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Received: 22 October 2019    Revised: 9 April 2020    Accepted: 10 April 2020

DOI: 10.1111/phn.12735

P O P U L AT I O N S AT R I S K A C R O S S T H E
L I F E S PA N – P O P U L AT I O N S T U D I E S

What influences adolescents to continuously use e-cigarettes?

Gyumin Han MS, RN  | Hyunmi Son PhD, RN

College of Nursing, Pusan National

University, Yangsan-si, Republic of Korea
Correspondence
Hyunmi Son, College of Nursing, Pusan
National University, 49, Busandaehak-ro,
Mulgeum-eup, Yangsan-si, Gyeongsangnam-
do, 50612, Republic of Korea.
Email: hmson@pusan.ac.kr
Funding information
Pusan National University
Abstract
Objective: The use of e-cigarettes is rapidly increasing in adolescents. Health care
providers pay attention to e-cigarette users because of the risk of developing addic-
tion and problematic behavior. Based on ecological perspective, this study investi-
gated factors influencing continued e-cigarette use.
Methods: We classified 1556 current e-cigarette users into experimental and contin-
ued users using the Korean national representative data. Data were analyzed using
the chi-square test and logistic regression based on a complex sample analysis.
Results: Among current e-cigarette users, 55.1% were continued users. Adolescents
who use e-cigarettes because of the belief that they are less harmful than cigarettes,
concealment, easy purchase, and adding various flavors had a high risk of continued
use. Continued users were more likely to have a higher weekly allowance, lower rate
of living with family, and higher chance of smoking parents and exposure to passive
smoking at home.
Conclusions: Continued e-cigarette use was influenced by interpersonal and envi-
ronmental factors, such as ease of purchase and addition of flavoring substances.
Improving the environment of adolescents can prevent continued use of e-cigarettes.

KEYWORDS

adolescents, ecological model, electronic cigarettes, KYRBS

1 |  I NTRO D U C TI O N The use of e-cigarettes in adolescents shows a different pattern

Worldwide efforts have decreased rates of smoking conventional
cigarettes in adolescents; however, the rate of smoking electronic
cigarettes (e-cigarettes) is increasing. The e-cigarette use rate among
adolescents in South Korea, which was 0.5% in 2008 when e-ciga-
rettes were first introduced, reached 7.9% in 2018 and is an increas-
ing trend (Korea Health Promotion Institute, 2019). According to a
2016 report by the United States Department of Health and Human
Services, 5.3% of middle school students and 16.0% of high school stu-
dents in the United States currently use e-cigarettes. Compared to the
0.6% and 1.5% rates, respectively, in 2011, this is a tenfold increase in
the past 5 years (US Department of Health & Human Services, 2016).
The World Health Organization has instructed countries worldwide
to limit the sale, promotion, and use of e-cigarettes (Gulland, 2016).
from that in adults. Adults start using e-cigarettes to quit smoking
while adolescents start out of simple curiosity and the belief that
they are less harmful than conventional cigarettes (Kong, Morean,
Cavallo, Camenga, & Krishnan-Sarin, 2014; Tsai et al., 2018).
Additionally, some adolescents who start using e-cigarettes to quit
smoking become smokers of both conventional cigarettes and e-cig-
arettes instead of quitting smoking (Chen, Chang, Hsu, & Lee, 2018;
Doran et al., 2017; Wills et al., 2017).
The patterns of drug use in adolescents can be divided into
stages, of which the first is the experimental stage, involving the use
of a new type of drug in small amounts for a short time out of cu-
riosity or sense of adventure (Rice & Dolgin, 2005). However, if the
use of the new type of drug does not stop at the experimental stage
but evolves into continuous use, the physical and mental effects that

