Navigating regulatory challenges: a cross-sectional survey of vaping and smoking behaviours among university students in Yunnan, China

Abstract

Background

The global rise in vaping has become a significant public health concern among the young population. This study aims to investigate vaping behaviours among university students in China.

Methods

Students were selected from eight universities in Yunnan Province. The questionnaire collected baseline characteristics and vaping behaviours. Vapers were classified into vaping only, smoking only, both vaping and smoking, and neither vaping nor smoking. Descriptive statistics were used to estimate prevalence, and multinomial logistic regression was conducted to identify factors associated with current vaping and smoking.

Results

A total of 2259 students were recruited. The ever, current, and past prevalence rates of vaping among university students were 8.8%, 1.9%, and 6.9%, respectively, whereas the ever, current, and past prevalence rates of smoking were higher, at 20.0%, 8.0%, and 12.8%, respectively. Most students initiated vaping and smoking at a young age. The common reasons for vaping were appealing to flavours (81.0%), preventing smoking relapse (69.2%), and pleasure (69.2%). Among the most popular flavours, fruity was preferred by 53.5% of the students, followed by tobacco and menthol/mint, each accounting for 32.6%. Students vaped at bars/pubs (79.1%), universities (60.5%), and at home (53.5%), with nearly half of smokers obtaining them online, followed by convenience stores. Current vapers had higher levels of nicotine dependence than smokers did (22.9% vs. 3.8%). They had a lower likelihood of quitting combustible smoking (47.1% vs. 64.6%). Multinomial regression analysis revealed that significant factors associated with vaping included a positive attitude toward vaping (RRR = 1.67, 95% CI: 1.43–1.96) and a greater number of vapers in their social circle (RRR = 2.25, 95% CI: 1.58–3.19).

Conclusion

University students initiated vaping since they were below the legal age range, had a higher level of nicotine addiction, and perceived vaping as harmless. In addition, they had a low level of knowledge of vaping harm and regulation but a positive attitude towards vaping. This information should be beneficial for curbing vaping in Yunnan.

Introduction

Vaping has recently emerged and spread rapidly around the world, with an estimated 114 million vapers worldwide in 2023 (Global State of Tobacco Harm Reduction, 2024) [1]. The global prevalence rates of ever use, current use, and dual use with smoking, primarily among individuals under 25, were 15.3%, 7.7%, and 4.0%, respectively [2, 3].

The industry claims it is harmless, and many smokers use it for harm reduction or smoking cessation [4]. However, accumulated scientific evidence has consistently shown that vaping can increase the risk of many diseases, life-threatening conditions, and death. In 2019, e-cigarette or vaping use-associated lung injury (EVALI) resulted in 2,807 hospitalizations and 68 deaths in the U.S [5]. Recent evidence has shown that factors contributing to EVALI include Vitamin E acetate [6], flavoring agents [7], heavy metals [8], propylene glycol, and vegetable glycerin [9, 10]. Compared with nonsmokers, vapers have increased odds of asthma (1.3 times), chronic obstructive pulmonary disease (COPD) (1.5 times), and myocardial infarction (1.8 times) [11–13]. Even short-term exposure to vaping induces immunomodulatory, inflammatory, and sympathetic changes in the airway and blood circulation [14, 15]. There has been a concern regarding the potential oncogenicity of vaping [16]. In vitro studies in animal and human cells provided the evidence that vaping promotes breast cancer growth and metastasis [17].

