Introduction

The use of electronic cigarettes (e-cigarettes) has rapidly increased on a global scale in recent years [1], in both high-income and low- or middle-income countries [2, 3]. E-cigarettes are battery-operated vaporizing devices, which may have the appearance of a cigarette, and is used to deliver nicotine vapour to users [4]. The devices are designed to replicate smoking behaviour without the use of tobacco [5].

E-cigarette devices have been promoted as safer and less addictive relative to cigarettes and other nicotine-containing products. This has created a perception among conventional smokers that e-cigarettes are ideal for smoking cessation [6]. However, there is limited scientific evidence of the health effects of e-cigarettes compared to conventional cigarettes [7, 8]. According to Jonkawski and colleagues, e-cigarettes as nicotine delivery devices may be more addictive than conventional smoking products [9]. Short term exposure to a low or high dose of e-cigarette by-products has been associated with headaches, upper respiratory tract irritation, eye irritation, nausea, allergic reaction, dizziness and vomiting [7]. There is limited evidence at this stage of the health effects of long-term use or exposure, including second-hand exposure, to e-cigarettes [5, 10, 11].

Numerous factors, apart from perceptions of the product, influence the uptake and use of e-cigarettes. Studies undertaken in various parts of the world such as USA, Korea and Scotland showed that adolescents are often influenced by friends and family to take up e-cigarette use (12–15), while among adults, spousal influence is a major risk factor [12, 13]. Marketing strategies (billboards, type of message, etc.) and social media platforms (such as Twitter, Facebook and Instagram) have contributed immensely to the use of e-cigarettes amongst users globally [14, 15].

Studies in high-income countries and a few LMIC’s have described the factors associated with use and perceptions of e-cigarette use, including health effects [2, 16,17,18]. Such information could help inform the development and implementation of e-cigarette public health prevention strategies [13]. There is a gap in scientific knowledge on the risk factors and perceptions of e-cigarettes and its use, especially in LMIC’s such as South Africa. The current study sought to determine practices and risk factors associated with the use of e-cigarettes, and to our knowledge, is the first such study in southern Africa.

Methods

We conducted a cross-sectional study at e-cigarette outlets in the suburb of Greenstone Hill within the City of Johannesburg, Gauteng Province, South Africa during [July 2017]. We identified all e-cigarette outlets in the Greenstone Hill area using online data sources. Thereafter, we randomly selected five outlets for inclusion in the study. Using a convenience sampling technique, we approached and invited clients aged 18 years or older, who visited the five selected e-cigarette outlets, to participate in the study.

Data were collected using a questionnaire administered by one of the researchers (MN) during both weekdays and weekends. The questionnaire was administered in English and it comprised 54 open- and closed-ended questions. The questionnaire was divided into three sections: socio-demographic data, e-cigarette use, perception of the use and health implications as well as reasons for using e-cigarettes. The questionnaire was piloted in a similar population elsewhere and the results were not included in this study.

Data were captured on Microsoft Excel 2013 for organizing, cleaning and coding, and transferred to IBM SPSS version 25 for the conduct of analyses. Responses with missing data were not included in the final analysis. Descriptive statistics were used to portray the characteristics of the sample. The Pearson correlation coefficient was used to determine the potential association between demographic information and behaviour, reasons for using and perceptions on e-cigarettes use and health impact. To determine any correlation between the variable, the p-value was set at p < 0.05. The data analysis was conducted with biostatistical support from the STATKON Unit at the University of Johannesburg.

The study protocol was submitted to the University of Johannesburg, Faculty of Health Sciences Higher Degree Committee (HDC) for scientific review, where after it was approved by the Research Ethics Committee (Certificate no: REC-01-102-2017). The researchers approached the e-cigarette outlet owner for permission to approach their clients. Participants gave informed consent before taking part in the study.