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2       HAN et al.
follow induce major health problems in adolescents. Continuous ex-
posure to nicotine during adolescence can cause addiction and harm
the developing adolescent brain (US Department of Health & Human
Services, 2016). To reduce the potential negative effects of e-ciga-
rettes on the health of adolescents, it is necessary to understand the
behavior patterns of adolescents who continue to use e-cigarettes.
Problematic health behaviors of adolescents are the result of
the interaction of several factors. An ecological perspective sug-
gests that adolescents mature and develop in complex system with
numerous layers centered on their environment (McLeroy, Bibeau,
Steckler, & Glanz, 1988). Drinking, smoking, and drug use are related
to the social and environmental factors surrounding adolescents
(Ssewanyana et al., 2018). An ecological approach is useful to under-
stand adolescent behaviors, allowing several hazards to be examined
simultaneously, with an attempt to understand the manner of inter-
action between various hazards. This approach to health risk can
increase the understanding of public health nurses about hazards,
improve insight into how hazards can interact, and provide direction
for interventions to decrease health risk.
The individual factors affecting e-cigarette use in adolescents
include gender, school year, and allowance amount (Lee, Grana, &
Glantz, 2014) Interpersonal relationships with family, siblings, and
friends affect the use of e-cigarettes (Barrington-Trimis et al., 2015;
Hwang & Park, 2016; Kinnunen et al., 2015). Environmental fac-
tors, including commercials and peers, affect e-cigarette use in ad-
olescents (Dai & Hao, 2016; Vasiljevic, Petrescu, & Marteau, 2016).
While work has been done on previous and current use of e-ciga-
rettes, few studies have identified the factors on the continued use
of e-cigarettes in adolescents.
The goal of this study was to identify characteristics of groups
that do and do not continuously use e-cigarettes using an ecological
perspective with a national database.
2 |  M E TH O DS
2.1 | Data/sample
We used the dataset of the 12th Korean Youth Risk Behavior Web-
based Survey (KYRBS) in accordance with the regulations on dis-
closure and management of source data of the Korea Centers for
Disease Control and Prevention (KCDC) (Korea Center for Disease
Control and Prevention, 2016). The KYRBS is an anonymous, self-
administered, online survey conducted annually since 2005 on the
health behaviors of youth in South Korea. The 2016 survey used
a multistage cluster sampling design to obtain a nationally repre-
sentative sample from the target population of all public and private
middle and high school students in 17 provinces. The 12th KYRBS
surveyed 67,983 students from 800 schools (400 middle schools and
400 high schools), and 65,528 students from 798 schools (96.4%)
participated in the survey. The primary sampling unit was one school
selected from each district using the systematic sampling method;
within the selected schools, one classroom from each grade level
was randomly selected. In this study, we selected 1,556 students
who were current e-cigarette users.
2.2 | Variables and measures
2.2.1 | E-cigarette use
Adolescents who had use e-cigarettes within the last 30 days were
classified into experimental and continued e-cigarette users (Amato,
Boyle, & Levy, 2015). We based this classification on one ques-
tion in the raw data: “How many days did you use e-cigarettes in
the past 30 days?” Respondents who responded from 6 to 30 days
within the last 30 days were classified as continued e-cigarette
users. Respondents who responded from 1 to 5 days within the last
30 days were categorized as experimental e-cigarette users.
2.2.2 | Individual and environmental factors
Based on the ecological framework (McLeroy et al., 1988), individual
factors included gender, grade, weekly allowance, residence type, and
smoking status. Environmental factors included close friend smoking,
parent smoking, sibling smoking, passive smoking at home, reason for
e-cigarette use, smoking cessation education at school, exposure to
tobacco advertisements, and exposure to anti-smoking campaigns.
The study did not include variables on national policy because it was
conducted in one country and therefore subject to the same policy.
2.3 | Analytic strategy
All data were analyzed using SPSS Statistics 25 with a complex sample
design for accurate statistical analysis because the KYRBS was con-
ducted with a complex sample design. We used strata, cluster, weight,
and finite population correction information as complex sample design
elements according to the guidelines for the analysis of the KYRBS of
the KCDC. The difference in the use of e-cigarettes according to the
general characteristics was confirmed by unweighted frequency and
weighted percentage, and the chi-square test was performed. The
complex sample logistic regression analysis was conducted to identify
the factors that influence continued e-cigarette use. Significant vari-
ables in the chi-square test were inputted for complex sample logistic
regression, and variables were included in the model.
3 | R E S U LT S
3.1 | Individual and environmental characteristics
depending on e-cigarette use
Of the 1,556 students who had used e-cigarettes in the last
30 days, 845 (55.1%) were continued users of e-cigarettes and
HAN et al.
711 (44.9%) were experimental users. Table 1 shows the re-
sults of analyzing the relationship between experimental and
continued e-cigarette use according to individual and environ-
2
mental factors. Individual factors, such as grade (χ  = 23.37,
p < .001), weekly allowance (χ 2 = 21.91, p ≤ .001), residence type
2 2
(χ  = 41.15, p ≤ .001), reason for use (χ  = 2,427.36, p ≤ .001), and
conventional smoking status (χ 2 = 9.04, p = .010), had statistically
      3|
significant differences. Among the environmental factors, peer
(χ 2 = 49.44, p  ≤  .001) and parental (χ 2 = 27.67, p  ≤  .001) smok-
ing and passive smoking at home (χ 2 = 17.95, p ≤ .001) had sta-
tistically significant differences. School-based prevention or
cessation program, experience on anti-smoking campaign, and
exposure to tobacco advertisements did not have statistically
significant differences.