Chinese health authorities are concerned about addiction, lung disease, and other diseases in the young population. As a result, the government banned online sales of e-cigarettes in 2019 and, in 2022, officially classified them as tobacco products under state control through the Electronic Cigarette Management Measures. Clean air regulations and flavour limitations have been implemented [18]. The regulations also limit the marketing, sale, and use, particularly among minors and at educational institutions. Although the legal smoking age in China is 18 years, universities aim to discourage smoking among young adults. Most Chinese universities follow the government’s tobacco control policies, which ban smoking (including e-cigarettes) in classrooms, dormitories, and other campus areas. Many universities have adopted smoke-free campus policies in line with national efforts to control tobacco use. However, a significant increase in e-cigarette vaping has been reported among university students in other areas, including Shanghai (4.6%) [19], Guangzhou (19.3%) [20], and Hangzhou (8.2%) [21]. However, evidence regarding the period following the implementation of the Electronic Cigarette Management Measures remains limited. This study aimed to investigate the current situation of vaping, including its prevalence, vaping behaviour, and associated factors, among university students in Yunnan Province, China. The findings will be useful for policy decisions to promote the health and well-being of university students.

Methods

Study design and setting

A web-based survey was conducted between November and December 2023 among university students in Kunming, the capital of Yunnan Province. Kunming has 52 universities, including 20 public universities and 32 junior colleges. We selected six public universities among the largest universities in Yunnan. Each university was a key university for different disciplines, including (1) social sciences, (2) medicine, (3) traditional medicine, (4) education, (5) agriculture, and (6) engineering and polytechnic fields. The other two institutes were public and private vocational colleges. One was the key college for engineering and accounting. The other one was famous for computer science and technology. These universities and colleges can present different characteristics of university students in Yunnan.

Participants, sample size estimation, and sampling

Eligible students were Chinese nationals who were proficient in Mandarin and enrolled in undergraduate or postgraduate programs. The study required at least 1,771 students, based on a 2.2% prevalence of vaping among Chinese university students, as reported by the 2018 Global Adult Tobacco Survey (GATS) [22], with a precision of 1%. This estimate also accounted for a design effect of 1.5 and a 30% nonresponse rate. The estimated number of students from each university was proportional to university size. We subsequently informed the staff at each university of the required sample size and requested them to select students from their universities.

Measurements of variables

Electronic cigarettes (e-cigarettes) were defined as battery-operated devices that aerosolize liquid solution for inhalation. Combustible cigarettes were defined as traditional tobacco products requiring ignition and combustion to produce smoke. Vaping refers to the act of using e-cigarettes. The online anonymous questionnaire was created via the WJX platform (https://www.wjx.cn/). It consists of 40 questions divided into three main sections: (i) socioeconomic and demographic information; (ii) behaviours, attitudes, and knowledge regarding vaping; and (iii) use of other types of cigarettes and alcohol. The response time ranged from 5 to 15 min. The questionnaires were modified from the GATS 2018 [22] and a previous study [23].

We classified vaping and smoking into three groups: current (used daily or less), past (ever used but not currently used), and never (neither vaping nor smoking). Additionally, dual users were defined as both currently smoking and vaping. Nicotine dependence of cigarette smoking was evaluated via the Fagerström Test for Nicotine Dependence (FTND) [24]. Drinking frequency was assessed by the WHO Alcohol Use Disorders Identification Test (AUDIT) [25], which is categorized as never, monthly or less, 2–4 times a month, 2–3 times a week, and four or more times a week. Information on other substances was not available.

Attitudes towards vaping were assessed via a five-point Likert scale ranging from “fully agree” to “fully disagree,” whereas knowledge was assessed via three options: “yes,” “no,” and “do not know.” The social circle includes classmates, friends, and family. A pilot test was conducted, and the questionnaire was adjusted accordingly before being used.

Data collection

This study was approved by the Human Research Ethics Committee at the Faculty of Medicine, Prince of Songkla University (No. 66-397-18-1). After Institutional Review Board approval, we contacted the rectors of eight universities to explain the study’s purpose and details and to invite them to participate. All of them agreed and approved the study. We subsequently sent a questionnaire with a unique QR code or link to each university coordinator. Then, they sent it to the selected students. Eventually, the students who were informed about the study voluntarily decided whether to complete the questionnaire. The data were anonymized to protect participants’ confidentiality.