Results

There were 160 males (85%) and 28 females (15%) who participated in the study. Most participants were under the age of 30 years old (Table 1). The majority of participants were White (107/56.9%) while 47 (25%) were Black African. Participants were conversant with or spoke at least one South African home language. Afrikaans (68/ 36.1%) and English (65/ 34.5%) were the main languages spoken. To determine the socio-economic status, participants were asked about their ownership of certain commodities: 90.4% (n = 170) owned a car, while 152 (80.9%) had computers at home, 128 (68.1%) had gaming consoles, 166 (88.3%) had laptops and 165 (87.7%) had access to the internet. One hundred and eighty-two households owned microwave ovens (96.8%), 174 had radio sets (92.6%), 185 had smartphones (98.4%) and 139 (73.9%) had tablets.

Table 1 Participants’ characteristics
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All participants reported being e-cigarette users. Among the total of 188 participants, 42.6% had been using e-cigarettes for less than 12 months and 26 participants (13.8%) had used the product for more than 49 months. One hundred and thirty participants (69.1%) were dual users (e-cigarettes and conventional cigarettes) and 58 (30.9%) were using e-cigarettes exclusively. The majority (84%, n = 158) had smoked conventional cigarettes prior to commencing use of e-cigarettes compared to 16% (n = 30) who had started using conventional cigarettes after having used e-cigarettes. All e-cigarettes users were able to define “what an e-cigarette is” (Table 1).

The main reasons users first tried e-cigarettes were curiosity (n = 61, 32.4%), as a substitute for conventional cigarettes (n = 57, 30.3%) and saw a friend using (n = 42, 22.3%). Yet, the circumstances that lead participants to use daily were diverse: boredom (n = 14, 7.4%), to socialize (n = 16, 8.5%), for pleasure (n = 22, 11.7%), relaxing technique (n = 39, 20.7%), management of tobacco cravings (n = 46, 24.5%) and feeling worried or stressed (n = 44, 23.4%). Nonetheless, 96 participants (51.1%) indicated that they obtained their first e-cigarette from a friend. While, others got their first product from an e-cigarette outlet (n = 53, 28.2%), family member (n = 23, 12.2%), supermarket (n = 11, 5.9%) and two participants (1.1%) did not specify where they got their first product. There are contradictions about what the participants like most and least of the e-cigarette products. The participants indicated that they liked the e-cigarette products because of: its odorless properties (n = 13, 6.9%), financial affordable (n = 4, 2.1%), perceived to be safer and more convenient than conventional smoking (n = 24, 12.8%), taste and flavourings (n = 77, 41.0%), device design and packaging (n = 7, 3.7%), health benefits (n = 55, 29.3%) and assist in smoking cessation (n = 8, 4.3%). While twenty-four participants (12.8%) indicated that they don’t like the smell from the e-cigarette flavours. The other participants were concerned about the accidents related to e-cigarette products (n = 8, 4.3%), addictive ability (n = 11, 5.9%), can lead to development or cause ill-health (n = 29, 15.4%), cost implication (n = 67, 35.6%), need for maintenance such as charging (n = 38, 20.7%) and 11 participants (5.9%) did not specify any dislike.

Most participants reported having started using e-cigarettes during their adolescent years or early adulthood (16–25 years old, n = 96; 51.1%). One hundred and twenty-seven (n = 127, 67.6%) participants used e-cigarettes with their partner while 61 (32.4%) used it with a relative. Participants first used an e-cigarette at friend’s house (n = 85, 45.2%), e-cigarette stall (n = 39, 20.7%), family member’s house (n = 24, 12.8%), high school (n = 7, 3.7%), shopping centre/supermarket (n = 7, 3.7%), a party (n = 9, 4.8%) and tertiary institution (n = 4, 2.1%). Twelve participants (6.4%) did not recall where they used their first e-cigarette. Most participants (n = 169, 89.9%) bought their e-cigarettes, while 19 (10.1%) have never bought any e-cigarette products. Expenditure on one e-cigarette device ranged from R100 to R6000 with the mean expenditure equaling R1312.06. Thirty-one (16.5%) received e-cigarette devices as a gift and 157 (83.5%) had never purchased a device.