TA B L E 1   Individual and environmental characteristics depending on e-cigarette usage (N = 1556)

Experimental users (n = 711) Continued users (n = 845)

Characteristics Categories Unweighted frequency(Weighted %) Unweighted frequency (Weighted %) χ 2(p)

Gender Girl 158 (22.9) 169 (19.7) 2.33 (0.152)

Boy 553 (77.1) 676 (80.3)
Grade 7th 26 (3.0) 16 (2.0) 23.37 (0.001)
8th 64 (6.9) 43 (4.3)
9th 101 (14.1) 100 (10.6)
10th 155 (22.1) 168 (19.3)
11th 187 (25.9) 218 (25.5)
12th 178 (28.0) 300 (38.2)
Weekly allowance <$50 477 (67.3) 477 (55.6) 21.91 (<0.001)
≥$50 234 (32.7) 368 (44.4)
Residence type With family 647 (91.2) 667 (79.4) 41.15 (<0.001)
Without family 64 (8.8) 178 (20.6)
Conventional cigarette Nonsmoker 123 (17.4) 113 (13.2) 9.04 (0.010)
Former smoker 75 (10.3) 65 (8.0)
Current smoker 513 (72.2) 667 (78.8)
Peer smoking None 49 (6.0) 32 (4.1) 49.44 (<0.001)
Some 251 (34.3) 172 (19.7)
Most/All 411 (59.7) 641 (76.2)
Parental smoking No 354 (48.6) 305 (35.4) 27.67 (<0.001)
Yes 357 (51.4) 540 (64.6)
Sibling smoking No 605 (85.5) 681 (81.3) 5.05 (0.023)
Yes 106 (14.5) 164 (18.7)
Passive smoking No 355 (48.8) 320 (38.1) 17.95 (<0.001)
At home Yes 376 (51.2) 525 (61.9)
School-based No 255 (37.2) 302 (38.0) 0.012 (0.728)
prevention or Yes 456 (62.8) 543 (62.0)
cessation program
Experience in No 151 (20.8) 183 (23.2) 1.28 (0.293)
antismoking campaign Yes 560 (79.2) 662 (76.8)
Exposure to tobacco No 155 (21.7) 170 (20.6) 0.25 (0.602)
ads Yes 556 (78.3) 675 (79.4)
Reasons for E-cigarette Curiosity 114 (16.1) 39 (4.0) 2,427.36
use Cessation/ 238 (32.5) 264 (31.4) (<0.001)
health
consideration
Concealment 146 (21.2) 246 (29.9)
Ease to buy 16 (2.4) 37 (4.5)
Flavoring 162 (23.2) 215 (24.6)
Others 35 (4.7) 44 (5.6)
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4       HAN et al.