Data management and statistical analysis

The data from each university was retrieved as Excel files and then merged. The data were deidentified before analysis. Nicotine dependence was reclassified into two levels: very low to moderate and high. The knowledge responses were reclassified into two groups:“yes” and “no or do not know.” Each correct response was assigned 1 point, yielding a total score ranging from 0 to 15. The attitude scale was reduced to a 3-point scale: “fully agree and agree,” “neutral,” and “disagree and fully disagree.” The frequency of alcohol use was reduced from five to three: never, monthly, and weekly.

Descriptive statistics were used to estimate the prevalence of vaping. Chi-square tests and Fisher’s exact tests were used to identify significant differences among various vaping groups. Student’s t-test was used to examine differences in continuous variables between these groups. Multinomial regression analysis was used to examine factors associated with vaping. All analyses were conducted via R version 4.2.2 [26].

Results

The study included 2,259 students from six public universities and two junior colleges. The ever, current, and past prevalence rates of vaping among university students were 8.8%, 1.9%, and 6.9%, respectively, whereas the ever, current, and past prevalence rates of smoking were higher, at 20.0%, 8.0%, and 12.8%, respectively. Table 1 shows that past vapers were more than three times as prevalent as current vapers. Vaping was more prevalent among males who lived in urban areas, studied the social sciences, and had higher living allowances. However, current vapers were more common among postgraduates than among undergraduate students.

Table 1.

Prevalence of ever, current, and past vaping by sociodemographic status among university students (N = 2259)

Sociodemographic status	N	Vaping, n (%)
		Ever (N = 195)	Current (N = 43)	Past (N = 152)
Age (years) Mean (SD)	20.1 (2.7)	20.0 (4.6)	20.9 (6.8)	19.8 (3.7)
Gender
Female	1219	31 (2.5)	9 (0.7)	22 (1.8)
Male	995	164 (16.5)	34 (3.4)	130 (13.1)
Home residence
Rural	1305	107 (8.2)	18 (1.4)	89 (6.8)
Urban	909	88 (9.7)	25 (2.8)	63 (6.9)
Study year
1st -2nd year	1485	144 (9.7)	26 (1.8)	118 (7.9)
3rd -5th year	392	31 (7.9)	7 (1.8)	24 (6.1)
Postgraduate	337	20 (5.9)	10 (3.0)	10 (3.0)
Living allowance (RMB)*
200 ~ 1200	579	42 (7.3)	11 (1.9)	31 (5.4)
1200 ~ 1800	1071	82 (7.7)	7 (0.7)	75 (7.0)
1800 ~ 5000	537	64 (11.9)	19 (3.5)	45 (8.4)
Program**
Social sciences	279	29 (10.4)	9 (3.2)	20 (7.2)
Natural sciences	1761	151 (8.6)	29 (1.6)	122 (6.9)
Others	174	15 (8.6)	5 (2.9)	10 (5.7)

 ^*RMB= Renminbi (1 RMB = 0.14 USD)

^**Programs in social sciences included the faculties of arts, economics, philosophy, law, education, literature, history, and management. Programs in natural sciences included the faculties of agriculture, medicine, engineering, and science. Others referred to the remaining programs

Vaping behaviours among university students

More than half of the current vapers vaped daily, as shown in Table 2. The average age at initiation was 15.5 years, and nearly 80% of participants vaped for more than 1 year. The three main reasons for vaping were flavour attraction, avoidance of smoking, and pleasure. Other main reasons were perceived as less harmful, addictive to nicotine, used as a smoking cessation aid, for socialization, or to maintain smoking when smoking was prohibited. More than half reported the use of nicotine-containing liquids. The five most popular flavours were fruity, tobacco, menthol/mint, alcohol, and dessert/candy/other sweets, while only 11.6% used unflavoured products. Students primarily vaped at bars/pubs, at university, and at home. Most were purchased from online stores, convenience stores, social media applications, and pharmacies, whereas a few students received them for free.

Table 2.

