14,951,196
Buddhism	330 (9.5)	1,809,317
Christianity	254 (5.0)	953,256
Hinduism	174 (5.5)	1,051,885
Others	39 (1.0)	191,886
Marital status
Married	3057 (68.1)	12,916,105
Living with partner	15 (0.4)	72,737
Separated	13 (0.3)	65,132
Divorced	43 (0.9)	162,991
Widowed	190 (3.7)	701,685
Single	964 (26.6)	5,049,944
Residence
Urban	2123 (49.5)	14,478,772
Rural	2165 (50.5)	4,526,484

Responses from the subjects on perception toward EC are shown in Table 2. Majority (74.5%, n = 2796) of the subjects did not believe that ECs are helpful in smoking cessation. In maintaining tobacco abstinence, ECs were not believed to be helpful (79.7%, n = 2969). More than half (63.0%, 2299) of the subjects also believed that ECs do not reduce tobacco use.

Table 2

Perception toward electronic cigarettes use

Item		Total
		n	%	N	95%CI
1	Electronic cigarette helps people quit smoking tobacco cigarette.
	Agree	867	25.5	4,253,391	23.5, 27.5
	Disagree	2796	74.5	12,440,420	72.5, 76.5
		3663		16,693,811
2	Electronic cigarette helps people maintain cigarette abstinence.
	Agree	690	20.3	3,389,422	18.6, 22.1
	Disagree	2969	79.7	13,315,254	77.9, 81.4
		3659		16,704,677
3	The urge to smoke is reduced by using electronic cigarette.
	Agree	1034	32.9	5,296,624	30.7, 35.1
	Disagree	2432	67.1	10,820,508	64.9, 69.3
		3466		16,117,132
4	Electronic cigarette is more effective than medication for quitting smoking.
	Agree	440	14.7	2,224,552	13.0, 16.6
	Disagree	2826	85.3	12,905,212	83.4, 87.0
		3266		15,129,764
5	Electronic cigarette is not a transition to quit nicotine.
	Agree	1276	41.1	6,134,719	37.6, 44.6
	Disagree	1954	58.9	8,806,743	55.4, 62.4
		3230		14,941,462
6	Electronic cigarette helps people cut down tobacco smoking.
	Agree	1201	37.0	5,978,588	34.6, 39.5
	Disagree	2299	63.0	10,191,310	60.5, 65.4
		3500		16,169,899
7	Breathing is improved after using electronic cigarette.
	Agree	428	15.4	2,162,318	13.9, 17.1
	Disagree	2577	84.6	11,837,933	82.9, 86.1
		3005		14,000,252
8	Coughing is improved by using electronic cigarette.
	Agree	391	14.2	1,943,599	12.7, 15.9
	Disagree	2585	85.8	11,756,095	84.1, 87.3
		2976		13,699,695
9	Electronic cigarette is less satisfying than tobacco smoking.
	Agree	1211	51.9	5,934,372	48.5, 55.3
	Disagree	1213	48.1	5,499,543	44.7, 51.5
		2424		11,433,915
10	People react more positively to electronic cigarette users than that to tobacco smokers.
	Agree	940	26.7	4,509,926	24.4, 29.1
	Disagree	2770	73.3	12,391,435	70.9, 75.6
		3710		16,901,361
11	The smell of an electronic cigarette is better than a tobacco cigarette.
	Agree	2129	64.6	10,009,710	61.8, 67.3
	Disagree	1208	35.4	5,486,098	32.7, 38.2
		3337		15,495,809
12	Electronic cigarette should be allowed in places where smoking is banned.
	Agree	320	8.2	1,481,549	7.0, 9.7
	Disagree	3693	91.8	16,512,719	90.3, 93.0
		4013		17,994,268
13	Electronic cigarette is less harmful to health of the user compared to tobacco smoking.
	Agree	713	22.9	3,536,617	20.7, 25.2
	Disagree	2673	77.1	11,926,012	74.8, 79.3
		3386		15,462,629
14	Electronic cigarette is less addictive than tobacco cigarette.
	Agree	982	33.2	4,811,151	30.9, 35.5
	Disagree	2140	66.8	9,691,865	64.5, 69.1
		3122		14,503,017
15	Craving for using electronic cigarette is as much as for tobacco cigarette.
	Agree	1640	54.8	7,704,488	52.2, 57.3
	Disagree	1372	45.2	6,366,852	42.7, 47.8
		3012		14,071,340
16	Electronic cigarette allows for more nicotine use compared to tobacco cigarette.
	Agree	1378	55.1	6,670,129	52.2, 58.0
	Disagree	1188	44.9	5,425,242	42.0, 47.8
		2566		12,095,372
17	Electronic cigarette vapor is more harmful to others compared to tobacco smoke.
	Agree	1827	55.6	8,093,553	53.0, 58.1
	Disagree	1358	44.4	6,476,100	41.9, 47.0
		3185		14,569,653
18	The urgency of quitting electronic cigarette is not the same as with tobacco cigarette.
	Agree	1064	35.2	5,091,283	32.3, 38.3
	Disagree	2001	64.8	9,363,907	61.7, 67.7
		2951		13,440,222
19	Electronic cigarette solutions cause poisoning.
	Agree	2415	80.8	10,853,898	78.9, 82.5
	Disagree	536	19.2	2,586,323	17.5, 21.1
		2951		13,440,222
20	Electronic cigarette should be regulated rather than banned completely.
	Agree	1410	36.6	6,582,099	34.2, 39.2
	Disagree	2616	63.4	11,381,634	60.8, 65.8
		4026		17,963,733