3.2 | Factors affecting continued e-cigarette use
We included nine variables in the logistic regression model that
showed statistically significant differences in the chi-square test.
The Nagelkerke R 2 was 0.148 (Table 2). Adolescents with an aver-
age weekly allowance of ≥$50 were 1.366 times more likely to
continue using e-cigarettes than those with an allowance of <$50.
Adolescents who did not live with their family members were 2.011
times more likely to use e-cigarettes continuously than those who
lived with their family members. If parents smoked, there was a
1.428-fold increase in the risk of continued use of e-cigarettes (odds
ratio [OR] = 1.428, p = .002). Passive smoking at home (OR = 1.364,
p = .009) also influenced adolescents’ continued use of e-cigarettes.
Particularly, adolescents who used e-cigarettes for smoking cessa-
tion or health consideration were 3.433 times more likely to use e-
cigarette continuously than adolescents who used e-cigarettes due
to curiosity.
4 |  D I S CU S S I O N
To identify the factors that affected the continued use of e-cigarettes
in adolescents, this study considered not only the individual factors
of adolescents but also environmental factors, such as friends, fam-
ily, and commercials. Among adolescents who were current users,
44.9% stopped at experimental use, while 55.1% continued to use
e-cigarettes; that is, more than half of adolescents used e-cigarettes
continuously rather than irregularly. This result suggests that health
care providers have to pay greater attention to continued e-cigarette
users.
E-cigarette purchasing usability had the greatest influence on the
continued use of e-cigarettes. This has a similar result with previous
study that there is a high frequency of e-cigarette use in high school
students who are able to purchase e-cigarettes (Mantey, Barroso,
Kelder, & Kelder, 2019). In most countries, the purchase of e-cig-
arettes by adolescents is legally prohibited. However, adolescents
said that it is possible to purchase e-cigarettes without difficulty in
a store that does not massively verify the identification or on the in-
ternet where checking identification card is difficult (Pepper, Coats,
Nonnemaker, & Loomis, 2019). E-cigarette sales regulations should
be strengthened to restrict adolescents from purchasing e-ciga-
rettes online and offline.
The characteristic of e-cigarettes that they can be hidden because
they do not smell like conventional cigarettes have had an effect on
continued use of e-cigarettes. Previous study has shown that the most
attractive point of e-cigarettes compared to conventional cigarettes
in adolescents is that e-cigarettes do not smell like conventional cig-
arettes and, therefore, can be hidden (Lee, Kim, et al., 2017). Health
care providers should be aware that the characteristic of the e-ciga-
rette and this affects the pattern of continued use among adolescents.