Vaping behaviours among current vapers (N = 43)

Vaping behaviours	n (%)
Vaping daily	24 (55.8)
Age at initiation (years) Mean (SD)	15.5 (3.3)
Vaping durations (years)
< 1	6 (20.7)
1–2	9 (31.0)
> 2	14 (48.3)
Main reasons for vaping
Flavours appeal	34 (81.0)
Avoiding cigarette smoking	27 (69.2)
Pleasure	27 (69.2)
Perceived as less harmful	16 (47.1)
Addicted	15 (45.5)
Used by friends or family	13 (39.4)
An alternative to cigarette smoking when it is prohibited	13 (38.2)
Smoking cessation aid	12 (32.4)
Used nicotine-containing liquid	24 (55.8)
E-liquid flavours
Fruity	23 (53.5)
Tobacco	14 (32.6)
Menthol/mint	14 (32.6)
Alcohol	14 (32.6)
Dessert/candy/other sweets	13 (30.2)
Spices	11 (25.6)
Coffee/tea	10 (23.3)
Unflavoured	5 (11.6)
Vaping venues
Bars/pubs	34 (79.1)
University	26 (60.5)
Home	23 (53.5)
Purchased or obtained from
Online shop	21 (48.8)
Convenient store	19 (44.2)
Social media application	10 (23.3)
Pharmacy store	9 (20.9)
Given by others	8 (18.6)
Others	8 (18.6)

Comparisons of smoking cessation and drinking behaviours between current vapers and smokers

Almost all current vapers (85.4%) also smoked other tobacco products (Table 3). Compared with current smokers, vapers started smoking cigarettes one year earlier. Most current smokers smoked fewer than ten cigarettes per day, while almost half of current vapers smoked more than ten cigarettes per day. Moreover, 14.3% of current vapers reported smoking ≥ 31 cigarettes per day, whereas none of the current smokers did. Consistently, current vapers had significantly greater levels of nicotine addiction than the daily smokers. Current vapers had a lower rate of intention to quit smoking than did current smokers, but this difference was not statistically significant. Vapers tended to choose counselling and acquire other sources of nicotine, such as nicotine replacement therapy, smokeless tobacco, and vaping, for quitting. Smokers also preferred counselling, other sources of nicotine, and medication. None of the smokers wanted to use vaping as a smoking cessation aid. Almost all current smokers also drank alcohol (87.1%) and had a significantly higher rate of drinking than current vapers did (63.4%).

Table 3.

Comparison of smoking cessation and alcohol consumption behaviours between current vapers and current smokers (N = 173)

Behaviours	Current vapers* (n = 41) n (%)	Current smokers* (n = 132) n (%)	P value
Age at initiation of smoking or vaping (years) Mean (SD)	14.1 (6.0)	15.4 (2.8)	0.629
Number of cigarettes smoked per day			< 0.001
10 or fewer	19 (54.3)	104 (78.8)
11–20	9 (25.7)	25 (18.9)
21–30	2 (5.7)	3 (2.3)
31 or more	5 (14.3)	0 (0.0)
Nicotine dependence levels of cigarette smoking			< 0.001
Very low to moderate	27 (77.1)	126 (96.2)
High	8 (22.9)	5 (3.8)
Intention to quit cigarette smoking	16 (47.1)	82 (64.6)	0.097
Preference for cigarette smoking cessation methods			< 0.001
Counselling	5 (29.4)	16 (19.3)
Nicotine replacement therapy	3 (17.6)	6 (7.2)
Smokeless tobacco	3 (17.6)	10 (12.0)
E-cigarettes	3 (17.6)	0 (0.0)
Medications	1 (5.9)	1 (1.2)
Traditional medicines	0 (0.0)	4 (4.8)
Hotline	0 (0.0)	1 (1.2)
Others	2 (11.8)	45 (54.2)
Alcohol drinking	26 (63.4)	115 (87.1)	0.001

Current vapers and current smokers (N = 173)

^*Current vapers were defined as all e-cigarette users (including dual users), whereas current smokers referred to exclusive combustible cigarette smokers

