Article Text

Perceptions of and responses of young adults who use e-cigarettes to flavour bans in China: a qualitative study
  1. Xue Weng1,
  2. Chu Yu Song2,
  3. Kefeng Liu3,
  4. Yongda Socrates Wu4,
  5. Jung Jae Lee4,
  6. Ningyuan Guo5,
  7. Man Ping Wang4
  1. 1Institute of Advanced Studies in Humanities and Social Sciences, Beijing Normal University, Zhuhai, China
  2. 2School of Social Development and Public Policy, Beijing Normal University, Beijing, China
  3. 3Department of Pulmonary and Critical Care Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine, Zhuhai, Guangdong, China
  4. 4LKS Faculty of Medicine, School of Nursing, The University of Hong Kong, Hong Kong, China
  5. 5School of Nursing, Shanghai Jiao Tong University, Shanghai, China
  1. Correspondence to Dr Xue Weng, Institute of Advanced Studies in Humanities and Social Sciences, Beijing Normal University, Zhuhai, China; xueweng{at}bnu.edu.cn; Dr Ningyuan Guo, School of Nursing, Shanghai Jiao Tong University, Shanghai, China; nyguo{at}shsmu.edu.cn

Abstract

Background China has banned all flavoured e-cigarettes to reduce e-cigarette use among young people, but little is known about the views and reactions of people who use e-cigarettes. This study explored the perceptions of, and responses by, young adults who use e-cigarettes to the flavour ban.

Methods Semistructured interviews were conducted with 25 Chinese young adults aged 18–25 years who had used e-cigarettes daily in the past 3 months. Thematic analysis was used to analyse the interview data.

Findings Four themes were identified from the data: (1) understanding of the public health benefits, (2) resistance to and misperceptions of the flavour ban, (3) circumvention of the flavour ban and (4) acceptance of the flavour ban. Some participants expressed support for the ban due to perceived public health benefits, while others who resisted the ban emphasised their right to choose preferred flavours and questioned the rationale behind the policy. Participants responded to the flavour ban by utilising a variety of adaptive strategies, including purchasing flavoured e-cigarettes through illegal channels or exploring alternative ways to obtain flavours. Those who complied with the ban responded with different strategies, including switching back to combustible cigarettes, using tobacco-flavoured e-cigarettes, or quitting vaping.

Conclusions The findings suggest the need for comprehensive regulatory measures, including stringent enforcement measures, transparent health communication and vigilant monitoring of e-cigarette manufacturers’ tactics, to reduce e-cigarette use among young adults.

  • Electronic nicotine delivery devices
  • Public policy
  • Prevention

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Flavour is the main factor that attracts young adults to e-cigarettes.

  • The views and reactions of Chinese young adults who use e-cigarettes to the country’s e-cigarette flavour ban are unexplored.

WHAT THIS STUDY ADDS

  • Participants expressed mixed views on the flavour ban; some supported it due to its public health benefits, while others held misperceptions and opposed it.

  • Participants continued to access and use banned flavours from illicit sources or flavour capsule cigarettes.

  • The flavour ban motivated some participants to switch to tobacco-flavoured e-cigarettes or tobacco-flavoured e-cigarettes or quit vaping.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Clear communication is essential to reduce misconceptions and boost public support for flavour bans.

  • Stringent enforcement measures are needed, and banning all flavoured tobacco products may prevent young people from switching to other flavoured products.

