18B.12 Influences on the uptake of e-cigarettes

Last updated:  August 2021

Suggested citation: Greenhalgh, EM, & Scollo, MM. 18B.12 Influences on the uptake of e-cigarettes. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from:  http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes

 

Use of e-cigarettes by children and non-smokers—either as a step toward smoking (see Section 18B.6.2) or exclusively—is a concern to public health specialists and regulators. During 2017–2018, 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 In 2019, 27.5% of US high school students and 10.5% of middle school students reported current use of e-cigarettes.3 Exposure to nicotine during adolescence may have significant and lasting health consequences,4 including long-term addiction.5 Further, although the long-term health risks are not well understood, limited evidence suggests that e-cigarette use—particularly when e-liquids include sweet flavourings6, 7—may increase users’ risks of cardiovascular and respiratory disease (see Section 18B.5). Some adolescents are also using e-cigarettes for vaping cannabis and other substances that pose additional risks (see Section 18B.4).8

As with tobacco cigarettes, there are a range of demographic, environmental, behavioural and personal factors that predict the likelihood that a person will start using e-cigarettes. This section summarises research on the relationship between e-cigarette uptake and:

It also examines the effectiveness of policies and programs aiming to prevent the uptake of e-cigarettes.

18B.12.1 Demographics

Prevalence of e-cigarette use is generally highest among teenagers and young adults. Research in the US,9 Canada,10 and UK11 has found that e-cigarette use is more common among older adolescents compared with those in their early teen years. Among Australian high school students in 2017, although ever use of e-cigarettes increased with age, recent and frequent use was more common among those aged 12–15 than 16–17 year olds.12 Among Australian adults, use was substantially more common among young adults compared with middle-aged and older adults in 2019, both for Aboriginal and Torres Strait Islander peoples13 and other Australians14—see Section 18B.3.

Research in Australia,12 as well as overseas,12, 15-21 has consistently found that e-cigarette use is more common among males than females. Studies in the US have generally found that e-cigarette use is more common among young White people than young Black people.15, 22 In Australia, use of e-cigarettes is less common among Aboriginal and Torres Strait Islander peoples than among other Australians.13, 23

18B.12.2 Health and temperament

18B.12.2.1 Physical health

Researchers have identified a number of 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.15 Other studies have similarly found that e-cigarette use was more common among young people with asthma.16, 24 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 products25—see Section 18B.5

A person’s weight may also influence their likelihood of vaping, with studies finding that adolescents who are overweight/obese,15 or perceive themselves to be overweight,26 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.27, 28

18B.12.2.2 Mental health

People with mental health conditions are far more likely than those without to smoke tobacco cigarettes (see Section 7.12). A growing body of research suggests the same is true for e-cigarettes; studies have found that young people with mental illness,29, 30 including depression,15, 24, 31 anxiety,24 ADHD,24 and internalising and externalising problems30 are more likely to use e-cigarettes. Those with exposure to childhood trauma32 and adverse childhood experiences33, 34 also appear to be more vulnerable to e-cigarette use. An Australian study found that in 2016, e-cigarette use was correlated with higher levels of psychological distress among adults.35

18B.12.2.3 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 risk behaviours. For example, studies have shown that engaging in unsafe sex,36 experiencing injury and violence,36, 37 having been arrested or suspended from school,38 using other substances,24, 36, 37, 39 associating with delinquent peers,40 drink driving,39 texting while driving,39 and driving without a seatbelt15 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 vaping.41, 42 Curiosity about the products is also often cited as one of the main reasons young people experiment with e-cigarettes.43-45