Factors associated with vaping among university students

Table 4 presents the factors associated with current vaping among university students, comparing vapers, smokers, and never-users. Compared with current smokers only and never smokers, current vapers had significantly more observations of other people vaping and e-cigarette outlets near campuses. They also knew that e-cigarettes contained nicotine, but only a few of them were aware of the health consequences compared with the other two groups. Overall, university students had inadequate knowledge about the harm of vaping, specifically an increased risk of cancer, heart disease, stroke, and erectile dysfunction, and more addiction than combustible cigarettes. Moreover, current smokers and nonsmokers had twice as much knowledge that e-cigarettes were not approved for smoking cessation. Although vapers had less knowledge about the vaping policy than did the other two groups, they knew that the tobacco control policies also applied to e-cigarettes. Positive attitudes towards vaping were much more highly observed among current vapers than among other students. They perceived that vaping made them look cool, more socially acceptable, represented a new generation, and facilitated social interaction with friends.

Table 4.

Comparison of social circles, knowledge, attitudes toward vaping by vaping and smoking status among university students (N = 2108)

Factors	Current vapers (n = 41)	Current smokers (n = 132)	No vaping/smoking (n = 1935)	P value
Observation of other people vaping
Family members	16 (39.0)	8 (6.1)	107 (6.5)	< 0.001
Close friends	31 (75.6)	51 (38.6)	277 (16.8)	< 0.001
Classmates	26 (63.4)	28 (21.2)	650 (39.4)	< 0.001
Unknown people	28 (68.3)	59 (44.7)	675 (40.9)	0.002
Observation of EC outlets near  campus	21 (51.2)	22 (16.7)	183 (11.1)	< 0.001
Knowledge related to vaping
Total score (Mean (SD))	9.8 (4.0)	13.0.2 (2)	11.6 (3.8)	< 0.001
Health-related:
Contained nicotine	30 (73.2)	92 (69.7)	989 (60.0)	0.024
Harmful to health	11 (26.8)	94 (71.2)	1013 (61.4)	< 0.001
Risk of cancer	28 (68.3)	84 (63.6)	750 (45.5)	< 0.001
Risk of stroke	24 (58.5)	77 (58.3)	682 (41.4)	< 0.001
Risk of heart disease	26 (63.4)	78 (59.1)	693 (42.0)	< 0.001
Risk of erectile dysfunction	24 (58.5)	61 (46.2)	608 (36.9)	0.002
More addictive than combustible cigarettes	12 (29.3)	45 (34.1)	455 (27.6)	0.275
No evidence for smoking cessation aid	13 (31.7)	89 (67.4)	1033 (62.6)	< 0.001
Policy-related:
Prohibition of minor vaping	20 (48.8)	100 (75.8)	1111 (67.4)	0.005
Restriction of flavoured products	16 (39.0)	54 (40.9)	538 (32.6)	0.112
Prohibition of vaping in nonsmoking areas	22 (53.7)	84 (63.6)	946 (57.4)	0.324
Regulated by the tobacco control policy	22 (53.7)	28 (21.2)	153 (9.3)	< 0.001
Attitude towards vaping
It looked cool and socially  acceptable	25 (61.0)	29 (22.0)	214 (13.0)	< 0.001
Modernized and presented a new generation	20 (48.8)	3 (2.3)	47 (2.9)	< 0.001
Getting along with friends	13 (31.7)	4 (3.0)	24 (1.5)	< 0.001

Table 5 shows that males or younger students were at a greater risk of vaping than their peers. Specifically, males had 9.5 times the relative risk of being a current vaper compared to females. Observing an e-cigarette outlet, having other people vaping in social circles, and positive attitudes towards vaping increased the risk of vaping by 2.4, 2.3, and 1.7, respectively. The factors associated with current smoking were being male and alcohol drinking. Knowledge of health consequences and policy-related issues is slightly associated with both vaping and smoking.

Table 5.

