Use of e-cigarettes by children and non-smokers—either as a step toward smoking (see Section 18.7) or exclusively—is a concern to public health specialists and regulators. During 2017–18, current e-cigarette use among US high school students increased by 78% (from 11.7% to 20.8%),1 leading the US FDA to label e-cigarette use among youth an ‘epidemic’.2 Similarly in Australia, between 2017 and 2022–23, past-month e-cigarette use among students (aged 12–17 years) increased by 274% (from 4% to 16%).3 (See Section 18.3 for further detail on the prevalence of e-cigarette use in Australia and overseas). Exposure to nicotine during adolescence may have significant and lasting health consequences,4 including long-term addiction.5 Further, there are known short-term health risks from e-cigarette use, and there is insufficient evidence to support the safety of long-term vaping(see Section 18.6). Some adolescents are also using e-cigarettes for vaping cannabis and other substances that pose additional risks (see Section 18.4).6
As with tobacco cigarettes, a range of demographic, environmental, behavioural and personal factors predict the likelihood that a person will start using e-cigarettes. This section summarises research on the relationship between e-cigarette uptake and:
For a discussion of the effectiveness of policies and programs aiming to prevent the uptake of e-cigarettes among children and non-smokers, see Section 18.10.
18.9.1 Demographics
18.9.1.1 Age
Prevalence of e-cigarette use is generally highest among teenagers and young adults. Among adults in Australia, current e-cigarette use was substantially more common among young adults compared with middle aged and older adults in 2022–23. About one-fifth (21%) of young adults aged 18–24 and 14% of young adults aged 25–29 were current e-cigarette users.7 Among Australian high school students, about one-sixth (16%) had used e-cigarettes in the past month in 2022–23.7 Use was more common among older students (16- and 17-year-olds) compared to younger students (12- to 15-year-olds) across all recency periods (ever use, past-month use, regular use and daily use).3 Research in the US,8 Canada,9, 10 and UK11 has similarly found that e-cigarette use is more common among older adolescents compared with those in their early teen years. See Section 18.3 for further detail on the prevalence of e-cigarette use among adults and adolescents in Australia and overseas.
18.9.1.2 Gender and sexuality
Research in Australia,12 as well as overseas, 12-19 has generally found that e-cigarette use is more common among males than females. Among adults in Australia, 8% of men were current e-cigarette users compared to 6% of women in 2022–23.7 However, among adolescents e-cigarette use has become more common among girls than boys. The 2022–2023 Australian Secondary Students’ Alcohol and Drug (ASSAD) survey found higher proportions of girls reported ever use, past-month use, regular use and daily use of e-cigarettes compared to boys.3
The prevalence of current e-cigarette use was higher among transgender and gender diverse people (aged 14 and over) (14%) compared with the cisgender population (7%), in Australia in 2022–2023.7 However, this disparity primarily stemmed from the younger age demographic of transgender and gender diverse people and the greater likelihood of e-cigarette use among younger people. Upon accounting for age variations, transgender and gender diverse individuals exhibit a comparable likelihood of current e-cigarette use to their cisgender counterparts.20
Gay, lesbian and bisexual people were twice as likely as heterosexual people in Australia to currently use e-cigarettes in 2022–23, after adjusting for differences in age.20 Research in the US and Canada has similarly found that e-cigarette use and the use of e-cigarettes to consume cannabis is more common among young people who are lesbian, gay, bisexual and transgender. 21-2324 It is noteworthy that sexual minority youth are more likely to report having mental health conditions, 25, 26 which are also associated with an increased risk of e-cigarette use (see 18.9.2.2 Mental health). Sexual orientation appears to compound this risk, with findings from US research indicating that young sexual minority males with mental health conditions are more like to use e-cigarettes than heterosexual males with similar mental health conditions.27
18.9.1.3 Socioeconomic and cultural factors
See Section 18.3 for the prevalence of e-cigarette use among Aboriginal and Torres Strait Islander peoples and other priority populations in Australia.
18.9.2 Health and temperament
18.9.2.1 Physical health
Researchers have identified several chronic health conditions associated with e-cigarette use among young people. One US study found that compared with young adult never smokers without the conditions, those with a history of arthritis or diabetes, and those who currently had asthma, had increased odds of e-cigarette use.13 Additional studies have also found a higher prevalence of e-cigarette use among young people with asthma.14, 28, 29 However, another study found that young people with asthma were less likely to use e-cigarettes; this effect could potentially be attributed to the lower expectations that e-cigarettes would induce a sense of relaxation among individuals with asthma.30 Notably, adolescents with asthma may be particularly vulnerable to the health effects of e-cigarette use, with research suggesting that they are more likely to have an increase in respiratory symptoms and exacerbations compared with adolescents with asthma who do not use the products31 —see Section 18.6.2 Health effects of e-cigarette using during adolescence.
