Objective To assess the awareness and prevalence of electronic cigarettes (e-cigarettes) and associated factors among Chinese adults (15 years and older). Method This study examined data from Global Adults Tobacco Survey China Project, which was nationally representative and used stratified multiphase cluster randomised sampling design. Data were collected in 2018 through a household survey with in-person interviews using tablet computers. Complex sampling weighted analysis method was used. Results 48.5% of Chinese adults had heard of e-cigarettes. The proportions of Chinese adults who had ever used, had used in the last 12 months, and currently used e-cigarettes were 5.0%, 2.2% and 0.9%, respectively; people in the 15–24 years group showed the highest rates of ever use, last 12-month use and current use at 7.6%, 4.4%, and 1.5%, respectively. Among males, higher e-cigarette use was associated with 15–24 years age group, college/university or above education, and daily use of combustible cigarettes. Among all e-cigarette users, 90.6% also used combustible cigarettes. The most common reason for e-cigarette use was smoking cessation (46.2%) while among ever smokers, 9.5% of ever e-cigarette users had quit smoking and 21.8% of never e-cigarette users had quit smoking (adjusted OR 0.454, 95% CI 0.290 to 0.712). Conclusion Prevalence of e-cigarettes among Chinese adults had increased since 2015, especially among young people aged 15–24. The high level of dual use and lower quit rate among e-cigarette users indicated e-cigarettes had not shown cessation utility at the population level in China. Regulation of e-cigarettes is needed to protect youth and minimise health risks.

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What is already known about this topic? In 2019, China CDC conducted the National Youth Tobacco Survey among secondary school students, and the prevalence rates of ever, current, and frequent smoking were 17.9%, 5.9%, and 1.8%, respectively. What is added by this report? The prevalence rate of cigarette use in males decreased largely from 2019 to 2021 in China, while it increased in 18 provincial-level administrative divisions (PLADs) for females. The tobacco control situation remains challenging among vocational senior high school (VSHS) students. Significant geographical disparities existed in cigarette use. What are the implications for public health practice? Targeted tobacco control policies aimed at VSHS students are needed, specifically those PLADs with higher smoking rates. Additionally, close attention should be paid to female smokers.

What is already known about this topic? After the framework convention on tobacco control (FCTC) came into force, the health warnings on cigarette packaging in the mainland of China had been changed in three rounds. But the warning label is still only pure text and without descriptions of specific health consequences caused by tobacco use. What is added by this report? Although there were two rounds of changes from 2010 to 2018, current health warning labels did not work in increasing Chinese smokers’ smoking cessation intention compared with the previous one. Large pictorial warning labels were more effective than the current health warning label in stimulating Chinese smoker’s willingness to quit. What are the implications for public health practice? Pictorial health warnings could play a great role in promoting the realization of the tobacco control goals of Healthy China 2030. Pictorial health warnings should be printed on cigarette packs in the mainland of China as soon as possible.

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