E-cigarette use patterns, brand preference and knowledge about vaping among teenagers (13–16 years) and parents of children attending Christchurch Hospital
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E-cigarette use (vaping) has been increasing rapidly both among adults and teenagers in New Zealand. A 2019 study which investigated smoking and vaping in high school students (n=7,721) found 10% of students vaped at least monthly and 6% vaped weekly or more often.[[1]] The ASH year 10 Snapshot Survey in 2021[[2]] found that vaping had increased since 2019, and daily vaping was 9.6% overall and up to 19% among Māori teenagers. Unlike adults who often vape as a means to reduce tobacco use or quit smoking,[[3]] most teenagers are attracted to e-cigarettes because of simple curiosity,[[4]] flavours, friends, and ability to use vape products discreetly.[[5–7]]
There is general consensus among the scientific community that vaping is less harmful than smoking conventional cigarettes, but not harmless.[[8]] However, there remains disagreement among policymakers internationally on the role of vaping in tobacco control, owing to limited evidence.[[9]] Concerns about e-cigarette use have been raised by the major international respiratory societies.[[10–13]] These include known and unknown long-term health risks, and the potential for vaping to serve as a gateway to smoking, especially among adolescents and young adults. Several studies have shown an association between e-cigarette use and subsequent onset of smoking among teenagers,[[13,14]] while one study reported an association between vaping and attempted smoking cessation although the success rate was only 13.5%.[[15]]
Currently in New Zealand, patients are asked about whether they smoke on admission to hospital, but information is lacking whether vaping is also asked. Understanding the e-cigarette use habits and knowledge of patients about vaping presenting to hospital can enable clinicians to provide relevant information to help patients make informed decisions. We sought to explore these areas in a pilot study to test the validity and acceptability of research tools before deployment to a wider study of vaping knowledge and brand preference in high school students.
Method
Data was collected as part of a summer studentship between 9 December 2021 and 23 February 2022 at Christchurch Hospital. Teenagers aged 13–16 years and parents of children presenting in the paediatric outpatient department were eligible to participate. The study was approved by the Human Ethics Committee (Health) of the University of Otago (H21/169), and locality authorisation was provided by the Canterbury District Health Board. Information about the study was provided to prospective participants in the waiting area and they were invited to take part. Written or online consent was obtained before completing the survey (for teenagers aged 13–15 years old we required their parental as well as their own consent).
The questionnaire included previously validated questions as well as new questions. The methods including these new questions were piloted for use in a wider study on vaping in high schools. Most questions on e-cigarette use (ever-use, frequency of use, reason for use, nicotine use, type of vaping device, and harm perception) were adapted from Pearson and colleagues.[[16]] The question on gender was adapted from previous research on smoking and vaping among university students in New Zealand.[[17]] The ethnicity question was based on the question in the New Zealand census.[[18]]
Participants could complete the survey online or on paper. Digital devices (iPads) were provided for participants to scan a QR code and complete the questionnaire anonymously. Participants were asked to complete the survey independently, without parents or teenagers viewing or influencing each other’s responses and no issues were reported. We reassured teenagers that the study was anonymous, and that there were no repercussions on them, to encourage them to answer questions about smoking and vaping openly. Information was provided for participants to contact Quitline for support if they were concerned about their smoking or vaping. All participants completed the survey online and the questionnaire took five minutes on average.
Survey measures
Demographic information
For the purpose of analysis, participants aged 13–16 years were categorised as teenagers and participants aged 17 years or older were categorised as parents. Participants could identify their gender as male, female, other and “prefer not to say”; however, only male and female options were selected by participants. Participants indicated the ethnicities they identified with, and these were categorised as New Zealand European, Māori, Pasifika (included Samoan, Cook Island Māori and Tongan), Asian (included Indian and Chinese) and Other, consistent with previous research.[[17]]
E-cigarette use
Participants were asked if they had ever used an e-cigarette or vaping device (ever-use); whether they currently vaped at least monthly (current use); how often they vaped “in home” or “in car” when other people were present (never/almost never vs other); the primary reason for using an e-cigarette/vaping device; and whether their usual e-cigarette/vaping device contained nicotine. Additionally, participants were asked about the type of e-cigarette (disposable pod, rechargeable pod, mod system, large modular system); brand of the vaping device that they used the most and the main reason for choosing the brand; their favourite e-liquid/e-juice; and the main source of vaping supplies. Participants were asked about their perceptions of the harmfulness of e-cigarettes compared with tobacco cigarettes.
Knowledge about vaping
Participants were asked how much they agreed or disagreed with four statements about vaping: (1) e-cigarettes can be helpful in smoking cessation; (2) e-cigarettes can be dangerous to children; (3) vaping can be addictive; and (4) vaping is a healthy habit. The responses were agree (agree/strongly agree), neutral, and disagree (disagree/strongly disagree). The primary sources of information about vaping were also assessed and the options included vape shops, social media, friends/relatives, healthcare providers, commercials, and other.
Data analysis
Data was analysed descriptively using IBM SPSS Statistics V.28 and results reported as overall proportions by participant group (teenagers vs parents). Contingency table tests were used to compare the responses of teenagers and parents on knowledge about vaping and two-sided p<0.05 was considered statistically significant.
Results
Participants
A total of 102 participants took part and 95 were included in analysis (Table 1). Of those excluded, four were aged 12 or younger and three did not provide their age. Eight participants (8.4%) smoked conventional cigarettes at least monthly (4.8% of teenagers, 11.3% of parents).
E-cigarette use
Table 2 shows e-cigarette use characteristics of participants, harm perception, reasons for choosing their preferred vaping device, and favourite flavours.
Ever e-cigarette use was similar in teenagers and parents (33.3% vs 30.8%), but current use (i.e., vaping at least once a month) was higher in parents than in teenagers (15.1% vs 7.1%).
The common reasons for vaping in teenagers included curiosity (38.5%), enjoyment (30.8%), and to socialise or fit in with friends (15.4%), whereas most parents reported vaping to quit smoking (50.0%), reduce smoking, and to avoid returning to smoking (25.0%). Other reasons given by parents were vaping when unable to smoke, and curiosity (25.0%).
