See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/323493334

Prevalence and characteristics of e-cigarette use among adults

in Malaysia

Article in Tobacco Induced Diseases · March 2018

DOI: 10.18332/tid/83854

CITATIONS READS

2 2,033

8 authors, including:

Jamalludin Ab Rahman Mohamad Haniki Nik Mohamed

International Islamic University Malaysia International Islamic University Malaysia
135 PUBLICATIONS 1,192 CITATIONS 91 PUBLICATIONS 888 CITATIONS

SEE PROFILE SEE PROFILE

Muhammad Fadhli Mohd Yusoff Norny Syafinaz Ab Rahman

Ministry of Health Malaysia International Islamic University Malaysia
129 PUBLICATIONS 18,265 CITATIONS 39 PUBLICATIONS 410 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Mohamad Haniki Nik Mohamed on 28 October 2020.

The user has requested enhancement of the downloaded file.

834735
research-article2019
APHXXX10.1177/1010539519834735Asia Pacific Journal of Public HealthAb Rahman et al

Article
Asia Pacific Journal of Public Health
2019, Vol. 31(7S) 9S­–21S
The Prevalence of E-Cigarette © 2019 APJPH
Article reuse guidelines:
Use Among Adults in Malaysia sagepub.com/journals-permissions
DOI: 10.1177/1010539519834735
https://doi.org/10.1177/1010539519834735
journals.sagepub.com/home/aph

Jamalludin Ab Rahman, MD, MPH1 ,

Muhammad Fadhli Mohd Yusoff, MD, MPH2,
Mohamad Haniki Nik Mohamed, BPharm, PharmD1,
Balkish Mahadir Naidu, MSc2,
Kuang Hock Lim, MSc, Dip Public Health3,
Guat Hiong Tee, BBioMedSC, MMedSc2,
Maria Safura Mohamad, MBChB, MSc2,
Mira Kartiwi, MInfoSys, PhD1 , Samsul Draman, MMed1,
Norny Syafinaz Ab Rahman, MPharm, PhD1,
and Tahir Aris, MD, MPH2

Abstract
Electronic cigarettes (e-cigarettes) are a new method for the consumption of nicotine.
A nationwide survey among 4288 Malaysian adults was conducted in 2016 to measure the
prevalence and to describe the population characteristics of e-cigarette users. A complex
sampling design was used, and data were collected using a face-to-face questionnaire. The overall
prevalence of current, ever, former, and dual users of e-cigarettes in Malaysia were 3.2% (95%
confidence interval [CI] = 2.5-4.1), 11.9% (95% CI = 10.5-13.5), 8.6% (95% CI = 7.5-9.8), and
2.3% (95% CI = 1.8-3.1), respectively. The prevalence of all type of e-cigarette use was higher in
urban than in rural areas. Current e-cigarette users were likely to be younger, males, and with
higher education level. Among current e-cigarette users, 74% (95% CI = 64-82) also smoked
conventional cigarettes (dual user). E-cigarette use is prevalent in Malaysia. It is common among
younger adults, males, and cigarette smokers.

Keywords
electronic cigarette, survey, complex sampling, population, Malaysia

What We Already Know

•• Prevalence of e-cigarette use among adults was reported ranging from 6-13% in most
western countries and data on the prevalence of e-cigarette use among adults in Asian
countries is lacking

1International Islamic University Malaysia, Kuantan, Malaysia

2Institute for Public Health, Ministry of Health, Kuala Lumpur, Malaysia
3Institute for Medical Research, Ministry of Health, Kuala Lumpur, Malaysia

Corresponding Author:
Jamalludin Ab Rahman, MD, MPH, Department of Community Medicine, Kulliyyah of Medicine, International Islamic
University Malaysia, 25250 Kuantan, Malaysia.
Email: arjamal@iium.edu.my
10S Asia Pacific Journal of Public Health 31(7S)

•• Many studies reported that e-cigarette users were commonly those who wish to quit con-
ventional cigarette smoking, hence we expect higher number of current e-cigarette users
are former cigarette smokers.

What This Article Adds

•• The overall prevalence of current, ever, former, and dual users of e-cigarettes in Malaysia
were 3.2%, 11.9%, 8.6%, and 2.3%, respectively.
•• More than 70% of current e-cigarette users were found to be conventional cigarette smok-
ers as well, and only 14% were former cigarette smokers.