TA B L E 2   Factors affecting continued

Characteristics Reference Item OR (95% CI) p
e-cigarette usage (N = 1556)
Grade 12th 7th 0.764 (0.379–1.540) 0.450
8th 0.605 (0.357–1.023) 0.061
9th 0.626 (0.421–0.929) 0.020
10th 0.719 (0.528–0.980) 0.037
11th 0.779 (0.566–1.071) 0.124
Weekly allowance <$50 ≥$50 1.366 (1.086–1.719) 0.008
Residence type With family Without family 2.011 (1.431–2.827) <0.001
Conventional Former smoker Nonsmoker 0.915 (0.613–1.363) 0.660
cigarette smoking Current smoker 1.110 (0.775–1.591) 0.568
Peer smoking None Some 0.722 (0.434–1.202) 0.522
Most/All 1.177 (0.714–1.940) 0.209
Parental smoking No Yes 1.428 (1.145–1.781) 0.002
Sibling smoking No Yes 1.225 (0.926–1.619) 0.154
Passive smoking No Yes 1.364 (1.083–1.718) 0.009
At home
Reasons for Curiosity Cessation/ 3.433 (2.239–5.262) <0.001
E-cigarette use health
consideration
Concealment 4.077 (2.635–6.308) <0.001
Ease to buy 4.411 (2.089–9.315) <0.001
Flavoring 3.393 (2.238–5.145) <0.001
Others 3.783 (2.121–6.748) <0.001
2
Note: Nagelkerke R  = 0.148.
HAN et al.
Besides, adolescents who used e-cigarettes because of avail-
ability of adding various flavors had higher risk of using e-ciga-
rettes continuously. Unlike adults, adolescents are largely affected
by various flavors and scents, and the frequency of use varies ac-
cording to these flavors and scents (Morean et al., 2018). In some
countries, such as the United States and China, regulations on
the flavor added to e-cigarettes are being strengthened (US an-
nounces countrywide ban on flavoured e-cigs, 2020). However, in
most countries, such as South Korea, there are no regulations on
e-cigarette flavoring yet because they are not included as tobacco
products. Considering the influence of the flavor on continued use
of e-cigarettes in adolescents, laws should be revised to regulate
the flavored substances.
Regarding the effects of interpersonal environments, smok-
ing of parents, and passive smoking at home, they were congru-
ent with previous studies on use of e-cigarettes in adolescents
(Barrington-Trimis et al., 2015). It is already common knowledge
that smoking of adolescents is affected by the smoking of parents
(Bauman, Carver, & Gleiter, 2001). To stop the continued use of
e-cigarettes in adolescents, there should be not only interventions
for the adolescents themselves but also methods that consider
interpersonal environments, such as providing a smoking-free
environment.
On the other hand, this study showed that conventional ciga-
rette smoking did not affect the continued use of e-cigarettes.
Existing e-cigarette research focused on adolescents who use e-cig-
arettes among conventional cigarette smokers (Goniewicz, Lingas,
& Hajek, 2013; Kalkhoran, Grana, Neilands, & Ling, 2015; Lee, Lee,
& Cho, 2017). However, a study showed that the frequency of elec-
tronic cigarette use is not affected by conventional cigarette smok-
ing (Zavala-Arciniega et al., 2019). This result is interpreted as the
study analyzed the influence factors of continued users. Therefore,
we recommend further research ascertaining the association be-
tween conventional cigarette smoking and continued or regular use
of e-cigarettes.
Despite the significance of this study, as the data have high rep-
resentability to identify the influence factors of adolescents’ con-
tinued use of e-cigarettes, there are several limitations. The online
survey on the health status of adolescents was a cross-sectional
study, so it was difficult to directly identify the causes and effects.
Secondly, this study is a secondary analysis of the national data,
which has limited use of variables, including the number of e-cig-
arettes used per day and the relationship with other problematic
behaviors. Lastly, no variables that were directly related to environ-
mental factors related to e-cigarettes were included.
5 | CO N C LU S I O N
The problem of adolescents’ continued use of e-cigarettes is influ-
enced by not only individual but also environmental factors. Due to