n = sample, N = estimated population for all samples

Majority of subjects did not feel that EC users would improve in breathing and coughing, subjects did not differ much in opinions about whether ECs or tobacco cigarettes were more satisfying. At the very least, the use of EC is perceived by this survey’s respondents to worsen breathing (84.6%) and coughing (85.8%).

Most subjects (80.8%, n = 2415) believed that ECs could cause poisoning. But opinion on whether people would crave more toward ECs or toward tobacco cigarettes did not differ much.

The number of subjects who wanted to completely ban ECs (63.4%, n = 2616) was lower than the number of subjects who did not want to allow ECs in places where tobacco cigarettes are banned (91.8%, n = 3693).

Six items were selected for further discussion on the respondents’ perception toward safety, effectiveness, and policy. Logistic regression was carried out to compare the difference of answers among different types of users [Table 3].

Table 3

Perception of respondents on items representative of safety (items 17 and 19), effectiveness (items 1 and 4), and policy (items 12 and 20)

Item 17	Overall (N = 3175), n (%)	Perception on “Electronic cigarette vapor is more harmful to others compared to tobacco smoke,” n		Logistic regression Adjusted odds ratio (95 % CI) for agree versus disagree for “Electronic cigarette vapor is more harmful to others compared to tobacco smoke.”
		Agree N = 1820 (57.3%)	*Disagree N = 1355 (42.7%)
Electronic cigarette use status
Current	102 (3.2)	18	84	0.270 (0.90–0.808)
Never	2829 (89.1)	1719	1100	2.785 (2.080–3.729)
Former	244 (7.7)	83	161	Reference
Tobacco cigarette use status
Current	734 (23.1)	355	379	0.866 (0.657–1.141)
Never	2105 (66.3)	1275	830	1.005 (0.789–1.279)
Former	336 (10.6)	190	146	Reference
Dual use status
No	3103 (97.7)	1806	1297	0.551 (0.162–1.869)
Yes	72 (2.3)	14	58	Reference
Item 19	Overall (N = 2944), n (%)	Perception on “Electronic cigarette solutions cause poisoning,” n		Logistic regression Adjusted odds ratio (95 % CI) for agree versus disagree for “Electronic cigarette solutions cause poisoning”
		Agree N = 2408 (81.8%)	*Disagree N = 536 (18.2%)
Electronic cigarette use status
Current	96 (3.3)	37	59	0.469 (0.208–1.058)
Never	2636 (89.5)	2245	391	3.424 (2.481–4.724)
Former	212 (7.2)	126	86	Reference
Tobacco cigarette use status
Current	659 (22.4)	472	187	0.674 (0.456–0.978)
Never	1971 (66.9)	1675	296	0.895 (0.638–1.255)
Former	314 (10.7)	261	53	Reference
Dual use status
No	2876 (97.7)	2384	492	1.133 (0.445–2.881)
Yes	68 (2.3)	24	44	Reference
Item 1	Overall (N = 3652), n (%)	Perception on “Electronic cigarette helps people quit smoking tobacco cigarette,” n		Logistic regression Adjusted odds ratio (95 % CI) for agree versus disagree for “Electronic cigarette helps people quit smoking tobacco cigarette.”
		Agree N = 865 (23.7%)	*Disagree N = 2787 (76.3%)
Electronic cigarette use status
Current	110 (3.0)	71	39	3.778 (1.667–8.561)
Never	3260 (89.3)	678	2582	0.388 (0.295–0.511)
Former	282 (7.7)	116	166	Reference
Tobacco cigarette use status
Current	855 (23.4)	252	603	0.944 (0.706–1.263)
Never	2406 (65.9)	508	1898	0.893 (0.691–1.154)
Former	391 (10.7)	105	286	Reference
Dual use status
No	3575 (97.9)	818	2757	1.687 (0.672–4.236)
Yes	77 (2.1)	47	30	Reference