A person’s weight may also influence their likelihood of vaping, with studies finding that young people who are overweight/obese,13, 32 or perceive themselves to be overweight,33 are more likely to use e-cigarettes. Use is also associated with intentions to lose weight and as a means of appetite control among teenagers and young adults. 34-38
18.9.2.2 Mental health
People with mental health conditions are far more likely than those without to smoke tobacco cigarettes (see Section 9A.3). A growing body of research suggests the same is true for e-cigarettes. In Australia, people who have been diagnosed or treated for a mental health condition were twice as likely as those without such conditions to currently use e-cigarettes in 2022–23 (12% versus 6%). Similarly, people experiencing high or very high levels of psychological distress were four times more likely than those with low distress levels to currently use e-cigarettes.39 Further studies have found evidence that e-cigarette use among young people is associated with mental health conditions including depression,40 anxiety,28 ADHD,28 eating disorders,41 internalising and externalising problems, 42, 43 and suicidal ideation44 . Those with exposure to online racism,45 childhood trauma,46 adverse childhood experiences, 47-51 and sexual assault,44 also appear to be more vulnerable to e-cigarette use.
The increased prevalence of e-cigarette use among individuals with mental illness may stem from a misperception that vaping is helpful for alleviating feelings of stress, anxiety or boredom (i.e., the ‘self-medication’ hypothesis).36 However research on smoking has shown that quitting actually improves mental health and quality of life, and suggests that the relationship between smoking and poorer mental health is likely attributable to chronic nicotine use.52 Emerging evidence similarly indicates that e-cigarette use is associated with worsening symptoms of depression.53
18.9.2.3 Temperament
Research on adolescent smoking suggests that it is more likely to occur in the context of a range of risk-taking behaviours (see Section 5.5). Similarly, a growing body of research suggests that e-cigarette use is more common among young people who engage in other risky behaviours. Studies have shown that engaging in unsafe sex,54 experiencing injury and violence, 54, 55 rule-breaking42 and delinquent behaviour (e.g., theft, vandalism),56 having been arrested or suspended from school,57 using other substances,28, 54, 55, 58, 59 associating with delinquent peers,60 drink driving,58 texting while driving,58 and driving without a seatbelt13 are associated with increased e-cigarette use among youth. Sensation seeking—a personality trait characterised by the desire to experience novel sensations and the willingness to take risks—is also associated with e-cigarette use. 61-63 Similarly, impulsivity 64, 65 and deficits in executive function—cognitive capabilities for planning, working memory , self-control and attention shifting—are associated with e-cigarette use.66 Curiosity about the products is also often cited as one of the main reasons young people experiment with e-cigarettes.39, 67-70
18.9.3 Tobacco and other substance use
People who use tobacco products have a greater likelihood of trying e-cigarettes. 71-73 However, the majority of young people in Australia who vape had no prior history of smoking before trying e-cigarettes (see Section 18.3). Conversely, among middle-aged to older adults, experimentation with e-cigarettes appears to be relatively rare among those who do not smoke (see Section 18.3.1).
An Australian survey found adults were more likely than adolescents to initiate and continue using e-cigarettes for smoking cessation. Though among both adolescents and adults who smoked, the most common reason for current e-cigarette use was taste and flavours.70 Similarly, the 2022–23 National Drug Strategy Household survey found only one in five (21%) people who had ever used e‑cigarettes reported doing so in order to quit smoking. The main reason for trying e-cigarettes was curiosity, particularly among adolescents and young adults.7 The lower cost of e-cigarettes compared to tobacco cigarettes was also reported as a motivator for e-cigarette use,70 particularly among people who smoke.7
E-cigarette use also appears to share a strong relationship with alcohol consumption among young people.13, 14, 28, 42, 57, 65, 74-77 A systematic review and meta-analysis indicated that adolescents who use e-cigarettes are more than six times as likely to report alcohol use or binge drinking compared to those who do not use e-cigarettes.78 There is also evidence that e-cigarette use is related to use of other drugs, particularly marijuana.28, 42, 55, 58, 59, 65, 74, 77, 79 Several longitudinal studies in the US found that marijuana use is associated with initiation of e-cigarette use.80, 81 Another longitudinal study in the US found that binge drinking, marijuana use, marijuana vaping, prescription and illicit drug use were associated with escalated e-cigarette use among young people.82 Conversely, a longitudinal study in the US indicated that vaping was associated with increasing use of alcohol and marijuana over time.83 Dual users of alcohol and marijuana also appear to be at greater risk of e-cigarette use.84
18.9.4 Advertising and promotion of e-cigarettes
A growing body of studies have examined the effects of e-cigarette advertising on the appeal of e-cigarettes and tobacco cigarettes among children. As with adults, children exposed to e-cigarette adverts report more positive attitudes toward and greater curiosity about and intention to use the products. 85-90 Correlational 90-96 and longitudinal 97-101 studies have also found an association between e-cigarette marketing exposure and use of e-cigarettes. See Section 18.2 for a detailed discussion of the advertising and promotion of e-cigarettes.