Teenagers were less likely than parents to report vaping in home (21.4% vs 46.7%) or in car (7.1% vs 28.6%) when others were present. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%). Half of teenagers used a mod system with a tank that they refilled with vape juices/liquids, whereas a similar proportion of parents used a rechargeable e-cigarette or pod system that uses prefilled cartridges.
The sample of e-cigarette users was too small (13 teenagers, 16 parents) to provide useful information about brand preference, but there was no dominant brand for either group. Price (23.1%) and available flavours (23.1%) were the most common reasons that influenced the choice of preferred vaping device among teenagers, while recommendation from friend (26.7%), and price (20.0%), had the greatest influence among parents. Overall, fruit was the most preferred flavour (46.2% of teenagers, 40% % of parents). The primary source of vaping supplies for teenagers was friends/peers (53.8%) and vape shop for parents (40.0%).
Knowledge about vaping
Parents were significantly more likely than teenagers to agree that e-cigarettes can be dangerous to children (p=0.042); there were no statistically significant differences between parents and teenagers in other knowledge questions. Almost all (96.7%) agreed that e-cigarettes can be addictive, and 84.6% disagreed with the statement that “vaping is a healthy habit” (Table 3).
Table 4 displays the primary sources of information about vaping. Overall, friends/peers (for 46.3% of teenagers and 31.4% of parents), social media (16.3% overall) and “Other sources” (17.4% overall) were the most commonly reported sources of information about vaping.
View Tables 1–4.
Discussion
To the best of our knowledge, this is the first study in New Zealand to assess the patterns of e-cigarette use, brand preferences, and knowledge about vaping in an outpatient setting. We estimate the prevalence of ever-use vaping, current vaping and current cigarette smoking of 33.3% vs 30.8%, 7.1% vs 15.1% and 4.8% vs 11.3%, respectively, among teenagers compared to parents. Parents were also more likely than teenagers to vape in home or car when other people were present. All teenagers who vaped used nicotine-containing e-liquids/juices, compared with 86.7% of parents. Overall, fruit was the most preferred flavour and friends/peers were the primary sources of information about vaping. All participants appeared to have a good understanding of the potential benefits and harms of vaping.
Our finding of current smoking among teenagers is consistent with a finding of a 2019 New Zealand Youth19 survey (4% smoked at least monthly),[[1]] but current vaping was lower in our study (7.1% vs 10%). This may be explained by our small opportunistic sample, and potential differences in sample characteristics and environmental factors. Teenagers in the current study were in hospital for follow-up of health conditions, including respiratory illnesses which might have influenced their reporting of vaping and smoking, whereas the 2019 New Zealand Youth19 survey was conducted in a general student population.
The prevalence estimates of current smoking among parents (11.3%) in our sample are comparable to estimates in the general population (10.9%), but current vaping was much higher in the current study (15.1% vs 8.2% in the general population).[[19]] It is possible that some parents may have chosen to vape rather than smoke while around children. This appears to be supported in part by a finding of higher rates of use of e-cigarettes by parents versus teenagers in the home (46.7% vs 21.4% respectively) or in the car (28.6%% vs 7.1%) when other people were present.
An interesting finding of this study was that among teenagers who vaped, 53.8% obtained their vape products from friends or peers and 15.4% each from a family member, or online and none from vape shops or convenience stores. On the one hand, this finding suggests that vape shops and convenience stores are adhering to their retail obligations. On the other hand, it indicates that current restrictions on e-cigarette access that are focused on vape shops, while necessary as part of a comprehensive strategy, will not prevent access to e-cigarettes among young people aged under 18 years. Additional strategies, including targeted media and educational interventions,[[20]] should be explored to increase young people’s knowledge on vaping-related health effects and possibly increase vaping cessation. Public health communication could focus on educating adults about the impact of nicotine exposure, especially on adolescent brain development and the increased generalised risk of drug misuse.[[21]]
Our data show that teenagers state they understand that vaping isn’t a healthy habit, but they are still vaping. It suggests teenagers are not acting on the information they have about vaping. One reason might be response bias: they are giving what they think are the socially acceptable, expected or model answers to the questions about the effects of vaping. Another may be because their primary sources of information about vaping are also the main sources of vaping supplies for teenagers, hence, the need for independent information/education, from a third party (e.g., public health, health professional). A third party may be in a better place to help a teenager to understand the insidious nature of nicotine addiction.
The questionnaire was well received, and participants did not seek assistance to complete the survey online using Qualtrics. This validates our research tools and gives us the confidence to use them in the upcoming survey on vaping in high school students.
Policy implications
The implications of our findings are twofold. First, they suggest more work is needed to improve the general understanding of the potential harms of exposure to e-cigarettes in young people. While it might be less harmful than smoking,[[1]] vaping is not harmless.[[8]] It is not desirable that a new generation of young people should become regular recreational users of an addictive product with unknown long-term effects. Mass media campaigns can be used to reinforce this message. Secondly, there is need for the Government to refocus efforts to reduce e-cigarette uptake among children and young people. The current regulations, including the Smokefree Environments and Regulated Products (Vaping),[[22]] have not prevented teenagers from accessing these products.
Limitations
The small sample restricted most of the analysis to descriptive statistics and the results may not be generalisable to an outpatient hospital population. Further, the questionnaire did not ask about the reasons why the teenage participants were being seen in the outpatient department. Information about participants’ health status, for example, respiratory or other medical conditions that could be aggravated by vaping or smoking, is useful when counselling patients about vaping.
Conclusion
Vaping was common among teenagers and parents. More parents than teenagers vaped in home or in car when other people were present. Teenagers, most commonly, vaped for curiosity and flavour and obtained e-cigarettes from sources other than vape shops, suggesting current vape shop regulations are unlikely to prevent teenagers from accessing vape products. Further educative and regulatory input is needed to reduce e-cigarette use in young people.
Summary
Abstract
Aim
Parents attending hospital with children in New Zealand are routinely asked about tobacco use, but information about vaping is lacking. We assessed e-cigarette use, brand preferences, and knowledge during paediatric outpatient attendance at Christchurch Hospital.