Introduction
Electronic cigarettes (e-cigarettes) or electronic nicotine delivery system have become a world-
wide phenomenon since their introduction into the market in 2004.1,2 E-cigarettes are battery-
powered devices that enable the vaporization of a solution usually containing propylene glycol,
glycerol, and flavoring agents, with or without nicotine. A rising prevalence of e-cigarette use has
been reported in several countries. In the United States, ever e-cigarette users increased from 1.8%
(2010) to 13.0% (2013) of the adult population, while current users increased from 0.3% to 6.8%.3
Ever-users and current users of e-cigarettes in New Zealand in 20144 were 13.1% and 0.8% of
adults, respectively; while in the United Kingdom, current adult e-cigarette users increased from
2.7% to 6.7% in 2010 and 2012.5 In 2017, the prevalence of current e-cigarette use was 5.5%,
representing 2.8 million of the population in Great Britain. This figure is significantly higher than
3.7% observed in 2014.6 In the United States, e-cigarette users were more likely to be younger,
males, non-Hispanic white, nonmarried, poorer, and conventional cigarette smokers.7
E-cigarette use or vaping is still relatively new for many countries including Malaysia. In
2011, the Global Adult Tobacco Survey reported that the awareness of e-cigarettes in Malaysia
was 21% and 0.8% of adults were current users. Use was higher among male, younger, more
educated, and wealthier respondents. The same survey also reported the prevalence of current use
of e-cigarette to be 0.3% in Indonesia, 0.9% in Qatar, and 1.9% in Greece.8 The International
Tobacco Control 2014 Malaysian survey shows that 62% of smokers were aware of e-cigarettes,
19% had tried one, and 14% were current users.9
Stakeholders have raised various issues about e-cigarettes, including the call for regulations,
and concerns over the long-term safety of use as well as questions over their effectiveness to help
tobacco smokers quit smoking.10-13 Policy makers need unbiased (nonindustry related) informa-
tion to make informed decisions. Hence, the Malaysian Ministry of Health conducted research to
ascertain a national estimate for the prevalence of e-cigarette use and the characteristics of users
among the Malaysian population.
This article presents the prevalence of e-cigarette use and the population characteristics among
Malaysian adults and their relationship with cigarette smoking. The method used to measure the
national prevalence is also described in detail. Other findings are presented elsewhere.

Methodology
Participants and Study Design
Approval for the study was obtained from the Medical Research and Ethics Committee of the
Ministry of Health Malaysia (NMRR-16-171-28819 [IIR]). This survey was designed to repre-
sent Malaysians aged 18 years and above in 2016, based on household population at national and
locality (urban and rural) levels. The Department of Statistics Malaysia defines a household as a
person or group of related or unrelated persons who usually live together and make common
Ab Rahman et al 11S

provision for food and other living essentials.14 Eligible respondents included adults who had
been living in the selected residences for at least 6 months in the last year, able to communicate
in Bahasa Melayu or English, and agreed to participate. Institutional populations such as those
staying in hotels, hostels, and hospitals were excluded from the survey.
Multistage stratified sampling was used in this survey. All 13 states and 3 federal territories were
selected. Three districts from each state, except Perlis, were selected randomly (primary sampling
unit). Perlis and each federal territory were considered as a stratum. Altogether 40 strata were formed
(Appendix 1; all appendixes are available online). Both urban and rural localities in all selected dis-
tricts were selected. From each locality, several Enumeration Blocks (EBs), proportionate to popula-
tion size, were selected (secondary sampling unit). EB is defined as a geographical area that is
artificially created and usually consists of specific boundaries such as natural boundaries, adminis-
trative boundaries, man-made boundaries, and imaginary boundaries. On average an EB consists of
80 to 120 living quarters (LQs). LQ is defined as separate and independent structures, which are
usually used as a place of abode. From each EB map, 12 LQs were randomly selected (final sampling
unit). Maps of the EB and LQ were obtained from the Department of Statistics Malaysia. All eligible
adults available in all selected LQs were invited to respond to the survey.