18.9.5 Product features
18.9.5.1 Flavours and packaging
E-cigarette liquids are available in a variety of flavours that appeal to children, such as cotton candy and gummy bear.102 The wide range of fruit, lolly, and other sweet flavours, and enjoyment of their taste are commonly cited reasons for using e-cigarettes among young people.67, 70, 103-112 Mint and menthol flavours and certain device types when first trying e-cigarettes, in particular, have been linked with transitions to more frequent e-cigarette use and dependence among young adults.113114
The perception that e-cigarettes offer a more appealing taste compared to traditional cigarettes is also a common motive for usage.7 Research also suggests that the branding and representations of flavours on e-cigarette product packaging itself influences adolescents susceptibility and interest in e-cigarette use.115, 116 E-cigarette manufacturers have also been criticised for creating child-friendly packaging that resembles juice boxes, lollies, and cookies.117 Further, some products have been designed to maximise discrete use,109, 118-121 which likely appeals to young people who may wish to hide e-cigarette use from parents and teachers. Technophilia—or the interest in and adoption of new technologies—is also associated with e-cigarette use among youth.122, 123 See Section 18.2 for a detailed discussion of each of these issues.
18.9.5.2 Nicotine content
The presence of nicotine in e-cigarette liquids can affect the likelihood that a person will become a regular user. Studies in the US have found that adolescents who use e-cigarettes with nicotine use the products more frequently than those who use nicotine-free e-cigarettes.110, 124, 125 Similarly in Australia, people who used e-cigarettes more frequently were more likely to report that the last e-cigarette they used contained nicotine.126 E-cigarettes with high nicotine levels, such as JUUL,127 are associated with nicotine dependence and more frequent e-cigarette use;128, 129 however several studies have shown that most young people are unaware of the high nicotine concentration in these products.130, 131 Analyses of US sales data between 2017 and 2022 indicate that nicotine levels have increased in e-cigarette products across nearly all product types and flavours, though particularly in single-use/disposable e-cigarettes which are more most popular among adolescent users.132, 133 There is also some evidence that the nicotine formulation used in e-cigarette liquids may also affect the product appeal.134
18.9.6 Social and environmental factors
18.9.6.1 Peer group
A young person’s peer group plays an important role in their likelihood of using tobacco and other substances, including e-cigarettes. Vaping is social activity for many young people, with most adolescent and young adult e-cigarette users sourcing e-cigarettes through friends and other social sources.7, 135, 136 Young adults also report using e-cigarettes in social situations such as parties to bond with peers and to generate social cachet by demonstrating tricks and devices.36 Virtual socialising is also associated with e-cigarette use among adolescents.137 Studies have consistently shown that adolescents are more likely to use e-cigarettes if they have friends who use e-cigarettes.68, 69, 80, 90, 138-142 Twin studies have found that environmental factors, such as having friends who use e-cigarettes, play a much more important role in predicting e-cigarette use than genetic factors.143 Having peers who use tobacco products19, 75, 80 and other substances57 has also been shown to predict e-cigarette use among teenagers.
