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Abstract
Background The present study aimed to examine the experience of actual electronic cigarette (e-cigarette) use in smoke-free areas of restaurants and workplaces and to explore the determinants associated with such use among Japanese adults who reported any experience using e-cigarettes (e-cigarette ever-users).
Methods An Internet-based self-reported questionnaire survey was conducted in 2015 on Japanese e-cigarette ever-users. The proportion of the respondents who had ever used or frequently used e-cigarettes in smoke-free restaurants and/or workplaces was calculated. Potential factors associated with e-cigarette use in those smoke-free areas were also examined by using multivariable logistic regression analyses.
Results In total, 1243 e-cigarette ever-users (662 current and 581 former e-cigarette users) were analysed. The majority of them (1020/1243, 82.1%) were male and their mean age ± SD was 47.0±10.4 years. The proportion of those who had ever used e-cigarettes in smoke-free restaurants was 28.8% (358/1243) and that in smoke-free workplaces was 25.5% (317/1243), respectively. The proportion of those who had frequently used e-cigarettes in smoke-free restaurants was 18.5% (230/1243) and that in smoke-free workplaces was 16.3% (202/1243), respectively. In general, the proportion of e-cigarette use in those smoke-free areas was higher among those having a higher educational level than those having a lower educational level.
Conclusion Among adult Japanese e-cigarette ever-users, approximately 26%–29% had ever used and 16%–19% had frequently used e-cigarettes in restaurants and/or workplaces where combustible tobacco smoking is not allowed. Policy-makers may need to establish explicit rules as to e-cigarette use in smoke-free environments.
- electronic cigarette
- Internet survey
- smoke-free area
- Japan
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Introduction
Since their introduction to market, electronic cigarettes (e-cigarettes) have sold exponentially.1 2 Originally invented by Chinese pharmacist Hon Lik in the early 2000s,3 e-cigarettes have been marketed to consumers as a less harmful alternative to conventional tobacco smoking.4 5 Some researchers consider e-cigarettes to be safer for both users and bystanders than conventional tobacco smoking,6–8 with potential to reduce the burden of smoking-related diseases and death.9 10 However, the actual health effects on users, the efficacy of e-cigarettes for cessation and the overall impact of e-cigarettes on public health are still under debate.11–16
E-cigarettes also have been marketed to consumers as a means of evading smoke-free policies.17 18 While the original aim of smoke-free policies was to protect non-smokers from secondhand smoke, such policies have been instrumental in denormalising smoking behaviour as well as lowering smoking prevalence, increasing quit-attempts and reducing tobacco consumption.19 The use of e-cigarettes in places where conventional tobacco smoking is prohibited could potentially renormalise tobacco smoking, sustain the dual use of e-cigarettes and tobacco, maintain nicotine addiction and complicate enforcement of smoke-free policies.2 20 21 The WHO recommends indoor use of e-cigarettes should be legally prevented, especially where smoking is banned, until reasonable evidence exists that the exhaled vapour is not harmful to bystanders and that smoke-free policy enforcement is not undermined.20 Considering the growing use of e-cigarettes worldwide,1 2 it is therefore important to monitor e-cigarette use in smoke-free public places. However, to our knowledge, only one previous study investigated the actual use of e-cigarettes in public places where conventional tobacco smoking is not permitted.22
Several types of e-cigarettes are currently available in Japan. The sale of e-cigarettes containing nicotine liquid is prohibited under the 2010 Pharmaceutical Affairs Act; their use in Japan is therefore limited to privately imported products. E-cigarettes that do not contain nicotine are not specifically regulated and are widely sold in Japanese marketplaces, even to minors. Two forms of non-liquid e-cigarette are also available for legal sale in Japan: Japan Tobacco’s ‘Ploom’ (introduced in December 2013), which vaporises tobacco leaves, and Philip Morris’s iQOS (introduced in November 2014), which heats tobacco leaves. Ploom and iQOS are legally regulated as tobacco products under the Tobacco Industries Act.