Sample Size and Sample Distribution

Sample size was calculated with the expected prevalence of current e-cigarette users of 5% and
the margin of error of 1.5%. Based on single proportion formulae, representing locality and the
design effect of 2 with 95% confidence interval (CI), the sample size required was 3248.
Anticipating LQ availability of 90%, a household response rate of 70% and eligibility rate of
90%, the final sample size calculated was 5722, which was rounded up to 6000 (see Appendix 2
for sample size calculation).
A sampling plan was executed to get the expected sample size of 6000 respondents. The dis-
tribution was calculated based on 3000 samples each for urban areas and rural areas at the national
level. This resulted in unequal sampling weights for urban and rural areas. Distribution at each
state and district were proportionate to the population size.
Appendix 3 shows the actual distribution and response rate of the selected LQs. Altogether, 3795
LQs were selected in the planning stage, but the number of available LQs was 2028 (93%) in urban
and 1466 (91%) in rural areas. Out of these LQs, 1324 and 1185 LQs had at least one respondent,
yielding LQ response rates of 65% and 81% for urban and rural areas, respectively. An unsuccessful
survey at the LQ level could be due to: Not LQ (the selected house was found not to be an LQ), LQ
destroyed (the selected house was found to be destroyed), Empty LQ (the selected house was found
to be unoccupied), Locked LQ (the selected house was found to be locked), Refusal (the occupants
refused to participate), and Others (eg, hostile or dangerous environment).
There were 10 370 individuals identified for this survey but only 3565 and 3284 were eligible
adults (as per selection criteria) from urban and rural localities, respectively. Out of 3521 total
ineligible individuals, 2509 (82.6%) were less than 18 years of age while the remaining were not
selected due to the language barrier. From all eligible individuals, 2561 (37.4%) refused to par-
ticipate (nonresponse). Finally, 2123 and 2165 agreed to participate in the survey, yielding
response rates of 60% and 66% for urban and rural localities, respectively (Figure 1). A nonre-
sponse at the individual level was due to at least one of the following reasons: Not at home—the
individual was not at home after 3 visits; Refusal—the individual refused to be interviewed.

Questionnaire
The National E-Cigarette Survey (NECS) Questionnaire was developed with input from the experts
in tobacco control, from both the Ministry of Health Malaysia and academia. The structured ques-
tionnaire was developed in both Bahasa Melayu and English. It was pretested and validated among
12S Asia Pacific Journal of Public Health 31(7S)

Figure 1. Sampling chart and survey response. FT, federal territory; EB, enumeration block; LQ, living
quarter.

adults with similar baseline characteristics. The questionnaire consisted of 8 sections (Appendix 4),
and for this study, the sections involved were those on background details, e-cigarette use, tobacco
smoking status, and dual use (concurrent e-cigarette use and cigarette smoking).

Definitions
Working definitions for e-cigarette users in our study were adopted from the National Health
Centre for Statistics (NCHS) Data Brief.15 Current e-cigarette user—used e-cigarettes during the
Ab Rahman et al 13S

last 30 days. Current daily e-cigarette users—answered Yes to question, “Do you smoke e-ciga-
rette/vape every day or less than every day?” Former e-cigarette user—used an e-cigarette but
stopped more than 30 days ago. Ever e-cigarette user—used at least one puff of an e-cigarette.
Definitions of tobacco-smoking status in our study were adopted from the Center for Disease
Control and Prevention.16 Current smokers—reported having smoked at least 100 cigarettes in
their lifetime and who are currently smoking. Former smoker—adults who were ever cigarette
smokers and did not smoke at the time of the interview. Never smoked—had never smoked even
a single puff of tobacco. Dual users were defined as those who were currently smoking both
tobacco cigarettes and e-cigarette at the time of interview.

Data Collection
The study population was divided into 6 zones for data collection: North (Perlis, Kedah, Penang,
and Perak), Central (Selangor, Kuala Lumpur, and Putrajaya), South (Melaka, Negeri Sembilan,
and Johor), East (Kelantan, Terengganu, and Pahang), Sabah, and Sarawak. Each zone was
headed by a Zone Coordinator (ZC), 1 or 2 Field Supervisors, and 6 to 14 Data Collectors (DCs),
depending on the number of samples to be collected.
The training manual consisted of terms and duties of the research personnel, the codebook for
variables, guidelines on the use of the questionnaire, and standard operating procedures for data
collection. Training was conducted 2 to 4 weeks before starting the actual data collection. A
1-day training on how to use the EB maps and to locate the respondents, as well as an explanation
of the questionnaire booklet, was conducted for each zone. Mock interview sessions involving
the use of the questionnaire in various scenarios were done. Only Field Supervisors and DCs who
completed their training sessions were allowed to be involved in this survey.
The data collections were carried out concurrently in all zones in May and June 2016. Data
were collected using face-to-face interviews. The summary of the data collection process is given
in Appendix 5.