Background

China is the world’s largest producer of e-cigarettes, accounting for approximately 90% of the global market.1 Many Chinese e-cigarette enterprises, such as RELX, YOOZ and MOTI, have used various marketing tactics to attract young consumers, such as sleek designs, flavours, discounts, free samples and vapour cloud competitions.2 These tactics have increased positive attitudes towards e-cigarettes and prevalence of their use among Chinese youth.3 4 In 2021, 16.1% of middle school students and 10.1% of college students in China had ever used e-cigarettes,5 compared with 5.0% in the general population.4 Flavours such as fruit, candy and mint/menthol are found to be the primary attraction for young adults (aged 18–24 years) compared with older adults (≥25 years).6 Flavours increase product appeal,6 e-cigarette initiation and regular use7 and facilitate the transition from combustible cigarettes to e-cigarettes.8 Flavours also pose potential risks, as they mask the harshness of the tobacco taste9 and reduce perceptions of the harm of e-cigarettes.10 Moreover, some disposable flavoured e-cigarettes, such as ‘milk tea cups’ and ‘coke cups’ that imitate the taste and packaging of milk tea and Coca-Cola, have gained popularity among Chinese youth.11 These products raise concern because they might attract young people who do not regularly smoke and increase nicotine dependence. According to a Chinese national tobacco survey, 90.6% of people who currently use e-cigarettes also use combustible cigarettes.4 The dual use of cigarettes and e-cigarettes may exacerbate nicotine addiction and impede smoking cessation.12

Policies have been implemented to ban or restrict the sale of flavoured e-cigarettes in many countries. In 2020, the USA announced a policy to restrict the sale of non-tobacco and non-menthol flavoured e-cigarettes, with at least 10 states enacting flavour bans (some including menthol) as of May 2023.13 European countries such as Finland prohibit non-tobacco flavours,14 whereas Denmark bans non-tobacco and non-menthol flavoured e-cigarettes.15 Some Asian countries/territories, such as Singapore, Thailand and Hong Kong SAR, have banned the sale of e-cigarettes of any flavour.16 17 In mainland China, e-cigarettes were in a regulatory grey zone before 2018.18 The state-owned China National Tobacco Corporation (CNTC) or the State Tobacco Monopoly Administration (STMA) is responsible for the production and sale of tobacco products as well as the enforcement of tobacco control policies and regulations.19 In 2018, a notice was issued by the STMA and the State Administration for Market Regulation to ban the sales of e-cigarettes to minors, marking the first nationwide regulation on e-cigarettes.20 In 2019, another notice was released to ban the sale of e-cigarettes through online platforms.21 With the amendment of the Tobacco Monopoly Law in 2021, the STMA officially incorporated e-cigarettes into the tobacco regulation framework.22 In October 2022, China adopted new national standards for e-cigarettes and implemented a nationwide flavour ban on the sale of non-tobacco-flavoured e-cigarettes.23

Previous studies examining flavour bans or sale restrictions have yielded mixed results. Longitudinal studies in the USA and Canada have found that such policies increased smoking cessation and reduced e-cigarette initiation.24–26 However, studies based on hypothetical scenarios have indicated the possibility of unintended consequences, such as the initiation of or transition to combustible tobacco use and an increase in illegal purchases of e-cigarette flavours.27–30 Our updated literature search in PubMed (up to November 2023) using the keywords ‘e-cigarette’, ‘vaping’, ‘flavour’ and ‘China’ found no research assessing the impact of flavour bans in China.

This qualitative study aimed to explore how young adults who use e-cigarettes perceived and reacted to the flavour ban in China.

Methods

Study design

We conducted a qualitative study using semistructured, in-depth interviews with young adults in China who currently use e-cigarettes. Interviews were conducted between November 2022 and January 2023, 1–3 months after the implementation of the nationwide flavour ban in October 2022.

Sampling and recruitment

Young adults aged 18–25 years who used e-cigarettes daily during the past 3 months were recruited using purposive and snowball sampling strategies (figure 1). Recruitment details were posted on widely used social media platforms in China (ie, WeChat Moments and groups). Potential participants who currently used e-cigarettes completed a short online survey on their sociodemographic characteristics and current e-cigarette use. This information was used to select participants. As recruitment proceeded, we used snowball sampling to obtain a sample with diverse vaping experiences and sociodemographic backgrounds.

Figure 1

Participant recruitment flowchart.