In an Internet survey conducted in 2015, we estimated that 6.6% of Japanese people had ever used some form of e-cigarette and 1.3% had used an e-cigarette in the last 30 days.23 There is currently no official restriction on e-cigarette use in public places in Japan; the only exception is the regulation enforced by The Hokkaido Railway Company, which prohibits e-cigarette use in trains and no-smoking areas within station buildings.24
We aimed to assess actual e-cigarette use in smoke-free areas of restaurants and workplaces and to explore factors associated with such use among Japanese e-cigarette ever-users. We focused on these places because of their relevance to smoke-free policies and smoking norms.25
Methods
Internet survey
A cross-sectional online survey of adult e-cigarette ever-users was conducted between 31 January and 9 February 2015. Participants were drawn from the register of Rakuten Research, one of Japan’s largest Internet research companies which maintains a pool of 2.3 million panellists covering all social categories (such as education, housing tenure and marital status) defined by the Japanese census.26 The study protocol was approved by the Research Ethics Committee of the Osaka Medical Center for Cancer and Cardiovascular Diseases in 2014 (no 1412175183).
Survey participants were randomly selected from 32 179 adult panellists (aged 20–69 years) who had previously reported ever user of e-cigarettes in two previous surveys conducted by Rakuten Research in 2013 and 2014. We aimed to collect data from 1600 panellists who had ever used e-cigarettes on a regular basis (800 current and 800 former users). The survey was closed when the target number of respondents who had answered all questionnaire items was met. In this survey, the term ‘e-cigarette’ refers to e-cigarettes containing nicotine, e-cigarettes without nicotine, Ploom and iQOS.23
Data collection
The outcome measure was self-reported e-cigarette use in restaurants or workplaces where tobacco smoking is not allowed. This was assessed using the question, “How frequently do (did) you use e-cigarettes in the following places where tobacco smoking is prohibited?” Respondents were asked this question in relation to restaurants (including cafés, taverns and bars) and workplaces with smoke-free policies. Individuals who replied ‘seldom’, ‘occasionally’ or ‘frequently’ were considered as ‘ever-users of e-cigarettes in smoke-free areas’, with those who replied ‘frequently’ defined as ‘frequent users of e-cigarettes in smoke-free areas’. Respondents were also asked their gender, age, combustible tobacco smoking status, educational level, and perceptions of e-cigarette risk to bystanders.
Quality control
To reduce the potential for overestimation or underestimation of outcome measures, invalid responses were excluded from the dataset. In order to ensure response consistency in relation to e-cigarette use, we also excluded respondents who replied that they did not know about e-cigarettes, had never tried e-cigarettes and had never used e-cigarettes in any places. In addition, those with inconsistent responses regarding their age and the number of household members were excluded from the analyses.23
Statistical analysis
The proportion of the respondents who had ever or frequently used e-cigarettes in smoke-free areas was calculated separately for smoke-free restaurants, workplaces and both restaurants and workplaces. Multivariable logistic regression models were used to assess the association between the respondents’ background characteristics and their e-cigarette use in smoke-free areas; ORs and their 95% CIs were calculated.
Results
We collected survey data from 1601 respondents (801 current and 800 former e-cigarette users, based on previous survey responses). Individuals who did not confirm e-cigarette use in this survey (n=358) were excluded, leaving 1243 e-cigarette ever-users (662 current and 581 former e-cigarette users). The majority (1020/1243, 82.1%) were male and their mean age±SD was 47.0±10.4 years.
Table 1 shows the proportion of the respondents who reported having used e-cigarettes in smoke-free restaurants and workplaces and the association of such use with other characteristics. The proportion of respondents who had ever and frequently used e-cigarettes in smoke-free restaurants was 28.8% (358/1243) and 18.5% (230/1243), respectively. The proportion of respondents who had ever and frequently used e-cigarettes in smoke-free workplaces was 25.5% (317/1243) and 16.3% (202/1243), respectively. The proportion of respondents who had ever and frequently used e-cigarettes in both smoke-free restaurants and workplaces was 17.5% (218/1243) and 8.5% (106/1243), respectively. In general, use of e-cigarettes in smoke-free areas was higher among those respondents with a higher educational level. Online supplementary table 1 shows the same data for the subset of respondents who reported current e-cigarette use; the results are similar to those for ever-users and current-e-cigarette users combined.
Supplemental material
Proportion of e-cigarette ever-users reporting e-cigarette use in smoke-free restaurants and workplaces (n=1243)
Discussion
This study examined reported use of e-cigarettes in restaurants and workplaces where combustible tobacco smoking is not allowed among adult e-cigarette ever-users in Japan. Approximately 30% of them have ever used and 20% have frequently used e-cigarettes in smoke-free areas of restaurants and workplaces. These results suggest that many e-cigarette users do not consider e-cigarettes to be covered by current smoke-free policies and that this may result in a degree of interference with existing tobacco-control efforts.