Method
We undertook an anonymous online survey of teenagers and parents attending paediatric outpatient clinic in December 2021 to February 2022. The sample (n=95) were 16% Māori and 8.4% currently smoked (4.8% teenagers, 11.3% parents). We used descriptive and contingency table analysis.
Results
Ever vaping was reported in 33.3% of teenagers and 30.8% of parents, and current use in 7.1% vs 15.1%, respectively. Most teenagers selected “curiosity/just wanted to try them” as their reason for vaping, whereas parents selected vaping to quit or reduce/avoid smoking. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%) and more parents vaped indoors (in home or car) when other people were present.
The most important reasons for choosing particular e-cigarette brands among teenagers were price and flavours, with fruit flavours preferred. No teenagers obtained their e-cigarettes from vape shops versus 40% of parents. The primary source of information about vaping for teenagers and parents was friends/peers.
Conclusion
Vaping was common among teenagers and parents; teenagers vaped for curiosity and flavours and obtained vape products from sources other than vape shops.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Ball J, Fleming T, Drayton B, et al. New Zealand Youth19 survey: vaping has wider appeal than smoking in secondary school students, and most use nicotine‐containing e‐cigarettes. Aust N Z J Public Health. 2021 Dec; 45(6):546-53.
2) Action for Smokefree 2025 (ASH). ASH Year 10 Snapshot Survey 2021: Topline - Youth smoking and vaping. Available from: http://ash.org.nz. Online, 2022.
3) Li J, Newcombe R, Walton D. The prevalence, correlates and reasons for using electronic cigarettes among New Zealand adults. Addict Behav. 2015 Jun;45:245-51. doi: 10.1016/j.addbeh.2015.02.006.
4) Wamamili B, Wallace-Bell M, Richardson A, et al. Electronic cigarette use among university students aged 18–24 years in New Zealand: results of a 2018 national cross-sectional survey. BMJ Open. 2020 Jun 22;10(6):e035093. doi: 10.1136/bmjopen-2019-035093.
5) Sapru S, Vardhan M, Li Q, et al. E-cigarettes use in the United States: reasons for use, perceptions, and effects on health. BMC Public Health. 2020 Oct 9;20(1):1518. doi: 10.1186/s12889-020-09572-x.
6) Bold KW, Kong G, Cavallo DA, et al. Reasons for trying e-cigarettes and risk of continued use. Pediatrics. 2016 Sep;138(3):e20160895. doi: 10.1542/peds.2016-0895.
7) Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: characterizing youth, young adult, and adult users. Prev Med Rep. 2016 Nov 11;5:33-40. doi: 10.1016/j.pmedr.2016.11.001.
8) Wilson N, Summers JA, Ait Ouakrim D, et al. Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking. BMC Public Health. 2021 Nov 8;21(1):2038. doi: 10.1186/s12889-021-12103-x.
9) Marques P, Piqueras L, Sanz M-J. An updated overview of e-cigarette impact on human health. Respir Res. 2021 May 18;22(1):151. doi: 10.1186/s12931-021-01737-5.
10) McDonald CF, Jones S, Beckert L, et al. Electronic cigarettes: A position statement from the Thoracic Society of Australia and New Zealand. Respirology. 2020 Oct;25(10):1082-1089. doi: 10.1111/resp.13904.
11) Bals R, Boyd J, Esposito S, et al. Electronic cigarettes: a task force report from the European Respiratory Society. Eur Respir J. 2019 Jan 31;53(2):1801151. doi: 10.1183/13993003.01151-2018.
12) Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J. 2018 May 30;51(5):1800278. doi: 10.1183/13993003.00278-2018.
13) O’Brien D, Long J, Quigley J, et al. Association between electronic cigarette use and tobacco cigarette smoking initiation in adolescents: a systematic review and meta-analysis. BMC Public Health. 2021 Jun 3;21(1):954. doi: 10.1186/s12889-021-10935-1.
14) Chatterjee K, Alzghoul B, Innabi A, et al. Is vaping a gateway to smoking: a review of the longitudinal studies. Int J Adolesc Med Health. 2016 Aug 9;30(3):/j/ijamh.2018.30.issue-3/ijamh-2016-0033/ijamh-2016-0033.xml. doi: 10.1515/ijamh-2016-0033.
15) Wang X, Zhang X, Xu X, et al. Electronic cigarette use and smoking cessation behavior among adolescents in China. Addict Behav. 2018 Jul;82:129-134. doi: 10.1016/j.addbeh.2018.02.029.
16) Pearson JL, Hitchman SC, Brose LS, et al. Recommended core items to assess e-cigarette use in population-based surveys. Tob Control. 2018 May;27(3):341-346. doi: 10.1136/tobaccocontrol-2016-053541.
17) Wamamili B, Coope P, Grace RC. Cigarette smoking and e-cigarette use among university students in New Zealand before and after nicotinecontaining e-cigarettes became widely available: results from repeat cross-sectional surveys. N Z Med J. 2021 Oct 8;134(1543):90-102.
18) Stats NZ. 2018 Census ethnic group summaries. Online: Statistics New Zealand, 2018.
19) Ministry of Health. New Zealand Health Survey: Annual Data Explorer - Tobacco use 2021 [updated November 2020. Accessed 12 April 2022. [Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2020-21-annual-data-explorer/_w_8ea33faa/#!/explore-topics].
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E-cigarette use patterns, brand preference and knowledge about vaping among teenagers (13–16 years) and parents of children attending Christchurch Hospital
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E-cigarette use (vaping) has been increasing rapidly both among adults and teenagers in New Zealand. A 2019 study which investigated smoking and vaping in high school students (n=7,721) found 10% of students vaped at least monthly and 6% vaped weekly or more often.[[1]] The ASH year 10 Snapshot Survey in 2021[[2]] found that vaping had increased since 2019, and daily vaping was 9.6% overall and up to 19% among Māori teenagers. Unlike adults who often vape as a means to reduce tobacco use or quit smoking,[[3]] most teenagers are attracted to e-cigarettes because of simple curiosity,[[4]] flavours, friends, and ability to use vape products discreetly.[[5–7]]
There is general consensus among the scientific community that vaping is less harmful than smoking conventional cigarettes, but not harmless.[[8]] However, there remains disagreement among policymakers internationally on the role of vaping in tobacco control, owing to limited evidence.[[9]] Concerns about e-cigarette use have been raised by the major international respiratory societies.[[10–13]] These include known and unknown long-term health risks, and the potential for vaping to serve as a gateway to smoking, especially among adolescents and young adults. Several studies have shown an association between e-cigarette use and subsequent onset of smoking among teenagers,[[13,14]] while one study reported an association between vaping and attempted smoking cessation although the success rate was only 13.5%.[[15]]
Currently in New Zealand, patients are asked about whether they smoke on admission to hospital, but information is lacking whether vaping is also asked. Understanding the e-cigarette use habits and knowledge of patients about vaping presenting to hospital can enable clinicians to provide relevant information to help patients make informed decisions. We sought to explore these areas in a pilot study to test the validity and acceptability of research tools before deployment to a wider study of vaping knowledge and brand preference in high school students.