Data Management and Quality Check

In the data collection phase, all DCs and ZCs were briefed on the use of a mobile application
called NECS Locator. The main purpose of this mobile application was to identify and record the
locations of these DCs during the data collection period. Booklet identification numbers (in QR
Code) and respondent identification number were recorded by a DC. Data collected from the
NECS Locator enabled the team and all ZCs to identify and monitor the number of question-
naires completed each day from each location. A real-time online dashboard that displayed these
details was used for monitoring the data collection process.
After the data collection was completed, the data were entered into the computer system in
Kuantan. In this phase, a data entry system with a double-entry validation method was used. A
training session was conducted 2 weeks before the data entry session begun. In each data entry
session, 2 different Data Entry Assistants (DEAs) entered the data. To ensure the integrity of the
double-entry validation method, a Research Officer randomly assigned each stack of booklets to
different DEA. Thus, none of the DEAs knew who had been paired with him/her to key in the
data into the system.
Through the double-entry method, an average of about 40% of the data had conflicts. The
conflicting values were mostly those that had to be handwritten (such as phone number, respon-
dent ID, identification number, etc). Two Data Verifiers (DVs) were recruited to rectify and ver-
ify these conflicting data.
14S Asia Pacific Journal of Public Health 31(7S)

Statistical Analysis
The data were analyzed in IBM SPSS Statistics (IBM Corp, Armonk, NY) for Windows, version
23, for analysis. The distributions and frequencies were examined. Outliers were identified from
the distribution and based on acceptable values of the variables. Outliers due to error in data entry
were corrected. The meaningful combination of categories was done when indicated. The com-
plex sample analysis procedures were used. The sample weight was calculated, first by calculation
of the base or design weight, which was then adjusted for the nonresponse. In general, the weight
of a sampled unit is the reciprocal of its probability of selection into the sample. The final weight
used was the post-stratification weight by locality (urban and rural), sex, and age groups based on
the 2015 Malaysian projected household population. Sociodemographic characteristics and preva-
lence of e-cigarette users were described using percentage and 95% CI of the proportion.
Complex survey logistic regression was done to measure the adjusted odds ratio (OR) for the
factors related to ever e-cigarette use and current e-cigarette use.

Results
Sociodemographic Characteristics
A total of 4288 individuals who responded to this household survey were weighted to represent
19 million Malaysians. Table 1 shows the population characteristics at national and locality lev-
els. The majority of the respondents were aged 25 to 44 years(44%), of Malay ethnicity (73%),
had completed secondary level of education (44%), were Muslim (79%), and were married
(68%). Males and females were equally represented. Most of the working respondents were
employed in nongovernmental sectors (24%), while others were homemakers (22%) and self-
employed (20%). Students constituted 7.5% of the study population.
Even though the actual number of respondents in urban and rural areas were similar, their sam-
pling weights were different, that is, 76% and 24% of the total weighted population, respectively.
Compared with urban areas, rural areas had more elderly people (12%), Malays (82%), Muslims
(88%), those with lower education levels, self-employed, as well as a homemaker (Table 1).

Prevalence of E-Cigarette Use

The overall prevalence of current, current daily, ever, former, and dual e-cigarette use in Malaysia
were 3.2% (95% CI = 2.5-4.1), 0.8% (95% CI = 0.5-1.3), 11.9% (95% CI = 10.5-13.5), 8.6%
(95% CI = 7.5-9.8), and 2.3% (95% CI = 1.8-3.1), respectively (Figure 2). The prevalence of all
types of e-cigarette use was higher in urban than in rural areas.

Factors Related to Ever and Current E-Cigarette Use

Ever e-cigarette users were more likely to be younger (OR = 7.2), male (OR = 2.8), working
with government (OR = 2.6), married (OR = 3.2), and currently (OR = 10) or previously (OR
= 4.8) smoked a conventional cigarette compared with participants who never used e-cigarettes
(Table 2). Current e-cigarette users showed a similar pattern except for occupation. They were
more likely to be younger (OR = 4.0), male (OR = 5.3), married (OR = 3.4), and currently (OR
= 7.5) or previously (OR = 3.8) smoked a conventional cigarette (Table 2).

Relationship Between E-Cigarette Use and Cigarette Smoking

The prevalence of current cigarette smoking was 23.4% (95% CI = 21.8-25.1) representing
more than 4.4 million Malaysian adults, while 11.2% (95% CI = 9.9-12.7) were former ciga-
rette smokers.
 Table 1. Study Population Characteristics at National, Urban, and Rural Level.
National Urban Rural

95% CI 95% CI 95% CI

Estimated Estimated Estimated
Population n % Lower Upper Population n % Lower Upper Population n % Lower Upper