Data collection

A total of 25 individual interviews were conducted using an interview guide with open-ended questions. The guide (see online supplemental file 1) covered a range of topics, including participants’ experiences of using e-cigarettes and their perceptions of reactions to the flavour ban. The findings from the interviews became repetitive after 22 interviews, and three further interviews were conducted to confirm information redundancy (ie, no new information arising from new interviews). Two members of the research team (XW and CYS) conducted the interviews. Ten interviews were conducted face-to-face and 15 were conducted online. The interviews lasted 60–90 min. We offered a cash incentive of 80 RMB (approximately 12 US$) to each participant. All interviews were audio-recorded and transcribed verbatim.

Supplemental material

Data analysis

A thematic analysis approach was used to analyse the interview data. XW and CYS led the data analysis and followed the six-stage process outlined by Braun and Clarke.31 The analysts conducted a line-by-line coding process to gain a more comprehensive understanding of the raw data and to identify recurring patterns as well as to explore possible interpretations. After a thorough reading of the data, the analysts labelled codes based on more extensive concepts, which were subsequently grouped into significant themes. Any disagreements on themes and codes were discussed with the research team for resolution. NVivo 12 software was used to support the data analysis.

The interview transcripts were analysed in the original Chinese. Key findings are illustrated using pseudonymised verbatim quotations. Selected quotes were translated into English and then back-translated by two bilingual researchers (who were proficient in Chinese and English) to ensure accuracy.

Results

Participant characteristics

The participants’ demographics and patterns of e-cigarette use are presented in table 1, and details of each participant are shown in online supplemental table S1. Our sample comprised 25 participants with a mean age of 22.5 years (SD=1.6). The majority of participants were men (52%). Ten participants used e-cigarettes exclusively, and 15 used cigarettes and e-cigarettes. Twenty three participants used RELX as their main brand and all had used fruit or fruit beverage flavours, followed by menthol/mint (n=15), coffee/tea (n=14) and candy (n=8) e-cigarette flavours.

Table 1

Participants’ demographics and smoking patterns (N=25)

Four main themes were identified: understanding of the public health benefits, resistance to and misperceptions of the flavour ban, circumvention of the flavour ban, and acceptance of the flavour ban.

Perceptions of the flavour ban

Understanding of the public health benefits

Preventing youth initiation

Participants perceived the flavour ban as a positive step to prevent youth initiation, particularly those who engaged in experimental use without establishing regular usage patterns.

There are definitely many benefits to a flavour ban. I saw many middle and high school students vaping. (The flavour ban) might deter their attempts. As for myself, I'm the kind of person who can choose whether or not to use e-cigarettes (ID17, M-21, exclusive e-cigarette use).

One participant mentioned the misleading packaging of fruit-flavoured milk tea cups and believed that removing flavours would make such products less appealing to young people.

I support the flavour ban. The packaging of the “milk tea cup” looks harmless; who wouldn't want to have a sip of milk tea? From a broader perspective, if the fruit flavour is removed, then the milk tea cup will not induce minors to smoke. Therefore, banning flavoured e-cigarettes is good (ID6, F-23, dual use).

Protecting public health

Participants recognised the public health benefits of the flavour ban, which could reduce e-cigarette usage and consequently lower the risk of secondhand e-cigarette aerosol, given that flavours in e-cigarette aerosol may harm others.

I absolutely support the flavour ban because e-cigarettes contain nicotine, and their second-hand aerosol is also harmful. It is not true that second-hand aerosol from e-cigarettes is harmless (ID9, M-21, dual use).

One participant expressed concern that the flavours in e-cigarette aerosols may mislead people to perceive these products as safer than combustible cigarettes. This participant supported the ban and prioritised public health benefits over self-centred considerations.

Some people believe that flavoured e-cigarettes are safer and nontoxic compared to traditional cigarettes, but I think that sweet-smelling aerosol is misleading and still has health risks. If we adopt a more responsible, ethical stance and avoid self-centeredness, it is still a type of tobacco product that harms public health (ID17, M-21, exclusive e-cigarette use).

Resistance and misperceptions of the ban

Access, choice, and personal freedoms

Despite public health benefits, participants who were resistant to the flavour ban clarified that they did not take into account the broader social responsibility to prevent youth initiation. The primary concern was whether the ban impacted them personally.