Method
Data was collected as part of a summer studentship between 9 December 2021 and 23 February 2022 at Christchurch Hospital. Teenagers aged 13–16 years and parents of children presenting in the paediatric outpatient department were eligible to participate. The study was approved by the Human Ethics Committee (Health) of the University of Otago (H21/169), and locality authorisation was provided by the Canterbury District Health Board. Information about the study was provided to prospective participants in the waiting area and they were invited to take part. Written or online consent was obtained before completing the survey (for teenagers aged 13–15 years old we required their parental as well as their own consent).
The questionnaire included previously validated questions as well as new questions. The methods including these new questions were piloted for use in a wider study on vaping in high schools. Most questions on e-cigarette use (ever-use, frequency of use, reason for use, nicotine use, type of vaping device, and harm perception) were adapted from Pearson and colleagues.[[16]] The question on gender was adapted from previous research on smoking and vaping among university students in New Zealand.[[17]] The ethnicity question was based on the question in the New Zealand census.[[18]]
Participants could complete the survey online or on paper. Digital devices (iPads) were provided for participants to scan a QR code and complete the questionnaire anonymously. Participants were asked to complete the survey independently, without parents or teenagers viewing or influencing each other’s responses and no issues were reported. We reassured teenagers that the study was anonymous, and that there were no repercussions on them, to encourage them to answer questions about smoking and vaping openly. Information was provided for participants to contact Quitline for support if they were concerned about their smoking or vaping. All participants completed the survey online and the questionnaire took five minutes on average.
Survey measures
Demographic information
For the purpose of analysis, participants aged 13–16 years were categorised as teenagers and participants aged 17 years or older were categorised as parents. Participants could identify their gender as male, female, other and “prefer not to say”; however, only male and female options were selected by participants. Participants indicated the ethnicities they identified with, and these were categorised as New Zealand European, Māori, Pasifika (included Samoan, Cook Island Māori and Tongan), Asian (included Indian and Chinese) and Other, consistent with previous research.[[17]]
E-cigarette use
Participants were asked if they had ever used an e-cigarette or vaping device (ever-use); whether they currently vaped at least monthly (current use); how often they vaped “in home” or “in car” when other people were present (never/almost never vs other); the primary reason for using an e-cigarette/vaping device; and whether their usual e-cigarette/vaping device contained nicotine. Additionally, participants were asked about the type of e-cigarette (disposable pod, rechargeable pod, mod system, large modular system); brand of the vaping device that they used the most and the main reason for choosing the brand; their favourite e-liquid/e-juice; and the main source of vaping supplies. Participants were asked about their perceptions of the harmfulness of e-cigarettes compared with tobacco cigarettes.
Knowledge about vaping
Participants were asked how much they agreed or disagreed with four statements about vaping: (1) e-cigarettes can be helpful in smoking cessation; (2) e-cigarettes can be dangerous to children; (3) vaping can be addictive; and (4) vaping is a healthy habit. The responses were agree (agree/strongly agree), neutral, and disagree (disagree/strongly disagree). The primary sources of information about vaping were also assessed and the options included vape shops, social media, friends/relatives, healthcare providers, commercials, and other.
Data analysis
Data was analysed descriptively using IBM SPSS Statistics V.28 and results reported as overall proportions by participant group (teenagers vs parents). Contingency table tests were used to compare the responses of teenagers and parents on knowledge about vaping and two-sided p<0.05 was considered statistically significant.
Results
Participants
A total of 102 participants took part and 95 were included in analysis (Table 1). Of those excluded, four were aged 12 or younger and three did not provide their age. Eight participants (8.4%) smoked conventional cigarettes at least monthly (4.8% of teenagers, 11.3% of parents).
E-cigarette use
Table 2 shows e-cigarette use characteristics of participants, harm perception, reasons for choosing their preferred vaping device, and favourite flavours.
Ever e-cigarette use was similar in teenagers and parents (33.3% vs 30.8%), but current use (i.e., vaping at least once a month) was higher in parents than in teenagers (15.1% vs 7.1%).
The common reasons for vaping in teenagers included curiosity (38.5%), enjoyment (30.8%), and to socialise or fit in with friends (15.4%), whereas most parents reported vaping to quit smoking (50.0%), reduce smoking, and to avoid returning to smoking (25.0%). Other reasons given by parents were vaping when unable to smoke, and curiosity (25.0%).
Teenagers were less likely than parents to report vaping in home (21.4% vs 46.7%) or in car (7.1% vs 28.6%) when others were present. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%). Half of teenagers used a mod system with a tank that they refilled with vape juices/liquids, whereas a similar proportion of parents used a rechargeable e-cigarette or pod system that uses prefilled cartridges.
The sample of e-cigarette users was too small (13 teenagers, 16 parents) to provide useful information about brand preference, but there was no dominant brand for either group. Price (23.1%) and available flavours (23.1%) were the most common reasons that influenced the choice of preferred vaping device among teenagers, while recommendation from friend (26.7%), and price (20.0%), had the greatest influence among parents. Overall, fruit was the most preferred flavour (46.2% of teenagers, 40% % of parents). The primary source of vaping supplies for teenagers was friends/peers (53.8%) and vape shop for parents (40.0%).