Total 19 005 256 4288 14 478 772 2123 4 526 484 2165
Age group (years)
18-24 3 695 091 696 19.4 17.9 21.1 2 682 311 349 18.5 16.7 20.5 1 012 780 347 22.4 19.9 25.1
25-44 8 282 354 1687 43.6 41.3 45.9 6 569 316 889 45.4 42.5 48.3 1 713 037 798 37.8 35.2 40.5
45-64 5 285 947 1438 27.8 25.8 29.9 4 012 178 723 27.7 25.3 30.3 1 273 769 715 28.1 25.6 30.8
65 and above 1 741 864 467 9.2 7.7 10.8 1 214 966 162 8.4 6.6 10.5 526 898 305 11.6 10 13.6
Gender
Male 9 545 930 1987 50.2 48.2 52.3 7 266 413 1002 50.2 47.6 52.8 2 279 517 985 50.4 47.9 52.9
Female 9 459 326 2301 49.8 47.7 51.8 7 212 359 1121 49.8 47.2 52.4 2 246 967 1180 49.6 47.1 52.1
Racea
Malay 13 783 021 3215 72.6 67.8 77 10 080 063 1454 69.8 63.8 75.2 3 702 958 1761 81.8 75.5 86.8
Non-Malay 3 493 816 620 18.4 15.2 22.2 3 241 582 494 22.4 18.3 27.2 252 234 126 5.6 3.5 8.7
Other Bumiputera 1 697 657 448 8.9 6.3 12.6 1 128 297 171 7.8 4.8 12.5 569 360 277 12.6 8.2 18.7
Educationa
No formal education 1 351 823 429 7.1 6.1 8.2 830 559 132 5.7 4.6 7.1 521 264 297 11.5 9.7 13.6
Completed primary 4 472 862 1163 23.6 21.5 25.8 3 147 214 481 21.8 19.1 24.6 1 325 648 682 29.3 26.9 31.9
Completed secondary 8 402 672 1820 44.3 42.1 46.4 6 427 377 936 44.4 41.8 47.1 1 975 294 884 43.7 40.9 46.6
Completed college/university 4 753 257 871 25 22.6 27.6 4 057 381 572 28.1 24.9 31.4 695 876 299 15.4 13.4 17.6
Occupationa
Government 1 945 052 384 10.2 8.5 12.2 1 603 398 228 11.1 8.9 13.7 341 654 156 7.6 6.1 9.4
Non-government 5 002 612 958 26.3 24.3 28.4 4 107 444 572 28.4 25.9 31 895 168 386 19.8 17.2 22.7
Self-employed 3 830 211 928 20.2 18.2 22.2 2 665 895 384 18.4 16.1 21 1 164 315 544 25.7 23.1 28.5
Student 1 427 397 267 7.5 6.4 8.8 1 062 373 142 7.3 6 8.9 365 024 125 8.1 6.2 10.5
Homemaker 4 114 501 1106 21.7 20.1 23.3 3 027 096 495 20.9 19 23 1 087 405 611 24 22.1 26
Retiree 931 590 208 4.9 4.1 5.9 779 130 123 5.4 4.3 6.7 152 460 85 3.4 2.5 4.5
Not working 1 751 746 436 9.2 8.1 10.5 1 233 435 179 8.5 7.1 10.2 518 311 257 11.5 9.9 13.2

(continued)

15S
16S
Table 1. (continued)
National Urban Rural

95% CI 95% CI 95% CI

Estimated Estimated Estimated
Population n % Lower Upper Population n % Lower Upper Population n % Lower Upper

Religiona
Islam 14 951 196 3483 78.9 74.9 82.3 10 980 571 1589 76.1 71.2 80.3 3 970 625 1894 87.8 82.2 91.8
Not Islam 4 006 344 797 21.1 17.7 25.1 3 454 133 528 23.9 19.7 28.8 552 212 269 12.2 8.2 17.8
Marital statusa
Married 12 988 842 3072 68.5 66.4 70.5 9 957 208 1510 68.9 66.3 71.4 3 031 634 1562 67 64.2 69.7
Single 5 049 944 964 26.6 24.7 28.6 3 828 798 508 26.5 24.2 29 1 221 147 456 27 24.3 29.9
Separated/widow 929 808 246 4.9 4 6 659 614 101 4.6 3.5 5.9 270 194 145 6 5 7.1
Location
Urban 14 478 772 2123 76.2 72.3 79.6
Rural 4 526 484 2165 23.8 20.4 27.7

Abbreviation: CI, confidence interval.

ado not total up to 4,288 due to missing values.
Ab Rahman et al 17S

Figure 2. Weighted prevalence of current, current daily, former, and dual e-cigarette use at national,
urban, and rural levels.