the characteristics of e-cigarettes, such as ease of purchase, taste
and flavoring, and absence of tobacco smoke, the risk of continued
|
      5
use of e-cigarettes is particularly high. Legislation and specific in-
terventions are important in regulating e-cigarette sales rights and
addition of flavors.
AC K N OW L E D G E M E N T S
This work was supported by the Financial Supporting Project of
Long-term Overseas Dispatch of PNU's Tenure-track Faculty, 2017.
ORCID
Gyumin Han  https://orcid.org/0000-0002-2099-4562
Hyunmi Son  https://orcid.org/0000-0001-8226-1463
REFERENCES
Amato, M. S., Boyle, R. G., & Levy, D. (2015). How to define e-cig-
arette prevalence? Finding clues in the use frequency distri-
bution. Tobacco Control. https://doi.org/10.1136/tobac​cocon​
trol-2015-052236
Barrington-Trimis, J. L., Berhane, K., Unger, J. B., Cruz, T. B., Huh, J.,
Leventhal, A. M., … McConnell, R. (2015). Psychosocial factors associ-
ated with adolescent electronic cigarette and cigarette use. Pediatrics,
136(2), 308–317. https://doi.org/10.1542/peds.2015-0639
Bauman, K. E., Carver, K., & Gleiter, K. (2001). Trends in parent and
friend influence during adolescence: The case of adolescent cig-
arette smoking. Addictive Behaviors, 26(3), 349–361. https://doi.
org/10.1016/S0306​- 4603(00)00110​-6
Chen, P. C., Chang, L. C., Hsu, C., & Lee, Y. C. (2018). Dual use of e-cig-
arettes and traditional cigarettes among adolescents in Taiwan,
2014–2016. Nicotine & Tobacco Research, 21(1), 48–54. https://doi.
org/10.1093/ntr/nty003
Dai, H. Y., & Hao, J. Q. (2016). Exposure to advertisements and sus-
ceptibility to electronic cigarette use among youth. Journal of
Adolescent Health, 59(6), 620–626. https://doi.org/10.1016/j.jadoh​
ealth.2016.06.013
Doran, N., Brikmanis, K., Petersen, A., Delucchi, K., Al-Delaimy, W. K.,
Luczak, S., … Strong, D. (2017). Does e-cigarette use predict ciga-
rette escalation? A longitudinal study of young adult non-daily smok-
ers. Preventive Medicine, 100, 279–284. https://doi.org/10.1016/j.
ypmed.2017.03.023
Goniewicz, M. L., Lingas, E. O., & Hajek, P. (2013). Patterns of electronic
cigarette use and user beliefs about their safety and benefits: An in-
ternet survey. Drug and Alcohol Review, 32(2), 133–140. https://doi.
org/10.1111/j.1465-3362.2012.00512.x
Gulland, A. (2016). WHO urges restrictions on e-cigarettes. BMJ,
2016(355), i5991. https://doi.org/10.1136/bmj.i5991
Hwang, J. H., & Park, S. W. (2016). Association between peer ciga-
rette smoking and electronic cigarette smoking among adolescent
nonsmokers: A national representative survey. PLoS ONE, 11(10),
e0162557. https://doi.org/10.1371/journ​al.pone.0162557
Kalkhoran, S., Grana, R. A., Neilands, T. B., & Ling, P. M. (2015). Dual
use of smokeless tobacco or e-cigarettes with cigarettes and cessa-
tion. American Journal of Health Behavior, 39(2), 277–284. https://doi.
org/10.5993/AJHB.39.2.14
Kinnunen, J. M., Ollila, H., El-Amin, S. E. T., Pere, L. A., Lindfors, P. L., &
Rimpela, A. H. (2015). Awareness and determinants of electronic cig-
arette use among Finnish adolescents in 2013: A population-based
study. Tobacco Control, 24(E4), E264–E270. https://doi.org/10.1136/
tobac​cocon​trol-2013-051512
Kong, G., Morean, M. E., Cavallo, D. A., Camenga, D. R., & Krishnan-
Sarin, S. (2014). Reasons for electronic cigarette experimentation
and discontinuation among adolescents and young adults. Nicotine
& Tobacco Research, 17(7), 847–854. https://doi.org/10.1093/ntr/
ntu257
 |
6       HAN et al.
Korea Center for Disease Control and Prevention. (2016). Reports on the
Korea Youth Risk Behavior Web-based Survey, 2016. Cheongju, Korea:
Korea Centers for Disease Control and Prevention.
Korea Health Promotion Institute. (2019). 2019 school smoking preven-
tion guidelines. Retrieved from https://nosmk.kheal​ th.or.kr/nsk/
user/extra​ /ntcc/nosmo ​ k eFil ​ e /fileV ​ i ew/jsp/Page.do?siteM ​ e nuId​
x=81&dataN ​ o =24&dataG ​ r =3&fileN ​ o =550&postI ​ d x=591&level​