Knowledge about vaping
Parents were significantly more likely than teenagers to agree that e-cigarettes can be dangerous to children (p=0.042); there were no statistically significant differences between parents and teenagers in other knowledge questions. Almost all (96.7%) agreed that e-cigarettes can be addictive, and 84.6% disagreed with the statement that “vaping is a healthy habit” (Table 3).
Table 4 displays the primary sources of information about vaping. Overall, friends/peers (for 46.3% of teenagers and 31.4% of parents), social media (16.3% overall) and “Other sources” (17.4% overall) were the most commonly reported sources of information about vaping.
View Tables 1–4.
Discussion
To the best of our knowledge, this is the first study in New Zealand to assess the patterns of e-cigarette use, brand preferences, and knowledge about vaping in an outpatient setting. We estimate the prevalence of ever-use vaping, current vaping and current cigarette smoking of 33.3% vs 30.8%, 7.1% vs 15.1% and 4.8% vs 11.3%, respectively, among teenagers compared to parents. Parents were also more likely than teenagers to vape in home or car when other people were present. All teenagers who vaped used nicotine-containing e-liquids/juices, compared with 86.7% of parents. Overall, fruit was the most preferred flavour and friends/peers were the primary sources of information about vaping. All participants appeared to have a good understanding of the potential benefits and harms of vaping.
Our finding of current smoking among teenagers is consistent with a finding of a 2019 New Zealand Youth19 survey (4% smoked at least monthly),[[1]] but current vaping was lower in our study (7.1% vs 10%). This may be explained by our small opportunistic sample, and potential differences in sample characteristics and environmental factors. Teenagers in the current study were in hospital for follow-up of health conditions, including respiratory illnesses which might have influenced their reporting of vaping and smoking, whereas the 2019 New Zealand Youth19 survey was conducted in a general student population.
The prevalence estimates of current smoking among parents (11.3%) in our sample are comparable to estimates in the general population (10.9%), but current vaping was much higher in the current study (15.1% vs 8.2% in the general population).[[19]] It is possible that some parents may have chosen to vape rather than smoke while around children. This appears to be supported in part by a finding of higher rates of use of e-cigarettes by parents versus teenagers in the home (46.7% vs 21.4% respectively) or in the car (28.6%% vs 7.1%) when other people were present.
An interesting finding of this study was that among teenagers who vaped, 53.8% obtained their vape products from friends or peers and 15.4% each from a family member, or online and none from vape shops or convenience stores. On the one hand, this finding suggests that vape shops and convenience stores are adhering to their retail obligations. On the other hand, it indicates that current restrictions on e-cigarette access that are focused on vape shops, while necessary as part of a comprehensive strategy, will not prevent access to e-cigarettes among young people aged under 18 years. Additional strategies, including targeted media and educational interventions,[[20]] should be explored to increase young people’s knowledge on vaping-related health effects and possibly increase vaping cessation. Public health communication could focus on educating adults about the impact of nicotine exposure, especially on adolescent brain development and the increased generalised risk of drug misuse.[[21]]
Our data show that teenagers state they understand that vaping isn’t a healthy habit, but they are still vaping. It suggests teenagers are not acting on the information they have about vaping. One reason might be response bias: they are giving what they think are the socially acceptable, expected or model answers to the questions about the effects of vaping. Another may be because their primary sources of information about vaping are also the main sources of vaping supplies for teenagers, hence, the need for independent information/education, from a third party (e.g., public health, health professional). A third party may be in a better place to help a teenager to understand the insidious nature of nicotine addiction.
The questionnaire was well received, and participants did not seek assistance to complete the survey online using Qualtrics. This validates our research tools and gives us the confidence to use them in the upcoming survey on vaping in high school students.
Policy implications
The implications of our findings are twofold. First, they suggest more work is needed to improve the general understanding of the potential harms of exposure to e-cigarettes in young people. While it might be less harmful than smoking,[[1]] vaping is not harmless.[[8]] It is not desirable that a new generation of young people should become regular recreational users of an addictive product with unknown long-term effects. Mass media campaigns can be used to reinforce this message. Secondly, there is need for the Government to refocus efforts to reduce e-cigarette uptake among children and young people. The current regulations, including the Smokefree Environments and Regulated Products (Vaping),[[22]] have not prevented teenagers from accessing these products.
Limitations
The small sample restricted most of the analysis to descriptive statistics and the results may not be generalisable to an outpatient hospital population. Further, the questionnaire did not ask about the reasons why the teenage participants were being seen in the outpatient department. Information about participants’ health status, for example, respiratory or other medical conditions that could be aggravated by vaping or smoking, is useful when counselling patients about vaping.
Conclusion
Vaping was common among teenagers and parents. More parents than teenagers vaped in home or in car when other people were present. Teenagers, most commonly, vaped for curiosity and flavour and obtained e-cigarettes from sources other than vape shops, suggesting current vape shop regulations are unlikely to prevent teenagers from accessing vape products. Further educative and regulatory input is needed to reduce e-cigarette use in young people.
Summary
Abstract
Aim
Parents attending hospital with children in New Zealand are routinely asked about tobacco use, but information about vaping is lacking. We assessed e-cigarette use, brand preferences, and knowledge during paediatric outpatient attendance at Christchurch Hospital.
Method
We undertook an anonymous online survey of teenagers and parents attending paediatric outpatient clinic in December 2021 to February 2022. The sample (n=95) were 16% Māori and 8.4% currently smoked (4.8% teenagers, 11.3% parents). We used descriptive and contingency table analysis.
Results
Ever vaping was reported in 33.3% of teenagers and 30.8% of parents, and current use in 7.1% vs 15.1%, respectively. Most teenagers selected “curiosity/just wanted to try them” as their reason for vaping, whereas parents selected vaping to quit or reduce/avoid smoking. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%) and more parents vaped indoors (in home or car) when other people were present.
The most important reasons for choosing particular e-cigarette brands among teenagers were price and flavours, with fruit flavours preferred. No teenagers obtained their e-cigarettes from vape shops versus 40% of parents. The primary source of information about vaping for teenagers and parents was friends/peers.
Conclusion
Vaping was common among teenagers and parents; teenagers vaped for curiosity and flavours and obtained vape products from sources other than vape shops.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Ball J, Fleming T, Drayton B, et al. New Zealand Youth19 survey: vaping has wider appeal than smoking in secondary school students, and most use nicotine‐containing e‐cigarettes. Aust N Z J Public Health. 2021 Dec; 45(6):546-53.