Table 2. Complex Sampling Multivariate Logistic Regression for Ever and Current E-Cigarette Use.
Ever E-Cigarette Use Current E-Cigarette Use

CI CI

n % OR Lower Upper n % OR Lower Upper

Age group (years) 18-44 369 15.5 7.15 4.29 11.90 100 4.2 3.98 1.60 9.91
45 and above 40 2.1 1 10 0.5 1
Sex Male 366 18.4 2.82 1.20 6.60 103 5.2 5.35 1.14 25.09
Female 43 1.9 1 7 0.3 1
Education levela Low 74 4.6 0.87 0.61 1.24 16 1.0 0.71 0.35 1.42
High 204 11.2 1 52 2.9 1
Occupationb Government 50 13.0 2.56 1.35 4.85 14 3.6 2.26 0.74 6.94
Nongovernment 264 14.0 0.83 0.51 1.37 74 3.9 0.93 0.43 2.05
Not working 95 4.7 1 22 1.1 1
Race Non-Malay 51 7.1 1.81 0.54 6.05 14 1.9 0.63 0.11 3.75
Malay or other 358 10.0 1 96 2.7 1
Bumiputera
Religion Islam 355 10.2 1.98 0.67 5.84 95 2.7 0.62 0.12 3.17
Not Islam 54 6.8 1 15 1.9 1
Marital statusc Not currently 221 18.0 3.20 2.19 4.67 63 5.1 3.40 1.84 6.28
married
Currently 187 6.1 1 47 1.5 1
married
Cigarette smoking Current 280 29.3 9.97 4.78 20.80 77 8.0 7.52 1.94 29.07
status Former 62 14.1 4.73 2.07 10.77 19 4.3 3.85 0.85 17.35
Never 67 2.3 1 14 0.5 1

Abbreviations: OR, odds ratio; CI, confidence interval; Lower, lower limit of 95% CI for OR; Upper, upper limit for 95% CI for OR.
aLow education is secondary education and lower, while high education is tertiary education.
bNongovernment workers included private and self-employed workers.
cNot currently married included single, widow, or separated.
18S
Table 3. Cross-Tabulation of Weighted Prevalence Between Conventional Cigarette Smoking and E-Cigarette Use.
Current E-Cigarette Use Former E-Cigarette Use Never E-cigarette Use

% Within % Within % Within

% Within Smoking E-Cigarette Use % Within Smoking E-Cigarette Use % Within Smoking E-Cigarette Use
Status Status Status Status Status Status

Estimated 95% CI 95% CI Estimated 95% CI 95% CI Estimated 95% CI 95% CI

Population Population Population
Size N % Lower Upper % Lower Upper Size N % Lower Upper % Lower Upper Size N % Lower Upper % Lower Upper

Current cigarette 445 458 77 10.0 7.7 12.9 74.0 64.0 82.0 1 078 178 198 24.3 20.9 27.9 66.4 60.2 72.0 2 921 238 682 65.7 61.4 69.8 17.4 15.9 19.1
smoker
Former cigarette 85 293 19 4.0 2.3 7.0 14.2 8.4 22.9 237 164 41 11.1 8.0 15.2 14.6 10.8 19.4 1 810 591 379 84.9 80.5 88.4 10.8 9.4 12.4
smoker
Never cigarette 71 371 14 0.6 0.3 1.1 11.9 6.3 21.2 309 337 50 2.5 1.8 3.4 19.0 14.5 24.5 12,046,625 2828 96.9 95.9 97.7 71.8 69.9 73.6
smoker

Abbreviation: CI, confidence interval.

Ab Rahman et al 19S

Table 3 shows the relationship between cigarette smoking and e-cigarette use. Among current
e-cigarette users, 74% (95% CI = 64-82), representing 446 000 adults, also smoked conventional
cigarettes and among them 27% (95% CI = 17.6-39.1) were daily users. Overall, 14.2% (95% CI
= 8.4-22.9) of current e-cigarette users were former conventional cigarette, and 42% (95% CI =
22.3-65.9) used e-cigarette daily. A total of 11.9% (95% CI = 6.3-21.2) of current e-cigarette
users were never smokers, and none of these used e-cigarettes daily.
Among former e-cigarette users, 66.4% (95% CI = 60.2-72.0), representing more than 1 mil-
lion adults, were still smoking a conventional cigarettes. When further analyzed, 32% of those
who quit e-cigarette reported that e-cigarettes were not satisfying, and 14% of them disagreed
that e-cigarettes can help people to quit smoking a conventional cigarettes.
Most of current cigarette smokers (65.7%; 95% CI = 61.4-69.8) never used e-cigarettes,
while 10% (95% CI = 7.7-12.9) were current e-cigarette users and 24.3% (95% CI = 20.9-27.9)
had stopped using it. There were 4.3% (95% CI = 2.3-7.0) former cigarette smokers who were
current e-cigarette users while 11.1% (95% CI = 8.0-15.2) had stopped using it.
Among never cigarette smokers, 0.6% (95% CI = 0.3-11.9) and 2.5% (95% CI = 1.8-3.4)
were current and former e-cigarette users, respectively. This gave the prevalence of 3.1% of ever
e-cigarette use among never cigarette smokers.