Factors associated with current vaping and smoking among university students (N = 2259)

Factors	RRR (95%CI)
	Current vapers* (n = 41)		Current smokers* (n = 132)
Gender (male vs. female)	9.51*** (3.54 to 25.54)	10.15*** (5.70 to 18.08)
Age (years)	0.80* (0.66 to 0.97)	0.94 (0.87 to 1.02)
Alcohol drinking	1.41 (0.63 to 3.19)	6.70*** (3.90 to 11.52)
Health consequences and policy-related knowledge	1.15* (1.03 to 1.29)	1.14*** (1.08 to 1.20)
Positive attitude towards vaping	1.67*** (1.43 to 1.96)	1.09 (0.99 to 1.20)
Observation of vaping inside the social circle	2.25*** (1.58 to 3.19)	0.94 (0.74 to 1.21)
Observation of vaping outside the social circle	1.06 (0.43 to 2.57)	0.91 (0.59 to 1.41)
Observation of EC outlets near campus	2.36 (0.99 to 5.62)	1.41 (0.79 to 2.49)

The reference group consisted of individuals who had never vaped or smoked

RRR Relative risk ratio

^*Current vapers were defined as all e-cigarette users (including dual users), whereas current smokers referred to exclusive combustible cigarette smokers

^***p < 0.001; ^**p < 0.01^*p < 0.05

Discussion

To our knowledge, this is one of the first large-scale surveys conducted in China since the implementation of China’s National E-cigarette Regulatory Framework in 2022, through the Electronic Cigarette Management Measures, including clean air regulations, flavour limitations, and sales restrictions, particularly for minors and educational institutions. Our study reported the prevalence of ever, current, and past vaping was 8.8%, 1.9%, and 6.9%, respectively, among university students in Yunnan, China. The prevalence in our study was not significantly different from that in other cities, such as Hangzhou [21] (7.3% ever and 3.1% current, in 2020) and Shanghai [19] (4.6% ever and 1.7% current in 2018). However, the rates were lower than those reported in other countries, such as Thailand (28.5% ever, 12.6% current, 16.9% past), Saudi Arabia (37.1% ever, 14.7% current, 22.4% past), the UK (32.6% ever, 5.4% current, 27.2% past), the U.S. (19% ever, 9.2% current, and 9.8% past), Pakistan (68.4% ever, 42.2% current, 26.2% past), and Indonesia (36.4% ever, 13.2% current, 23.2% past) [27–32]. Although the current vaping rate in our study was low, almost 10% of university students had been exposed to vaping and started as early as their teenage years. A recent report estimated 86 million cases globally and 16.9 million vapers in China [33, 34].

Despite policies to protect minor from vaping, 30-day vaping among Chinese adolescents aged between 12 and 16 years was 9.5%, which was similar to the global average of 9.2% [35–39]. Our university students initiated either smoking or vaping at an average age of 15.5 years, which was consistent with the Chinese national data (15.9 years) [40] but slightly later than that among U.S. youth (14.7 years old) [41]. Underage individuals can easily access e-cigarettes from unregulated vendors via online sales, which often lack age verification [42–45]. Concrete measures, such as age-gating technologies using real-name authentication systems, third-party age-verification services, biometrics, and geofencing, must be strictly enforced [46]. Promotional activities related to vaping products should be banned on social media platforms frequently used by adolescents.

In addition, the industry has promoted sales to minors by making vaping devices look attractive, mimicking other daily products, and appealing by adding 10,000 varieties of flavours to them. Our study reported that appealing to flavours was the most common reason for vaping initiation, followed by smoking replacement, pleasure seeking, misperception that vaping was harmless, and nicotine addiction. However, studies in Western countries reported that the harmlessness of vaping was a primary reason for vaping, while socialization, enjoyment, and curiosity were also commonly cited [47]. The most common flavours reported in our study were fruity, tobacco, menthol, and mint, which is also consistent with other studies in China [43], the U.S [48]. , Australia [49] and Indonesia [50]. Since 2022, China has banned these flavours in addition to the tobacco-like flavour. However, public support for the ban has been limited, with concerns about personal freedom and autonomy in China and elsewhere [42, 44, 51, 52].