2) Action for Smokefree 2025 (ASH). ASH Year 10 Snapshot Survey 2021: Topline - Youth smoking and vaping. Available from: http://ash.org.nz. Online, 2022.
3) Li J, Newcombe R, Walton D. The prevalence, correlates and reasons for using electronic cigarettes among New Zealand adults. Addict Behav. 2015 Jun;45:245-51. doi: 10.1016/j.addbeh.2015.02.006.
4) Wamamili B, Wallace-Bell M, Richardson A, et al. Electronic cigarette use among university students aged 18–24 years in New Zealand: results of a 2018 national cross-sectional survey. BMJ Open. 2020 Jun 22;10(6):e035093. doi: 10.1136/bmjopen-2019-035093.
5) Sapru S, Vardhan M, Li Q, et al. E-cigarettes use in the United States: reasons for use, perceptions, and effects on health. BMC Public Health. 2020 Oct 9;20(1):1518. doi: 10.1186/s12889-020-09572-x.
6) Bold KW, Kong G, Cavallo DA, et al. Reasons for trying e-cigarettes and risk of continued use. Pediatrics. 2016 Sep;138(3):e20160895. doi: 10.1542/peds.2016-0895.
7) Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: characterizing youth, young adult, and adult users. Prev Med Rep. 2016 Nov 11;5:33-40. doi: 10.1016/j.pmedr.2016.11.001.
8) Wilson N, Summers JA, Ait Ouakrim D, et al. Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking. BMC Public Health. 2021 Nov 8;21(1):2038. doi: 10.1186/s12889-021-12103-x.
9) Marques P, Piqueras L, Sanz M-J. An updated overview of e-cigarette impact on human health. Respir Res. 2021 May 18;22(1):151. doi: 10.1186/s12931-021-01737-5.
10) McDonald CF, Jones S, Beckert L, et al. Electronic cigarettes: A position statement from the Thoracic Society of Australia and New Zealand. Respirology. 2020 Oct;25(10):1082-1089. doi: 10.1111/resp.13904.
11) Bals R, Boyd J, Esposito S, et al. Electronic cigarettes: a task force report from the European Respiratory Society. Eur Respir J. 2019 Jan 31;53(2):1801151. doi: 10.1183/13993003.01151-2018.
12) Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J. 2018 May 30;51(5):1800278. doi: 10.1183/13993003.00278-2018.
13) O’Brien D, Long J, Quigley J, et al. Association between electronic cigarette use and tobacco cigarette smoking initiation in adolescents: a systematic review and meta-analysis. BMC Public Health. 2021 Jun 3;21(1):954. doi: 10.1186/s12889-021-10935-1.
14) Chatterjee K, Alzghoul B, Innabi A, et al. Is vaping a gateway to smoking: a review of the longitudinal studies. Int J Adolesc Med Health. 2016 Aug 9;30(3):/j/ijamh.2018.30.issue-3/ijamh-2016-0033/ijamh-2016-0033.xml. doi: 10.1515/ijamh-2016-0033.
15) Wang X, Zhang X, Xu X, et al. Electronic cigarette use and smoking cessation behavior among adolescents in China. Addict Behav. 2018 Jul;82:129-134. doi: 10.1016/j.addbeh.2018.02.029.
16) Pearson JL, Hitchman SC, Brose LS, et al. Recommended core items to assess e-cigarette use in population-based surveys. Tob Control. 2018 May;27(3):341-346. doi: 10.1136/tobaccocontrol-2016-053541.
17) Wamamili B, Coope P, Grace RC. Cigarette smoking and e-cigarette use among university students in New Zealand before and after nicotinecontaining e-cigarettes became widely available: results from repeat cross-sectional surveys. N Z Med J. 2021 Oct 8;134(1543):90-102.
18) Stats NZ. 2018 Census ethnic group summaries. Online: Statistics New Zealand, 2018.
19) Ministry of Health. New Zealand Health Survey: Annual Data Explorer - Tobacco use 2021 [updated November 2020. Accessed 12 April 2022. [Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2020-21-annual-data-explorer/_w_8ea33faa/#!/explore-topics].
20) Chaplin MD, Brogie J, Burch A, et al. Effectiveness of an educational intervention on health risks of vaping for high school–aged adolescents. J Am Pharm Assoc (2003). Nov-Dec 2020;60(6):e158-e161. doi: 10.1016/j.japh.2020.05.008.
21) 21. Leslie FM. Unique, long-term effects of nicotine on adolescent brain. Pharmacol Biochem Behav. 2020 Oct;197:173010. doi: 10.1016/j.pbb.2020.173010.
22) 22. New Zealand Government. Smokefree Environments and Regulated Products (Vaping) Amendment Act 2020 2020 [updated August 2020]. [Available from: https://www.legislation.govt.nz/act/public/2020/0062/latest/LMS313857.html accessed 13 April 2022].
For the PDF of this article,
contact nzmj@nzma.org.nz
E-cigarette use patterns, brand preference and knowledge about vaping among teenagers (13–16 years) and parents of children attending Christchurch Hospital
View Article PDF
E-cigarette use (vaping) has been increasing rapidly both among adults and teenagers in New Zealand. A 2019 study which investigated smoking and vaping in high school students (n=7,721) found 10% of students vaped at least monthly and 6% vaped weekly or more often.[[1]] The ASH year 10 Snapshot Survey in 2021[[2]] found that vaping had increased since 2019, and daily vaping was 9.6% overall and up to 19% among Māori teenagers. Unlike adults who often vape as a means to reduce tobacco use or quit smoking,[[3]] most teenagers are attracted to e-cigarettes because of simple curiosity,[[4]] flavours, friends, and ability to use vape products discreetly.[[5–7]]
There is general consensus among the scientific community that vaping is less harmful than smoking conventional cigarettes, but not harmless.[[8]] However, there remains disagreement among policymakers internationally on the role of vaping in tobacco control, owing to limited evidence.[[9]] Concerns about e-cigarette use have been raised by the major international respiratory societies.[[10–13]] These include known and unknown long-term health risks, and the potential for vaping to serve as a gateway to smoking, especially among adolescents and young adults. Several studies have shown an association between e-cigarette use and subsequent onset of smoking among teenagers,[[13,14]] while one study reported an association between vaping and attempted smoking cessation although the success rate was only 13.5%.[[15]]
Currently in New Zealand, patients are asked about whether they smoke on admission to hospital, but information is lacking whether vaping is also asked. Understanding the e-cigarette use habits and knowledge of patients about vaping presenting to hospital can enable clinicians to provide relevant information to help patients make informed decisions. We sought to explore these areas in a pilot study to test the validity and acceptability of research tools before deployment to a wider study of vaping knowledge and brand preference in high school students.