I oppose the flavour ban, perhaps out of selfishness. I didn't give much thought to the broader social responsibility and was only concerned about whether the ban affected me personally (ID15, M-22, exclusive e-cigarette use)

Participants argued that the flavour ban violated their freedom of choice and restricted their access to preferred e-cigarette flavours.

This should be a matter of free trade. Flavours should not be forcefully removed to restrict our choices (ID16, F-24, exclusive e-cigarette use).

Conspiracy of the conventional tobacco industry

Participants doubted the independence of the tobacco control policy from industry because of the shared entities of the CNTC and STMA. They believed that the manufacturers of combustible cigarettes had significant influence over government policies and that a flavour ban was a strategy to limit competition from e-cigarettes.

Sometimes I don't really understand why the government (STMA) bans things like fruit-flavoured products. It’s not in line with the idea of reform and opening up. It’s like the e-cigarette products have already taken over the traditional tobacco market. It’s unfair to change policies on flavours (ID2, F-20, dual use).

From my perspective, e-cigarettes and traditional cigarettes are in competition with each other. The restriction on e-cigarette flavours perhaps aims to promote cigarette consumption and protect the traditional tobacco manufacturers under the CNTC (ID24, F-21, exclusive e-cigarette use)

Responses to the flavour ban

Circumvention of the flavour ban

Seeking flavoured e-cigarettes through illegal sources

Participants repeatedly remarked on the insufficient regulations of flavoured e-cigarette online trade in China. Before the ban, there was already a well-established online black market where unauthorised e-cigarettes made by small workshops were sold on platforms such as Taobao (a popular online shopping website) and WeChat Moments (a semi-closed social network). Despite the flavour ban, participants reported that they were able to purchase flavoured e-cigarettes through unregulated channels.

People who use e-cigarette users have turned to WeChat sellers to purchase foreign edition RELX pods, such as US or overseas editions. I buy them through WeChat sellers (after the flavour ban) (ID14, M-21, dual use).

Once I bought an e-cigarette protective case on Taobao. It included a small business card advertising the sale of fruit-flavoured pods, which are banned from online sales. I added them as a friend on WeChat. The seller posted the pods through their WeChat Moments, which is how I kept buying e-cigarette products through online sellers (ID20, F-25, exclusive e-cigarette use).

One participant noticed an increase in black market sales after the implementation of the flavour ban, similar to the situation during the US alcohol prohibition era.

I feel that the flavour ban has not had much effect because there are still many selling these fruit-flavoured products on WeChat Moments. Interestingly, I didn’t see many advertisements for these products before October, but after the ban, there has been an increase in the number of advertisings. It’s comparable to the US alcohol prohibition era, where the scarcity of alcohol caused an increase in the black market. The same thing is happening now (ID19, M-22, exclusive e-cigarette use).

However, participants were concerned that black market products are more dangerous or less regulated than products sold through authorised channels.

Some online sellers are selling e-cigarettes from unlicensed small workshops. These products may contain numerous additives that don't meet safety standards. Because of this (safety concerns), I am hesitant to use them (ID22, F-24, exclusive e-cigarette use).

Exploring alternative means of obtaining flavours

Due to dissatisfaction with tobacco-flavoured e-cigarettes, other participants explored alternative means of obtaining flavours. One participant reported purchasing a custom-made cartridge cover for tobacco-flavoured e-cigarettes that contained a crushable capsule capable of releasing flavours such as menthol.

I tried two types of tobacco flavours, the roasted and mild tobacco, but I cannot accept either of them because both are too harsh on my throat. I would cough every time I took a puff. …So I bought a cartridge cover that had a filter with a capsule. When the capsule is crushed, it can release a flavour and produce a sensation similar to that of capsule cigarettes (ID14, M-21, dual use).

Flavour capsule cigarettes are increasingly used as an alternative to flavoured e-cigarettes, especially among young women who smoked. One participant mentioned the use of flavour capsule cigarettes as a way to experience sensations similar to flavoured e-cigarettes.