18B.12.3 Tobacco and other substance use

Experimentation with e-cigarettes among non-smoking middle-aged to older adults appears to be relatively rare.46, 47 In Australia in 2019, about one-quarter to one-third of current smokers aged 40–69 reported having ever used e-cigarettes, compared with fewer than five per cent of non-smokers in the same age groups.14 Among young people, although e-cigarette use is also more common among those who also use tobacco products,15, 21, 22, 24, 37, 38, 42, 48-5455 vaping has increased among young never smokers over time.56 An analysis of trends from 2011 to 2015 in e-cigarette use among US adolescents found that past month e-cigarette users increasingly encompassed those who were not users of other tobacco products.57 In Australia in 2017, about one-third (34%) of high school students who were current e-cigarette users had not smoked cigarettes prior to using e-cigarettes.12 Among adults, one study reported that in 2016 in the US, 1.4% of never smokers reported using e-cigarettes, and of these users, about 60% were aged 18 to 24.58 Another US study found that the prevalence of current e-cigarette use increased significantly among adult never smokers between 2015 and 2018. 59 Similarly in Australia, lifetime use of e-cigarettes among non-smokers significantly increased between 2016 and 2019, with the highest prevalence of ever use among 18–24 year-olds (20%) and current use among 25–29 year-olds (3%) in 2019. 14

E-cigarette use also appears to share a strong relationship with alcohol consumption among young people.15, 16, 24, 30, 38, 48, 60 A systematic review and meta-analysis found that among adolescents, e-cigarette users had more than six-fold greater odds of reporting alcohol use or binge drinking compared to non-e-cigarette users.61 There is also evidence that e-cigarette use is related to use of other drugs, particularly marijuana.24, 30, 37, 39, 60 Longitudinal research in the US found that regardless of the level of vaping, e-cigarette use was associated with increasing use of alcohol and marijuana over time.62 Conversely, several other US longitudinal studies have found that marijuana use is associated with initiation of e-cigarette use.63, 64 Dual users of alcohol and marijuana also appear to be at greater risk of e-cigarette use.65

18B.12.4 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.66-70 Correlational71-75 and longitudinal76-79 studies have also found an association between e-cigarette marketing exposure and greater use of e-cigarettes.

See Section 18B.2 for a detailed discussion of the advertising and promotion of e-cigarettes.

18B.12.5 Product features

18B.12.5.1 Flavours and packaging

E-cigarette liquids are available in a variety of flavours that appeal to children, such as cotton candy and gummy bear.80 The wide range of fruit, lolly, and other sweet flavours is one of the most commonly cited reasons for using e-cigarettes among young people.43, 81-89 E-cigarette manufacturers have also been criticised for creating child-friendly packaging that resembles juice boxes, lollies, and cookies (sweet biscuits).90 Further, some products have been designed to maximise discrete use,87, 91-94 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.95, 96 See Section 18B.2 for a detailed discussion of each of these issues.

18B.12.5.2 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.88, 97 One of the most popular e-cigarette brands in the US among adolescents, JUUL, exposes users to high levels of nicotine;98 however several studies have shown that most young people are unaware of JUUL’s high nicotine concentration.99, 100

18B.12.6 Social and environmental factors

18B.12.6.1 Peer group

A young person’s peer group plays an important role in their likelihood of using tobacco and other substances, including e-cigarettes. Studies have consistently shown that adolescents are more likely to use e-cigarettes if they have friends who use e-cigarettes.44, 45, 63, 101 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.102 Having peers who use tobacco products21, 48, 63 and other substances38 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.101, 103 For example, beliefs that vaping will increase a young person’s social status might increase their risk of initiating e-cigarette use.104 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.105

18B.12.6.2 The home environment

Although peers play a predominant role in a young person’s likelihood of vaping, research shows that parents can 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.103 Another found that teens with weaker parental support and monitoring were more likely to be e-cigarette users.40 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.105 Having a higher amount of pocket money,21 or living in a household with someone who uses e-cigarettes,42 are also home-based predictors of e-cigarette use among young people.