The industry claimed that vaping could aid smoking cessation [53]. Our study, however, showed that most current vapers were dual users, smoked more cigarettes, exhibited greater nicotine dependence, and had lower intentions to quit smoking than exclusive cigarette smokers did. A previous study from the U.S. reported that only 6.7% of dual users successfully quit, and 4.8% switched to exclusively vaping [54]. Therefore, vaping is not appropriate as a smoking cessation aid.

While vapers had lower awareness of harm due to vaping, a lack of evidence for smoking cessation aid, and vaping policy control, they had more positive attitudes toward e-cigarettes than their peers did. Adolescents and young adults with peers or family members who vape are more likely to initiate and continue use, particularly in the presence of permissive parental attitudes or reduced parental monitoring, whereas effective parent-child communication appears protective [55, 56]. As students also frequently vaped in social settings such as bars and at universities, this indicates that vaping is embedded in social and academic environments. Moreover, our study revealed that a positive attitude toward vaping and observing other vapers in their social network was associated with a twofold greater chance of vaping than a positive attitude toward both vaping and smoking.

Vaping is a real threat to public health. The US CDC reported that 68 vapers died of EVALI in 2019 [5]. Accumulated scientific evidence has shown that an increasing number of physical and mental diseases are associated with vaping, such as popcorn lung [57] and depression [58]. This raises significant concerns about the future health of the younger generation, particularly the risk of noncommunicable diseases.

Our findings recommend integrating e-cigarette-specific content into existing university health education and tobacco programs. It should target education and peer-focused interventions to address misperceptions, increase awareness of health risks and vaping regulations, and reduce vaping in public and on university campuses. National and university-level regulations should explicitly prohibit vaping in both indoor and outdoor public spaces on campuses to reduce secondhand exposure and prevent the visibility of vaping behaviour that may encourage imitation [59].

Strengths and limitations

A key strength of this study is the large sample size comprising students from diverse academic backgrounds. Social desirability bias could be reduced because the online questionnaire ensured that students’ information remained confidential. Moreover, they did not need to provide any personal information or identifiable data to complete the questionnaire. This could encourage more truthful responses. Recall bias may affect the precise age of onset; however, the accuracy was considered acceptable as reported ages fall within the memorable adolescent phase. Although the actual non-response rate could not be determined due to the online recruitment strategy, the completion rate was 100%. The results should be interpreted with caution regarding generalizability. The conclusions regarding causality are limited due to the cross-sectional design.

Conclusion

Despite China’s vaping control policy, this study highlights the need for further improvement, particularly in regulating the sale of vaping products to minors, controlling flavours, restricting online sales, and prohibiting public vaping. Moreover, there is an urgent need to increase public education about the harm due to vaping and vaping regulations, and to demoralize positive attitudes towards vaping. These policy gaps are not unique to China but also exist globally.

Abbreviations

EVALI

E-cigarette or Vaping Use-Associated Lung Injury

COPD

Chronic obstructive pulmonary disease

GATS

Global Adult Tobacco Survey

FTND

Fagerström Test for Nicotine Dependence

AUDIT

Alcohol Use Disorders Identification Test

Authors’ contributions

CH conducted the literature review, designed the study, carried out the survey, analysed the data, drafted the initial manuscript, and reviewed and revised the manuscript. RC also conducted the literature review, designed the study, interpreted the data, reviewed, and revised the manuscript. VC contributed to the study design. YL contributed to the study design and conducted the survey. All the authors reviewed the manuscript and agreed to its submission.

Funding

This study was supported by the Memorandum of Agreement for Research Grant for Thesis in the Fiscal Year 2024, Graduate School, Prince of Songkla University.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to participant privacy and ethical restrictions, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Human Research Ethics Committee at the Faculty of Medicine, Prince of Songkla University (No. 66-397-18-1). Informed consent was obtained from all the participants in the study. The study adhered to the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.