Discussion
This survey collected face-to-face interview data from adults living in household in all the states
in Malaysia incorporating complex sampling design in the analysis to obtain weighted preva-
lence and population characteristics. From this survey, the prevalence of current cigarette smoke
was 23.4%, which was similar to the Global Adult Tobacco Survey 201117,18 and a more recent
study, the National Health and Morbidity Survey 2015.19 This validates our sampling design and
methodology used for this survey.
The items asked in our survey were similar with 8 core items proposed by Pearson et al,20
which were ever use, the frequency of use, perception of relative harm, former daily use, device
type, the presence of nicotine, flavor preference, and the reason for use.
Our national weighted prevalence estimate of current e-cigarette users (3.2%) was similar to
the previous study done in 2011 (3.9%)8 and to a more recent survey in the United States in 2014
(3.7%).6 However, Farsalinos et al21 found a lower prevalence (1.8%) of current e-cigarette users
in European countries. The prevalence of former e-cigarette users (8.6%) was comparable with
studies in the United States (9.1%) and European countries (7.2%, including those only experi-
menting with e-cigarette). From the current 19 million adults in Malaysia, the prevalence of cur-
rent e-cigarette users represented more than 6 00 000 adults, and another 1.6 million were former
e-cigarette users.
Our study also shows that e-cigarette use in Malaysia is associated with being young, male,
and more educated, which is similar to the studies reported elsewhere.5,7 Higher education is a
proxy for higher income, which may explain the affordability of e-cigarette devices and liquid for
this group.22
Previous studies reported that e-cigarette use was found almost exclusively among the current
or former cigarette smokers.5,18 Our study shares the same findings, with almost 90% of current
e-cigarette users were either current or former cigarette smokers. This supports the fact that
tobacco smoking could be the gateway for using other tobacco products and, in this case, e-cig-
arette. However, this hypothesis could only be proven in a longitudinal study.
In our study, only 27% of cigarette smokers used e-cigarettes daily, while 42% of those who
quit smoking conventional cigarettes used e-cigarettes daily. Nondaily use of e-cigarettes may
not be able to provide enough nicotine to help the users to quit cigarette smoking completely.23
Nondaily use of e-cigarettes may also indicate experimentation rather than an intention to quit
cigarette smoking.24-26
20S Asia Pacific Journal of Public Health 31(7S)

This study was a cross-sectional survey and therefore could not determine temporal associa-
tion between the variables. The larger sample size is needed to accommodate the smaller preva-
lence of e-cigarette use.

Conclusion
As in most other countries, e-cigarette use is prevalent in Malaysia. It is more common among
younger adults, male, and cigarette smokers.

Acknowledgments
We would like to thank the Government of Malaysia, in particular, the Ministry of Health Malaysia and
National Institute of Health, for the provision of a research grant. We also would like to thank the Director
General of the Ministry of Health for the permission to publish this article. Our special thanks also goes to
all the Zone Coordinators from Universiti Sains Malaysia, Universiti Malaysia Sabah, Universiti Malaysia
Sarawak, and Universiti Teknologi Malaysia for coordinating the data collection process.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: The grant for this project was awarded by the National Institute of Health, Ministry of
Health Malaysia (NIH/IPH/16-002).

Supplemental Material
Supplemental material for this article is available online.

ORCID iDs
Jamalludin Ab Rahman https://orcid.org/0000-0003-4323-1194
Mira Kartiwi https://orcid.org/0000-0002-3686-3575