Participants reported using e-cigarettes in public, including in the presence of vulnerable groups (Fig. 1). Participants were most likely to use e-cigarette products at workplaces (n = 76, 40.4%), tertiary institutions (n = 50, 26.6%), homes (n = 28, 14.9%) in vehicles (n = 24, 12.85) and public parks (n = 6, 3.2%). Ninety-two participants (48.9%) indicated that they have used e-cigarettes in the presence of children.

Fig. 1
figure 1

Main places of use of e-cigarettes

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The frequency of daily use of e-cigarettes ranged from 1 to 100 (times per day). Most participants (112, 59.6%) reported using their e-cigarettes 1 to 10 (times per day). Most participants had no particular preference by day or time of day for e-cigarette use. Seventeen percent (32) of the study sample reported having been reprimanded for use in public places.

Most of the participants either believe that e-cigarette is addictive (156, 83%) or harmful to their health (139, 73.9). The participants reported experiencing various health issues which included lung cancer (n = 81, 57.9%), respiratory-related diseases (n = 20, 14.3%), heart disease (n = 8, 5.7%), blood pressure issues, throat cancer, stomach disorder, brain disorder and 20 reported other health issues. Majority of the participants (n = 157, 83.7%) had never experienced accidents related to e-cigarette products. Whereas, 31 (16.5%) participants reported e-cigarette product-related accidents that included battery bursting (24), liquid spillage (2) and device breaking (7). All the participants wished they could stop using e-cigarettes because of health reason (n = 45), cost of the product (n = 3), the effects on children (2), failure to stop using conventional cigarette (2). Only 49 (26.1%) have tried to stop using e-cigarettes. However, they manage to stop for less than 24 months before using again (see Table 2 for more details).

Table 2 Participants’ perceptions of e-cigarettes use
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Most of the participants (83.55%) believed that their families and friends perceived e-cigarette use as dangerous to their health. While 23 were told that e-cigarettes is safer than conventional smoking and others did not know. Some participants (106) indicated that they will never recommend the use of e-cigarette products to their friends and family members. Yet, 82 participants were willing to recommend the use of e-cigarettes to their families and friends despite how they feel about e-cigarettes.

Pearson correlation was used to explore risk factors for e-cigarette use. E-cigarette users in this study first tried using an e-cigarette at young age” (r = 0.166; p = 0.023). Young e-cigarette users were most likely to use these products with their partner (r = 0.149; p = 0.042). Males were prone to start using at a young age (r = 0.149; p = 0.042) and to use with a family member(r = 0.157; p = 0.031), especially with either their mother (r = 0.186; p = 0.011) or son and daughter (r = 0.143; p = 0.047). Furthermore, males were most likely to use in public areas such as movie theatre (r =  − 0.174; p = 0.017), in a vehicle (r =  − 0.161; p = 0.028) or within a tertiary institution (r =  − 0.157; p = 0.031).

Discussion

According to our knowledge, this is the first study to describe e-cigarette users’ risk factors and perceptions of e-cigarette products in a middle-income-country within sub-Saharan Africa. Understanding is vital to develop and implement a health promotion strategy on prevention as well as enforcement of non-compliance. There were more male users in this study compared to female, this is similar to other studies conducted elsewhere [19,20,21]. This trend is similar to tobacco products used in South Africa [22]. E-cigarette use is popular amongst adolescents and young adults [23], the majority (n = 93, 49.5%) of participants in this study were between the age of 21 and 30 years. According to Williams, the majority of e-cigarette users smoked convention products before converting to e-cigarette products [24]. In this study 150 of the participants smoked before using e-cigarette products and 130 were dual users. Based on the ownership of products associated with socioeconomic status, the researchers assumed that majority of participants are from middle and high-income communities, this supports findings from rich countries [25, 26].