Item 4	Overall (N = 2944), n (%)	Perception on “Electronic cigarette is more effective than medication for quitting smoking,” n		Logistic regression Adjusted odds ratio (95 % CI) for agree versus disagree for “Electronic cigarette is more effective than medication for quitting smoking”
		Agree N = 439 (13.5%)	*Disagree N = 2818 (86.5%)
Electronic cigarette use status
Current	101 (3.1)	53	48	3.647 (1.652–8.055)
Never	2902 (89.1)	319	2583	0.343 (0.246–0.479)
Former	254 (7.8)	67	187	Reference
Tobacco cigarette use status
Current	779 (23.9)	142	637	1.175 (0.788–1.754)
Never	2122 (65.2)	250	1872	1.174 (0.819–1.681)
Former	356 (10.9)	47	309	Reference
Dual use status
No	3187 (97.9)	403	2784	1.261 (0.511–3.108)
Yes	70 (2.1)	36	34	Reference
Item 12	Overall (N = 2944), n (%)	Perception on “Electronic cigarette should be allowed in places where smoking is banned,” n		Logistic regression Adjusted odds ratio (95 % CI) for agree versus disagree for “Electronic cigarette should be allowed in places where smoking is banned”
		Agree N = 319 (8.0%)	*Disagree N = 3681 (92.0%)
Electronic cigarette use status
Current	107 (2.7)	30	77	5.393 (2.380–12.220)
Never	3615 (90.4)	252	3363	0.602 (0.404–0.898)
Former	278 (7.0)	37	241	Reference
Tobacco cigarette use status
Current	892 (22.3)	103	789	1.353 (0.878–2.086)
Never	2696 (67.4)	179	2517	0.904 (0.610–1.340)
Former	412 (10.3)	37	375	Reference
Dual use status
No	3926 (98.2)	302	3624	3.077 (1.199–7.897)
Yes	74 (1.8)	17	57	Reference
Item 20	Overall (N = 4013), n (%)	Perception on “Electronic cigarette should be regulated rather than banned completely,” n		Logistic regression Adjusted odds ratio (95 % CI) for agree versus disagree for “Electronic cigarette should be regulated rather than banned completely.”
		Agree N = 1404 (35.0%)	*Disagree N = 2609 (65.0%)
Electronic cigarette use status
Current	109 (2.7)	91	18	3.964 (1.334–11.773)
Never	3624 (90.3)	1107	2517	0.233 (0.175–0.311)
Former	280 (7.0)	206	74	Reference
Tobacco cigarette use status
Current	885 (22.1)	495	390	1.871 (1.449–2.415)
Never	2709 (67.5)	754	1955	0.815 (0.649–1.023)
Former	419 (10.4)	155	264	Reference
Dual use status
No	3936 (98.1)	1341	2595	3.195 (0.951–10.739)
Yes	77 (1.9)	63	14	Reference

*Reference category used in columns

Generally, there are significant differences in perception between current EC users and those who had never used EC. The current EC users believed that EC is less harmful than tobacco cigarettes and is more effective in smoking cessation. Current tobacco cigarette users believed that ECs can cause poisoning. A significant number of EC users wanted ECs to be allowed in places where tobacco smoking is banned. Current tobacco users also believed that EC use should be regulated rather than banned completely.

DISCUSSION

To fill up the gap mentioned by Wong et al.,[16] this study answered the question on how the public viewed ECs. Majority of the subjects in this study had never used ECs, which could be the reason why their perception differed from the study by Wong et al.,[16] where the subjects consisted of EC users. Overall, the general public in this study carried negative perception toward EC, some even portrayed misconceptions. Although the current EC users carried similar perceptions with the subjects of Wong et al., concerns of the general public toward EC use are not irrelevant.