Method
Data was collected as part of a summer studentship between 9 December 2021 and 23 February 2022 at Christchurch Hospital. Teenagers aged 13–16 years and parents of children presenting in the paediatric outpatient department were eligible to participate. The study was approved by the Human Ethics Committee (Health) of the University of Otago (H21/169), and locality authorisation was provided by the Canterbury District Health Board. Information about the study was provided to prospective participants in the waiting area and they were invited to take part. Written or online consent was obtained before completing the survey (for teenagers aged 13–15 years old we required their parental as well as their own consent).
The questionnaire included previously validated questions as well as new questions. The methods including these new questions were piloted for use in a wider study on vaping in high schools. Most questions on e-cigarette use (ever-use, frequency of use, reason for use, nicotine use, type of vaping device, and harm perception) were adapted from Pearson and colleagues.[[16]] The question on gender was adapted from previous research on smoking and vaping among university students in New Zealand.[[17]] The ethnicity question was based on the question in the New Zealand census.[[18]]
Participants could complete the survey online or on paper. Digital devices (iPads) were provided for participants to scan a QR code and complete the questionnaire anonymously. Participants were asked to complete the survey independently, without parents or teenagers viewing or influencing each other’s responses and no issues were reported. We reassured teenagers that the study was anonymous, and that there were no repercussions on them, to encourage them to answer questions about smoking and vaping openly. Information was provided for participants to contact Quitline for support if they were concerned about their smoking or vaping. All participants completed the survey online and the questionnaire took five minutes on average.
Survey measures
Demographic information
For the purpose of analysis, participants aged 13–16 years were categorised as teenagers and participants aged 17 years or older were categorised as parents. Participants could identify their gender as male, female, other and “prefer not to say”; however, only male and female options were selected by participants. Participants indicated the ethnicities they identified with, and these were categorised as New Zealand European, Māori, Pasifika (included Samoan, Cook Island Māori and Tongan), Asian (included Indian and Chinese) and Other, consistent with previous research.[[17]]
E-cigarette use
Participants were asked if they had ever used an e-cigarette or vaping device (ever-use); whether they currently vaped at least monthly (current use); how often they vaped “in home” or “in car” when other people were present (never/almost never vs other); the primary reason for using an e-cigarette/vaping device; and whether their usual e-cigarette/vaping device contained nicotine. Additionally, participants were asked about the type of e-cigarette (disposable pod, rechargeable pod, mod system, large modular system); brand of the vaping device that they used the most and the main reason for choosing the brand; their favourite e-liquid/e-juice; and the main source of vaping supplies. Participants were asked about their perceptions of the harmfulness of e-cigarettes compared with tobacco cigarettes.
Knowledge about vaping
Participants were asked how much they agreed or disagreed with four statements about vaping: (1) e-cigarettes can be helpful in smoking cessation; (2) e-cigarettes can be dangerous to children; (3) vaping can be addictive; and (4) vaping is a healthy habit. The responses were agree (agree/strongly agree), neutral, and disagree (disagree/strongly disagree). The primary sources of information about vaping were also assessed and the options included vape shops, social media, friends/relatives, healthcare providers, commercials, and other.
Data analysis
Data was analysed descriptively using IBM SPSS Statistics V.28 and results reported as overall proportions by participant group (teenagers vs parents). Contingency table tests were used to compare the responses of teenagers and parents on knowledge about vaping and two-sided p<0.05 was considered statistically significant.
Results
Participants
A total of 102 participants took part and 95 were included in analysis (Table 1). Of those excluded, four were aged 12 or younger and three did not provide their age. Eight participants (8.4%) smoked conventional cigarettes at least monthly (4.8% of teenagers, 11.3% of parents).
E-cigarette use
Table 2 shows e-cigarette use characteristics of participants, harm perception, reasons for choosing their preferred vaping device, and favourite flavours.
Ever e-cigarette use was similar in teenagers and parents (33.3% vs 30.8%), but current use (i.e., vaping at least once a month) was higher in parents than in teenagers (15.1% vs 7.1%).
The common reasons for vaping in teenagers included curiosity (38.5%), enjoyment (30.8%), and to socialise or fit in with friends (15.4%), whereas most parents reported vaping to quit smoking (50.0%), reduce smoking, and to avoid returning to smoking (25.0%). Other reasons given by parents were vaping when unable to smoke, and curiosity (25.0%).
Teenagers were less likely than parents to report vaping in home (21.4% vs 46.7%) or in car (7.1% vs 28.6%) when others were present. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%). Half of teenagers used a mod system with a tank that they refilled with vape juices/liquids, whereas a similar proportion of parents used a rechargeable e-cigarette or pod system that uses prefilled cartridges.
The sample of e-cigarette users was too small (13 teenagers, 16 parents) to provide useful information about brand preference, but there was no dominant brand for either group. Price (23.1%) and available flavours (23.1%) were the most common reasons that influenced the choice of preferred vaping device among teenagers, while recommendation from friend (26.7%), and price (20.0%), had the greatest influence among parents. Overall, fruit was the most preferred flavour (46.2% of teenagers, 40% % of parents). The primary source of vaping supplies for teenagers was friends/peers (53.8%) and vape shop for parents (40.0%).
Knowledge about vaping
Parents were significantly more likely than teenagers to agree that e-cigarettes can be dangerous to children (p=0.042); there were no statistically significant differences between parents and teenagers in other knowledge questions. Almost all (96.7%) agreed that e-cigarettes can be addictive, and 84.6% disagreed with the statement that “vaping is a healthy habit” (Table 3).