Many girls enjoy flavour capsule cigarettes, while boys tend to prefer unflavoured cigarettes. Currently, I use coconut-flavoured capsule cigarettes. (Despite the flavour ban) it appears that I still prefer using flavoured e-cigarettes to some extent…You squeeze the capsule, and the tobacco begins burning while producing a coconut flavour upon inhalation (ID2, F-20, dual use).

Acceptance of the flavour ban

Switching to combustible cigarettes or tobacco-flavoured e-cigarettes

Participants who used both cigarettes and e-cigarettes explained that the availability of flavours was a key factor in their decision to switch from combustible cigarettes to e-cigarettes. They reverted to using combustible cigarettes if they could not access their preferred flavours.

I initially turned to e-cigarettes as a substitute for combustible cigarettes. E-cigarettes produced a gentler throat hit and were less disruptive to other people in public places…(After the flavour ban) I can’t find my preferred flavours and find it difficult to tolerate the taste of tobacco flavours. I returned to smoking cigarettes (ID18, M-22, dual use).

Due to safety concerns about black market products, participants stated that they would switch to combustible cigarettes in response to the flavour ban.

Since the flavour ban, many nonbranded e-cigarettes like milk tea cups have emerged…I feel uncomfortable using nonbranded products myself and haven't purchased any. I continue to smoke combustible cigarettes (ID23, F-22, dual use).

While the taste of tobacco-flavoured e-cigarettes was not preferred, participants claimed that they would opt for tobacco-flavoured e-cigarettes because they could be used inconspicuously in public settings.

I noticed that many public places like shopping malls do not have a complete ban on e-cigarettes. Therefore, e-cigarettes are more convenient than combustible cigarettes. I will switch to tobacco-flavoured ones (ID25, F-24, dual use).

Quitting vaping

People who exclusively used e-cigarettes expressed the intention to quit vaping in response to the flavour ban. They had a low preference for combustible cigarettes and perceived the ban as an opportunity to stop using e-cigarettes.

I don’t smoke combustible cigarettes because I do not enjoy smoking them. I plan to quit vaping as I do not have a strong nicotine addiction and do not feel the urge touse e-cigarettes (ID17, M-21, exclusive e-cigarette use).

I'm now 25 years old and looking for a partner… A potential partner would prioritise health and express concern about my vaping habit, possibly even asking me to quit for the benefit of our health and relationship. I plan to quit vaping (after the flavour ban was implemented) (ID20, F-25, exclusive e-cigarette use).

Discussion

Our study provides novel evidence of the perceptions of and responses to flavour bans among young adults who use e-cigarettes in mainland China. Consistent with US qualitative research,32 participants’ views on the flavour ban differed. While some participants expressed support for the ban due to its public health benefits, the majority showed resistance to the ban by emphasising their right to choose preferred flavours and by questioning the rationale behind the policy. We found a variety of adaptive strategies in response to the flavour ban. Participants circumvented the flavour ban by purchasing flavoured e-cigarettes through illegal channels and exploring alternative means to acquire flavours. Participants who complied with the ban adopted different strategies, such as switching back to combustible cigarettes or tobacco-flavoured e-cigarettes or quitting vaping. Our study provides evidence that the Chinese government should review and strengthen its policies on e-cigarette regulation. Flavour bans may not be sufficient to reduce the widespread use and availability of flavoured e-cigarettes in the black market. Comprehensive regulatory measures and a total ban of all flavoured tobacco products without exception are needed.

Our results showed that participants’ views on the flavour ban were influenced by their personal/public interests regardless of their exclusive/dual use patterns. Participants who prioritised public health benefits favoured the flavour ban, which is in line with a prior survey of US young adult e-cigarette users.28 Participants who perceived the flavour ban as a violation of their freedom and used flavoured e-cigarettes as substitutes for combustible cigarettes opposed the flavour ban as it limited their options. As a result, they chose to circumvent the ban rather than comply with it. Additionally, we found that young smokers interpreted the intent of the flavour ban as a benefit to the manufacturers of combustible cigarettes. This interpretation could be attributed to the shared entities of the CNTC and STMA,19 leading to a sense of mistrust in government tobacco control policies. Such claims may be created by e-cigarette industry tactics to undermine support for the flavour ban.33 Policymakers should prioritise clear and open communication about the intent of the policy to protect minors from attempting to obtain flavours. This is important to increase public support for the policy and prevent misconceptions.