References
1. Lee S, Grana RA, Glantz SA. Electronic cigarette use among Korean adolescents: a cross-sectional
study of market penetration, dual use, and relationship to quit attempts and former smoking. J Adolesc
Health. 2014;54:684-690.
2. Yamin CK, Bitton A, Bates DW. E-cigarettes: a rapidly growing Internet phenomenon. Ann Intern
Med. 2010;153:607-609.
3. McMillen RC, Gottlieb MA, Shaefer RMW, Winickoff JP, Klein JD. Trends in electronic cigarette use
among US adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res. 2015;17:1195-
1202.
4. Li J, Newcombe R, Walton D. The prevalence, correlates and reasons for using electronic cigarettes
among New Zealand adults. Addict Behav. 2015;45:245-251.
5. Dockrell M, Morison R, Bauld L, McNeill A. E-cigarettes: prevalence and attitudes in Great Britain.
Nicotine Tob Res. 2013;15:1737-1744.
6. Office for National Statistics. Adult smoking habits in the UK: 2017. https://www.ons.gov.uk/people-
populationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghab-
itsingreatbritain/2017. Accessed February 28, 2018.
7. Wilson FA, Wang Y. Recent findings on the prevalence of e-cigarette use among adults in the US. Am
J Prev Med. 2017;52:385-390.
 Ab Rahman et al 21S

8. Palipudi KM, Mbulo L, Morton J, et al; GATS Collaborative Group. Awareness and current use of
electronic cigarettes in Indonesia, Malaysia, Qatar, and Greece: findings From 2011-2013 Global Adult
Tobacco Surveys. Nicotine Tob Res. 2016;18:501-507.
9. Gravely S, Fong GT, Cummings KM, et al. Awareness, trial, and current use of electronic cigarettes in
10 countries: findings from the ITC project. Int J Environ Res Public Health. 2014;11:11691-11704.
10. Cahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward
or a repeat of past mistakes? J Public Health Policy. 2011;32:16-31.
11. Callahan-Lyon P. Electronic cigarettes: human health effects. Tob Control. 2014;23(suppl 2):ii36-ii40.
12. Caponnetto P, Campagna D, Cibella F, et al. EffiCiency and Safety of an eLectronic cigAreTte
(ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study.
PloS One. 2013;8:e66317.
13. Hajek P, Etter JF, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: review of use, con-
tent, safety, effects on smokers and potential for harm and benefit. Addiction. 2014;109:1801-1810.
14. Department of Statistics, Malaysia. Glossary: Household. https://www.dosm.gov.my/v1/index.php
?r=column/cglossary2&menu_id=eWd2VFdIZ2xpdzBmT2Y0a0pweDcwQT09&keyword=TG5oZlhP
RWhEaFM5VWdVemt1dkxrZz09&release=1. Accessed October 11, 2018.
15. Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS Data
Brief. 2015;(217):1-8.
16. Global Tobacco Surveillance System (GTSS). Global Adult Tobacco Survey (GATS): indicator
guidelines: definition and syntax. https://www.who.int/tobacco/surveillance/en_tfi_gats_indicator
_guidelines.pdf. Published June 2009. Accessed February 28, 2018.
17. Asma S, Mackay J, Song SY, et al. The GATS Atlas: Global Adult Tobacco Survey. Atlanta, GA: CDC
Foundation; 2015.
18. Institute of Public Health. Report of the Global Adult Tobacco Survey (GATS) Malaysia, 2011. Kuala
Lumpur, Malaysia: Institute for Public Health, Ministry of Health Malaysia; 2012.
19. Institute for Public Health. National Health and Morbidity Survey 2015—Report on Smoking Status
Among Malaysian Adults. Kuala Lumpur, Malaysia; 2015.
20. Pearson JL, Hitchman SC, Brose LS, et al. Recommended core items to assess e-cigarette use in popu-
lation-based surveys. Tob Control. 2018;27:341-346.
21. Farsalinos KE, Poulas K, Voudris V, Le Houezec J. Electronic cigarette use in the European Union:
analysis of a representative sample of 27 460 Europeans from 28 countries. Addiction. 2016;111:2032-
2040.
22. Brown J, West R, Beard E, Michie S, Shahab L, McNeill A. Prevalence and characteristics of e-cig-
arette users in Great Britain: findings from a general population survey of smokers. Addict Behav.
2014;39:1120-1125.
23. Zhuang YL, Cummins SE Y, Sun J, Zhu SH. Long-term e-cigarette use and smoking cessation: a lon-
gitudinal study with US population. Tob Control. 2016;25(suppl 1):i90-i95.
24. Levy DT, Yuan Z, Luo Y, Abrams DB. The relationship of e-cigarette use to cigarette quit attempts and
cessation: insights from a large, nationally representative US survey. Nicotine Tob Res. 2018;20:931-
939.
25. Levy DT, Yuan Z, Li Y. The prevalence and characteristics of e-cigarette users in the US. Int J Environ
Res Public Health. 2017;14:E1200.
26. Amato MS, Boyle RG, Levy D. How to define e-cigarette prevalence? Finding clues in the use fre-
quency distribution. Tob Control. 2016;25(e1):e24-29.

View publication stats