A majority of the subjects in this study believed that EC do not aid in tobacco smoking cessation or reducing number of cigarette smoking. However, many studies revealed that the most common reason for people to use EC is to quit tobacco smoking.[1017171920] Current EC users from this study also supported the statement that EC could be helpful in smoking cessation, and it seemed to be more helpful than using medications. Although it remains controversial whether ECs really do help people to quit tobacco smoking, evidence suggest that EC use could help to reduce tobacco cigarette use,[1021] to prevent relapse (or, to maintain abstinence),[22] and to reduce the urge for craving.[2324] Nevertheless, it was proven that ECs are not actually effective in smoking cessation.[25] Therefore, concern from the general public about this issue remains valid.

It was suggested that former tobacco users who use ECs may not have the intention to quit nicotine use altogether.[26] Some EC users may not be able to or are unwilling to quit nicotine addiction, although they could stop smoking.[27] Also, because ECs could provide nicotine while acting as a smoke-free alternative, many users remained comfortable with ECs.[25] Therefore, it is not impossible for ECs to allow more nicotine use, in comparison to tobacco cigarettes.

Although more than half of the subjects in this study did endorsed the appealing smells of EC vapors, but they were not denying on the harmful effect caused by the vapors. Majority agreed that EC should be treated same as tobacco cigarette whereby both should be banned its use in prohibited places and did not want ECs to be used in places where tobacco cigarettes are banned. This is similar to the majority of the opinions of the general public in the United States, where second-hand EC vapor exposure is considered to be harmful to their health, and many people wanted ECs to be banned in public areas.[28] Currently, in public areas of Malaysia, the rules and regulations of the law have not been enforced on EC use. As the EC vapors have been proven to be harmful, banning of EC use in public areas should be implemented in public areas in Malaysia.

The subjects’ impression about the harmful effects of EC products is relevant. In Malaysia, many of the EC liquids on the market have been manufactured by unlicensed companies, and the exact components of these liquids are not known. Therefore, EC users should be warned that these liquids are not entirely harmless.[16] Although ECs are relatively less harmful than tobacco cigarettes, its use has been only intended for harm reduction and tobacco cessation, and it has been reported that EC vapors contain toxic and carcinogenic compounds.[29] Other findings from the NECS 2016 study revealed that out of 81 samples analyzed for nicotine content, a total of 13 samples had no label for nicotine but was found to contain nicotine. On the basis of the current regulations of nicotine, to ensure safety of users, strict enforcement is needed for EC liquid.

The general public should be educated about this fact, so that people who have not used ECs would not risk their health by picking up the habit. Those who perceived ECs as less harmful than conventional cigarettes were more likely to use ECs and, conversely, that those who use ECs perceive them as less dangerous.

Industry’s unsupported health-related claims and their apparent success in convincing individuals that ECs are a safer alternative presents a concerning picture unaddressed by current regulatory policies. Therefore, manufacturers and retailers of EC products must be strictly regulated.

One of the main reasons EC has gained more popularity in comparison to tobacco cigarette is that ECs are considered to be cheaper. However, the study by Wong et al.[16] revealed that, subjects from lower income groups and those who view ECs as expensive were more willing to quit EC use. Similarly, a study done in the United States also showed that subjects from a low-income background were more likely to quit EC use, and some actually quit due to the perceived high cost of ECs.[17] Thus, it was suggested that one of the possible ways to discourage EC and tobacco cigarette use is by increasing the prices of these products.

The authors in this study would also like to suggest future researchers to investigate how well-perceived health risks of using ECs correspond to objective risks, and whether beliefs about the perceived risks change as more safety data become available. Educating the general public regarding the purposes and harm of ECs may also be helpful in encouraging current tobacco smokers to seek a more harmless alternative, discouraging nonsmokers to start trying ECs, and keeping a scientific, unbiased view for the general public on EC use.

CONCLUSION

Concerns and negative perceptions regarding EC use among the general public in Malaysia were common. However, these concerns and impressions are not baseless. The general public should be educated about EC use and products, especially the purpose of using it as well as the harm it brings. Opinion about banning ECs in public areas should be taken into consideration, as EC use in public areas is harmful and unwelcomed. Authorities could also increase the price of cigarettes, whether ECs or tobacco cigarettes, to encourage people in quitting nicotine use.

It is important for the authorities to increase efforts to highlight the dangers of EC use so people will be more alert and concerned on its negative consequences.

Ethical policy and institutional review board statement

Ethical approval for this study was obtained from Medical Research Ethics Committee (MREC), MOH Malaysia (NMRR-16-171-28819 (IIR)).

Financial support and sponsorship

National E-Cigarette Survey (NECS 2016) was fully funded by the National Institute of Health, Ministry of Health Malaysia (grant no. NIH/IPH/ 16-002).

Conflicts of interest

There are no conflicts of interest.