Adolescents’ attitudes toward and use of e-cigarettes can be influenced by how the products are perceived within their friendship group.138, 144, 145 For example, beliefs that vaping will increase a young person’s social status might increase their risk of initiating e-cigarette use.146 Perceptions that the products are cool, fun, and help a young person ‘fit in’ can promote greater use, while for some adolescents, perceptions among peers that vaping is uncool and unfashionable can help to prevent use.147 Australian adults also cite the greater acceptability of e-cigarettes compared to traditional tobacco cigarettes as a motivating factor for their e-cigarette use.70
18.9.6.2 The home environment
Although peers play a predominant role in a young person’s likelihood of vaping, research indicates that parents may also influence their children’s perceptions and use of e-cigarettes. One study in the US found that parents' perceptions of the harms of e-cigarette use predicted both lower intentions and use of e-cigarettes among a sample of high school students, regardless of peer attitudes and norms.144 US studies have also found adolescents with strict home rules for e-cigarettes, such as household bans, perceived e-cigarettes as more harmful, were less likely to use e-cigarettes and demonstrated less frequent e-cigarette use.148149 A review found that parents may implicitly approve e-cigarette use as a smoking cessation device and through favourable comparisons with tobacco smoking, which can also influence adolescents’ attitudes and products use.147 Having a higher amount of pocket money,19 higher income,90 family conflict,150 having parents who have ever smoked,151 having family members who use e-cigarettes,90, 142, 152 or living in a household with someone who uses e-cigarettes,62 are also home-based predictors of e-cigarette use among young people.
18.9.6.3 The school environment
Higher levels of engagement with and achievement at school are associated with lower levels of tobacco use (see Section 5.9). Similarly, research has found that associations between e-cigarette use and lower levels of academic performance,15319, 60, 149 and school engagement (e.g., truancy, lower participation in extracurricular activites, feeling alienated at school)28, 60, 153-155 A review of longitudinal studies indicated that poor academic grades and truancy among adolescents predicted future e-cigarette use.153 Several studies have shown that adolescents who are bullied are also more likely to use e-cigarettes, especially girls.28, 156, 157 A US study found that lower school and family connectedness among high school students was associated with being motivated to use e-cigarettes to relax or relieve stress and anxiety.158
18.9.6.4 Exposure to e-cigarette and tobacco use
Given the rapidly increasing use of e-cigarettes in recent years, particularly in the US, it has become more common to see others vaping.159 Concerns have been raised that such exposure could serve to normalise e-cigarette use among young people and reduce perceptions of harm. Data from a nationally representative survey of US secondary school students showed that youth observation of vaping on school grounds was associated with significantly higher odds of being susceptible to smoking cigarettes and using e-cigarettes, especially among middle-school students.160 Another similarly found that observing e-cigarette use at school was associated with greater odds of e-cigarette use and susceptibility.161 Longitudinal research in Canada has found that teenagers and young adults who reported seeing anyone use e-cigarettes sometimes, very often, or always had over four times the odds of initiating e-cigarette use compared to those who had not seen anyone vape.162 Seeing e-cigarette use in public at least some days also predicted initiation of e-cigarette use in European study.163 Similarly among adults who smoke, longitudinal research in Canada, Australia , England and the US found that for those who perceived e-cigarette use as normalised were more likely to start using e-cigarettes.164 Exposure to secondhand tobacco smoke has also been found to predict use of e-cigarettes among young people.42, 165
18.9.7 Beliefs about health risks and addiction
Adolescents often have a poor understanding of addiction, with research on smoking showing that adolescent smokers often do not perceive themselves as addicted and are optimistic about their ability to quit (see Section 6.14). Similarly, a recent study on e-cigarettes found optimism bias among US teenagers about their ability to quit vaping.166 Further, despite some popular e-cigarettes containing very high levels of nicotine,127 many young people believe that e-cigarettes are less addictive than tobacco cigarettes, and such beliefs predict e-cigarette susceptibility, use and earlier uptake.28, 167, 168169
E-cigarettes are often marketed as less harmful than tobacco cigarettes (see Section 18.2). The belief that e-cigarettes are less harmful than smoking is commonly cited as a motivation for e-cigarette use.7 Studies have also shown that adolescents who believe vaping is less harmful than smoking are at greater risk of e-cigarette use.16, 28, 62, 75, 109, 167, 170 Other studies have found that some adolescents perceive e-cigarettes as posing little to no harm, regardless of their comparative risk with cigarettes, and that these adolescents are also more likely to use e-cigarettes and initiate e-cigarette use at an earlier age.90, 168-173 See Section 18.6 for a discussion of the health effects of e-cigarette use, including for adolescents.
An Australian survey found that adolescents who believed that e-cigarettes help manage moods and help people quit smoking are more susceptible to future e-cigarette use.142 For further information about the perceptions of e-cigarettes among adults and young people see Section 18.12.
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated March 2024)
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