One of the major behavioural findings from this study, the majority of the participants indicated that they have used in public places, especially male users. We found that participants have used e-cigarettes in the following: home (n = 28), workplace (n = 76), tertiary institution (n = 50) and vehicle (n = 24). While this behaviour exposes non-users to second-hand vaping. Despite the danger to non-users especially children and vulnerable people, 92 participants agreed to have used in the presence of children. These findings are similar to a study in a rich-income country that indicated parents were likely to use e-cigarettes at home and in a vehicle in the presence of their children [27]. The findings support studies that found e-cigarette users were using these products publicly in tertiary institutions and workplaces [28, 29]. This behaviour is attributed to the claims that e-cigarette is environmental and user-friendly due to its smokeless and odorless properties [30, 31]. Moreover, it could be linked to the lack of legislation or non-enforcement of tobacco control legislation on e-cigarette use [32]. In this study, a higher number of participants (n = 156) indicated that they have never been reprimanded for using an e-cigarette in public areas, especially by government or law officials. Those that have been reprimanded for using in smoke-free areas, were approached by public members.

Previous studies have found that family and friends (peers) influence, curiosity, conventional smoking cessation and marketing strategies are major risk factors for using an e-cigarette [1, 15, 33,34,35]. In this study we found that 61 participants initially started using e-cigarettes because of curiosity, 57 wanted to stop using conventional smoking and 42 peer pressure. While, the reasons for using daily were to fight conventional smoking, stress reliever and other health or societal benefits [36]. These findings support scientific evidence from a study conducted amongst different age groups and populations [16, 17, 37, 38]. Furthermore, a high percentage indicated that they received their first e-cigarette product from a friend and family. This has been highlighted by previous studies [33, 34, 39]. These are important findings for health educational strategy to prevent e-cigarette use. In addition, the understanding of likes and dislikes about e-cigarette from users can be vital for developing prevention strategies. In this study, most participants either like the taste and flavourings in the products or dislike the cost implications associated with e-cigarette products.

Perceived health benefits and addictiveness of e-cigarettes were inconsistent with other studies conducted in HIC, where participants believe that e-cigarette use is less harmful and addictive [40, 41]. While in this study many participants indicated that e-cigarette use is addictive and harmful, similar to a study conducted in Poland [9]. Despite the high negative perception associated with an e-cigarette, advice on dangers of e-cigarette from families and friends, willingness to quit using an e-cigarette and low occurrence of an incident with an e-cigarette. Only 49 participants have tried to quit using e-cigarettes but after a few months of quitting they started to use again. This could have been caused by the influence of family and friends as there were a high number of participants that had come close to them using. Interestingly, some participants indicated that they will recommend e-cigarettes use to their families and friends.

The study focused on e-cigarettes users’ risk factors and perceptions about e-cigarette products. The study shows worrying behaviours amongst users such as using in public and front of vulnerable groups. Furthermore, risk factors that lead participants to use e-cigarette products were family and friends’ influence, smoking cessation, socializing and perceived health benefits. These factors are important for developing and implementing public health prevention activities. In terms of health promotion strategies, it is encouraging to see users in this study indicating that e-cigarette products are very harmful and addictive.

Limitations of the study were, the study was conducted amongst e-cigarettes users only and from one area. Therefore, the study cannot be generalized to a larger population. Furthermore, a similar study should be conducted as a national survey.

Conclusions

The study findings indicate that the behaviour of e-cigarette users is a concern as it might expose non-users to substances emitted from the product. It also shows that family and friends ‘influence is a risk factor for e-cigarette use. This is critical for public health agencies or departments to develop prevention programmes or for policy development. Lastly, the e-cigarette users and their family perceptions about e-cigarette products being dangerous for one’s health, indicate that people are aware of the dangers of these products. Future research and public health actions that sought to understand and compare the knowledge, behaviours and influences between e-cigarette users and non-users should be considered. The role of public health should be re-evaluated to ensure that non-users are protected especially in public areas.