18B.12.6.3 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 e-cigarette users appear to be less likely to participate in music/dance/art,24 academic activities,24 and organised sports 24 or other types of physical activity.106 One review similarly noted that studies have generally found an association between e-cigarette use and lower school performance, being out of school, and attending a disadvantaged school.21 One study in the US of middle school students (grades 6–8) showed that compared with non-users, e-cigarette users performed worse in school, were more likely to feel alienated from school, and were more likely to to associate with delinquent peers.40 Several studies have shown that e-cigarette users are more likely to experience bullying.24, 107

18B.12.6.4 Exposure to e-cigarette and tobacco use

Given the rapidly increasing use of e-cigarettes in recent years, particularly in the US, exposure to vaping has become more common.108 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.109 Another similarly found that observing e-cigarette use at school was associated with greater odds of e-cigarette use and susceptibility.110 Longitudinal research in Canada has found that teenagers and young adults who reported seeing anyone use e-cigarettes sometimes, very often, or always had more than four times the odds of initiating e-cigarette use compared to those who had not seen anyone vape.111 Seeing e-cigarette use in public at least some days also predicted initiation of e-cigarette use in European study.112 Exposure to secondhand tobacco smoke has also been found to predict use of e-cigarettes among young people.30, 113

18B.12.7 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.114 Further, despite some popular e-cigarettes containing very high levels of nicotine,98 many young people believe that e-cigarettes are less addictive than tobacco cigarettes, and such beliefs predict e-cigarette susceptibility and use.24, 115

E-cigarettes are often marketed as less harmful than tobacco cigarettes (see Section 18B.2), and studies have shown that adolescents who believe vaping is less harmful than smoking are at greater risk of e-cigarette use.18, 24, 42, 48, 87, 115 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.50, 53, 116 See Section 18B.5 for a discussion of the health effects of e-cigarette use, including for adolescents.

18B.12.8 Policies and programs to prevent e-cigarette use

18B.12.8.1 Legislation to reduce use among young people

The issues outlined above have led to calls for policies and programs that would minimise use among young people and non-smokers, including restrictions on advertising and promotion, prohibiting use in smokefree areas, banning flavours that could appeal to youth, raising taxes, implementing health warnings, and prohibiting sales to minors.117, 118 Surveys in the US,119, 120 Canada,121 and Australia122  have found strong support for measures that aim to prevent e-cigarette use among teenagers. See Sections 18B.8 and 18B.9 for an overview of current Australian and international regulations.

An analysis of state-based policies in the US found that ever and current use of e-cigarettes among youth decreased in states that included e-cigarettes in their smokefree policies. In states with T21 policies (i.e., prohibiting sales of tobacco and e-cigarettes to people under 21), use of e-cigarettes remained steady, whilst increasing in states without such policies.123 However, other studies have shown that underage young people can often easily purchase e-cigarettes, particularly online.124, 125 In 2018 it was reported that the FDA had conducted large-scale undercover checks of retailers, resulting in a significant number of warning letters for violations related to the illegal sales of JUUL products to youth.126

18B.12.8.2 Public education campaigns

In 2018, the FDA launched a public education campaign to educate teenagers about the risks of e-cigarettes as part of its ‘Real Cost’ campaign that initially focused on cigarette smoking.2 The ads aimed to educate young people about addiction and other health effects of vaping. An analysis of the campaign found that it did succeed in generating higher risk beliefs about the harms of vaping, creating more negative attitudes toward vaping, and reducing intentions to use e-cigarettes among US adolescents.127

18B.12.8.3 School-based programs

Programs and policies have also been developed and implemented in some US high schools, aiming to prevent e-cigarette use among young people.93, 128, 129 For example, as at mid-2020 the ‘CATCH my Breath’ e-cigarette prevention program had been adopted in 4,000 US schools,130 and an evaluation of its pilot program found that ever e-cigarette use was lower among middle schools that implemented the program than among those that did not.128 School policies may also be helpful, with research in Canada showing that a ban on the use of e-cigarettes on school property may have contributed to decreased use of e-cigarettes among students.131

Despite some of these programs showing promise, a review in 2020 found that that there are few adolescent-focused e-cigarette prevention or cessation programs, and most have not been evaluated. It also found that many of the programs are not evidence-based nor grounded in theory, and the authors call for further research and the development of resources to address this gap.132

 

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