Regarding the response to the flavour ban, we found different patterns based on the participants’ exclusive/dual use patterns. Consistent with prior research,32 our study found that the flavour ban has the potential to motivate people who use e-cigarettes to quit vaping, particularly among exclusive users who do not prefer tobacco flavours. People who previously had dual use reported switching to either tobacco-flavoured e-cigarettes or combustible cigarettes after the flavour ban implementation. There have been concerns that flavour bans could discourage people with dual use from using e-cigarettes as a means of smoking cessation.34 However, we found that young adult with dual use perceived flavoured e-cigarettes as a substitute for combustible cigarettes mainly for convenience reasons and not as a cessation tool.

Despite the flavour ban, participants continued to use prohibited flavours, either by using their own stockpile or purchasing from illegal sources. Importantly, the black market existed before the flavour ban and the ban itself is not the cause of black market sales, which many participants misunderstood. Instead, ineffective policy enforcement enables this market to grow. Black market products may contain additional harmful chemicals and adulterants,35 exacerbating the products’ health risks. Some participants admitted that black market products were less attractive due to safety and security concerns. Future studies should explore the extent and impact of this black market as well as the drivers and patterns of consumers and sellers. These studies could provide valuable insights into the characteristics and consequences of the black market for flavoured e-cigarettes in China and inform the development and implementation of effective policies and interventions to address this issue. Furthermore, robust enforcement and strong supervision of the enforcement process are necessary to ensure the effective implementation of flavour bans,36 particularly for exported e-cigarettes that are sold domestically and black market sales.

We found that flavour capsule cigarettes were very popular among young people,37 with many using them as an alternative to flavoured e-cigarettes. In line with prior research,28 34 38 our study found that a total ban of all flavoured tobacco products without exception may be effective in preventing young people from switching to alternative flavoured tobacco products. Moreover, e-cigarette manufacturers should be closely monitored2 for attempts to undermine the intended effects of the flavour ban. For instance, we found that some manufacturers produce cartridge covers with crushable capsules that allow consumers to add preferred flavours to tobacco-flavoured e-cigarettes, thus circumventing the flavour ban.

The primary limitation of this study is that the qualitative data were collected within 6 months of the implementation of the flavour ban. Caution should be used in evaluating the impact of the flavour ban and interpreting the study findings. Long-term monitoring is warranted to track whether the perceptions and reactions of young adults who use e-cigarettes change over time. Furthermore, the majority of our participants were university students with relatively high educational levels. Our participants were from 14 provinces across China, and we purposely collected data from people who had both exclusive e-cigarette use and dual use of other tobacco products to ensure sample diversity. There is potential variation in the data obtained by different interview methods (in person or online). However, no differences were observed between the two groups of participants in terms of the themes, subthemes and codes that emerged from the data analysis.

Conclusion

Comprehensive regulatory measures, including stringent enforcement measures, transparent health communication and vigilant monitoring of e-cigarette manufacturers’ tactics, are needed to reduce the prevalence of e-cigarette use among young adults.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by the research ethics committee of the School of Social Development and Public Policy at Beijing Normal University. Participants gave informed consent to participate in the study before taking part.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors XW and NG conceived and designed the study. XW and CYS conducted the interviews and analysed the data. XW wrote the first draft of the manuscript. XW, CYS, and NG interpreted the data. KL, YSW, JJL, and MPW participated in the critical review of the manuscript. XW is the guarantor, taking full responsibility for the study, data access, and publication decisions. All authors approved the final submission.

  • Funding This work was support by the Start-Up Fund of Beijing Normal University, Zhuhai (310432104).

  • Competing interests No, there are no competing interests.

  • Provenance and peer review Not commissioned; externally peer-reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.