WHO reports that 49 countries have smoke-free legislation covering all public areas;27 yet, the national government of Japan has not yet implemented national-level legislative smoking bans in restaurants and workplaces. While an increasing proportion of restaurants have introduced their own smoke-free policies, smoking is still permitted in many restaurants in Japan.28 As for workplaces, many organisations have installed designated smoking rooms.28 Thus, tobacco control measures in Japan are currently the weakest in the developed world.27 There is a concern that e-cigarette use in smoke-free areas will make enforcement of smoke-free policies more complicated and undermine social norms that discourage tobacco smoking.2 20 21 Our findings provide important information for future research and for planning appropriate countermeasures against e-cigarette use in community settings.
Our results showed a lower proportion of e-cigarette use in smoke-free places than a previous study conducted in the USA, which reported that 59.5% of e-cigarette users had vaped where cigarette smoking was not allowed.22 We recently estimated that 6.6% of Japanese people have ever used e-cigarettes and 1.3% have used in the last 30 days;23 thus, the prevalence of e-cigarette use is still low in Japan and the impact of e-cigarette use in smoke-free areas may be small so far. If the popularity of e-cigarettes continues to increase, however, there is growing potential for e-cigarette use to interfere with smoke-free policies. There is no official policy restricting e-cigarette use in public places in Japan; policy-makers should therefore consider establishing explicit rules regarding e-cigarette use in smoke-free environments.
Limitations
This study has several limitations. First, the results may not apply to other countries. Considering that marketing strategies, regulation and other environmental circumstances will vary between countries, patterns of e-cigarette use and the impact on public health could differ. Second, the questionnaire survey was carried out with a convenience sample of those who had voluntarily registered themselves as internet research panellists, so our study subjects may not be representative of all e-cigarette users in Japan. In addition, since the survey was completed when the target sample size was reached, we could not determine the exact participation rate. In order to estimate the approximate participation rate, we designed a parallel survey that consisted of part of the present survey. An invitation email for the survey was sent to 2400 panellists who were randomly selected from the target population (ie, Internet research panellists who had previously reported e-cigarette use). According to this parallel survey, the participation rate after 6 days was estimated to be 32.2% (773/2400). Third, the validity of the questionnaire items was not confirmed. Considering that approximately 20% of respondents were excluded following a response consistency check, our data quality is considered to be low. These limitations may have caused overestimation or underestimation of the outcomes of interest, and our results should be interpreted with caution. However, we believe our survey design and exclusion of responses lacking internal consistency have minimised likely sources of bias so far as is possible.
Conclusion
In conclusion, 26%–29% of adult Japanese e-cigarette ever-users have ever used e-cigarettes in restaurants and/or workplaces where combustible tobacco smoking is not allowed and 16%–19% are frequent users. Policy-makers may need to establish explicit rules regarding e-cigarette use in smoke-free environments. Continued monitoring of e-cigarette use is necessary to assess their impact on tobacco control policies and development effective policy responses.
What this paper adds
Electronic cigarettes have been marketed via various types of advertising media as a less harmful alternative to combustible tobacco smoking and as a means of evading smoke-free policies.
Permitting the use of e-cigarettes in places where tobacco smoking is not allowed could renormalise tobacco smoking and complicate enforcement of smoke-free policies.
The actual usage of e-cigarettes in places where combustible tobacco smoking is not allowed is poorly understood.
The proportion of e-cigarette ever-users who had ever used e-cigarettes in smoke-free restaurants was 28.8% and that in smoke-free workplaces was 25.5% in Japan.
The proportion of those who had frequently used e-cigarettes in smoke-free restaurants was 16.3% and that in smoke-free workplaces was 18.5%.
Acknowledgments
We gratefully acknowledge Dr Paul Matychuk for language support.
References
Footnotes
KK and TT contributed equally.
Contributors Both authors conceptualised the study, wrote the manuscript and conducted the statistical analyses.
Funding This study was supported by the Ministry of Health, Labour and Welfare: Comprehensive Research on Life-Style Related Diseases including Cardiovascular Diseases and Diabetes Mellitus (H25-010, H26-023 and H28-002).
Competing interests None declared.
Patient consent The Internet panellists of Rakuten Research agreed to their participation in research surveys.
Ethics approval The Research Ethics Committee of the Osaka Medical Center for Cancer and Cardiovascular Diseases in 2014 (no 1412175183).
Provenance and peer review Not commissioned; externally peer reviewed.