1Idx=7&level​2Idx=24&datal​v=1
Lee, J. A., Lee, S., & Cho, H. J. (2017). The relation between fre-
quency of e-cigarette use and frequency and intensity of cigarette
smoking among South Korean adolescents. International Journal
of Environmental Research and Public Health, 14(3). https://doi.
org/10.3390/ijerp​h1403​0305
Lee, S., Grana, R. A., & Glantz, S. A. (2014). Electronic cigarette use
among Korean adolescents: A cross-sectional study of market pen-
etration, dual use, and relationship to quit attempts and former
smoking. Journal of Adolescent Health, 54(6), 684–690. https://doi.
org/10.1016/j.jadoh​ealth.2013.11.003
Lee, Y. R., Kim, H., Lee, S., Jeon, J., Chu, S., & Jee, S. H. (2017). Associations
between the attempts for quitting smoking and electronic cigarette use
in Korean adolescent. Korean Journal of Health Education and Promotion,
34(3), 71–83. https://doi.org/10.14367​/kjhep.2017.34.3.71
Mantey, D. S., Barroso, C. S., Kelder, B. T., & Kelder, S. H. (2019). Retail
access to e-cigarettes and frequency of e-cigarette use in high school
students. Tobacco Regulatory Science, 5(3), 280–290. https://doi.
org/10.18001​/ TRS.5.3.6
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological
perspective on health promotion programs. Health Education Quarterly,
15(4), 351–377. https://doi.org/10.1177/10901​98188​01500401
Morean, M. E., Butler, E. R., Bold, K. W., Kong, G., Camenga, D. R., Cavallo,
D. A., … Krishnan-Sarin, S. (2018). Preferring more e-cigarette flavors
is associated with e-cigarette use frequency among adolescents but
not adults. PLoS ONE, 13(1), e0189015. https://doi.org/10.1371/
journ​al.pone.0189015
Pepper, J. K., Coats, E. M., Nonnemaker, J. M., & Loomis, B. R. (2019).
How do adolescents get their e-cigarettes and other electronic va-
ping devices? American Journal of Health Promotion, 33(3), 420–429.
https://doi.org/10.1177/08901​17118​790366
Rice, F. P., & Dolgin, K. G. (2005). The adolescent: Development, relation-
ships and culture. Pearson Education New Zealand.
Ssewanyana, D., Mwangala, P. N., Marsh, V., Jao, I., van Baar, A., Newton,
C. R., & Abubakar, A. (2018). Socio-ecological determinants of alco-
hol, tobacco, and drug use behavior of adolescents in Kilifi County
at the Kenyan coast. Journal of Health Psychology. https://doi.
org/10.1177/13591​05318​782594
Tsai, J., Walton, K., Coleman, B. N., Sharapova, S. R., Johnson, S. E.,
Kennedy, S. M., & Caraballo, R. S. (2018). Reasons for electronic cig-
arette use among middle and high school students—National Youth
Tobacco Survey, United States, 2016. Morbidity and Mortality Weekly
Report, 67(6), 196. https://doi.org/10.15585​/mmwr.mm6706a5
US announces countrywide ban on flavoured e-cigs. (2020). BBC News.
Retrieved from https://www.bbc.com/news/busin​ess-50978321
US Department of Health and Human Services. (2016). E-cigarette use
among youth and young adults. Atlanta, GA: A report of the Surgeon
General.
Vasiljevic, M., Petrescu, D. C., & Marteau, T. M. (2016). Impact of ad-
vertisements promoting candy-like flavoured e-cigarettes on appeal
of tobacco smoking among children: An experimental study. Tobacco
Control, 25(E2), E107–E112. https://doi.org/10.1136/tobac​ cocon​
trol-2015-052593
Wills, T. A., Knight, R., Sargent, J. D., Gibbons, F. X., Pagano, I., & Williams,
R. J. (2017). Longitudinal study of e-cigarette use and onset of ciga-
rette smoking among high school students in Hawaii. Tobacco Control,
26(1), 34–39. https://doi.org/10.1136/tobac​cocon​trol-2015-052705
Zavala-Arciniega, L., Lozano, P., Kollath-Cattano, C., Gutierrez-Torres,
D. S., Arillo-Santillán, E., Barrientos-Gutiérrez, I., … Thrasher, J. F.
(2019). E-cigarette use frequency and motivations among current
users in middle school. Drug and Alcohol Dependence, 204, 107585.
https://doi.org/10.1016/j.druga​lcdep.2019.107585
How to cite this article: Han G, Son H. What influences
adolescents to continuously use e-cigarettes?. Public Health
Nurs. 2020;00:1–6. https://doi.org/10.1111/phn.12735