Table 4 displays the primary sources of information about vaping. Overall, friends/peers (for 46.3% of teenagers and 31.4% of parents), social media (16.3% overall) and “Other sources” (17.4% overall) were the most commonly reported sources of information about vaping.
View Tables 1–4.
Discussion
To the best of our knowledge, this is the first study in New Zealand to assess the patterns of e-cigarette use, brand preferences, and knowledge about vaping in an outpatient setting. We estimate the prevalence of ever-use vaping, current vaping and current cigarette smoking of 33.3% vs 30.8%, 7.1% vs 15.1% and 4.8% vs 11.3%, respectively, among teenagers compared to parents. Parents were also more likely than teenagers to vape in home or car when other people were present. All teenagers who vaped used nicotine-containing e-liquids/juices, compared with 86.7% of parents. Overall, fruit was the most preferred flavour and friends/peers were the primary sources of information about vaping. All participants appeared to have a good understanding of the potential benefits and harms of vaping.
Our finding of current smoking among teenagers is consistent with a finding of a 2019 New Zealand Youth19 survey (4% smoked at least monthly),[[1]] but current vaping was lower in our study (7.1% vs 10%). This may be explained by our small opportunistic sample, and potential differences in sample characteristics and environmental factors. Teenagers in the current study were in hospital for follow-up of health conditions, including respiratory illnesses which might have influenced their reporting of vaping and smoking, whereas the 2019 New Zealand Youth19 survey was conducted in a general student population.
The prevalence estimates of current smoking among parents (11.3%) in our sample are comparable to estimates in the general population (10.9%), but current vaping was much higher in the current study (15.1% vs 8.2% in the general population).[[19]] It is possible that some parents may have chosen to vape rather than smoke while around children. This appears to be supported in part by a finding of higher rates of use of e-cigarettes by parents versus teenagers in the home (46.7% vs 21.4% respectively) or in the car (28.6%% vs 7.1%) when other people were present.
An interesting finding of this study was that among teenagers who vaped, 53.8% obtained their vape products from friends or peers and 15.4% each from a family member, or online and none from vape shops or convenience stores. On the one hand, this finding suggests that vape shops and convenience stores are adhering to their retail obligations. On the other hand, it indicates that current restrictions on e-cigarette access that are focused on vape shops, while necessary as part of a comprehensive strategy, will not prevent access to e-cigarettes among young people aged under 18 years. Additional strategies, including targeted media and educational interventions,[[20]] should be explored to increase young people’s knowledge on vaping-related health effects and possibly increase vaping cessation. Public health communication could focus on educating adults about the impact of nicotine exposure, especially on adolescent brain development and the increased generalised risk of drug misuse.[[21]]
Our data show that teenagers state they understand that vaping isn’t a healthy habit, but they are still vaping. It suggests teenagers are not acting on the information they have about vaping. One reason might be response bias: they are giving what they think are the socially acceptable, expected or model answers to the questions about the effects of vaping. Another may be because their primary sources of information about vaping are also the main sources of vaping supplies for teenagers, hence, the need for independent information/education, from a third party (e.g., public health, health professional). A third party may be in a better place to help a teenager to understand the insidious nature of nicotine addiction.
The questionnaire was well received, and participants did not seek assistance to complete the survey online using Qualtrics. This validates our research tools and gives us the confidence to use them in the upcoming survey on vaping in high school students.
Policy implications
The implications of our findings are twofold. First, they suggest more work is needed to improve the general understanding of the potential harms of exposure to e-cigarettes in young people. While it might be less harmful than smoking,[[1]] vaping is not harmless.[[8]] It is not desirable that a new generation of young people should become regular recreational users of an addictive product with unknown long-term effects. Mass media campaigns can be used to reinforce this message. Secondly, there is need for the Government to refocus efforts to reduce e-cigarette uptake among children and young people. The current regulations, including the Smokefree Environments and Regulated Products (Vaping),[[22]] have not prevented teenagers from accessing these products.
Limitations
The small sample restricted most of the analysis to descriptive statistics and the results may not be generalisable to an outpatient hospital population. Further, the questionnaire did not ask about the reasons why the teenage participants were being seen in the outpatient department. Information about participants’ health status, for example, respiratory or other medical conditions that could be aggravated by vaping or smoking, is useful when counselling patients about vaping.
Conclusion
Vaping was common among teenagers and parents. More parents than teenagers vaped in home or in car when other people were present. Teenagers, most commonly, vaped for curiosity and flavour and obtained e-cigarettes from sources other than vape shops, suggesting current vape shop regulations are unlikely to prevent teenagers from accessing vape products. Further educative and regulatory input is needed to reduce e-cigarette use in young people.
Summary
Abstract
Aim
Parents attending hospital with children in New Zealand are routinely asked about tobacco use, but information about vaping is lacking. We assessed e-cigarette use, brand preferences, and knowledge during paediatric outpatient attendance at Christchurch Hospital.
Method
We undertook an anonymous online survey of teenagers and parents attending paediatric outpatient clinic in December 2021 to February 2022. The sample (n=95) were 16% Māori and 8.4% currently smoked (4.8% teenagers, 11.3% parents). We used descriptive and contingency table analysis.
Results
Ever vaping was reported in 33.3% of teenagers and 30.8% of parents, and current use in 7.1% vs 15.1%, respectively. Most teenagers selected “curiosity/just wanted to try them” as their reason for vaping, whereas parents selected vaping to quit or reduce/avoid smoking. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%) and more parents vaped indoors (in home or car) when other people were present.
The most important reasons for choosing particular e-cigarette brands among teenagers were price and flavours, with fruit flavours preferred. No teenagers obtained their e-cigarettes from vape shops versus 40% of parents. The primary source of information about vaping for teenagers and parents was friends/peers.
Conclusion
Vaping was common among teenagers and parents; teenagers vaped for curiosity and flavours and obtained vape products from sources other than vape shops.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Ball J, Fleming T, Drayton B, et al. New Zealand Youth19 survey: vaping has wider appeal than smoking in secondary school students, and most use nicotine‐containing e‐cigarettes. Aust N Z J Public Health. 2021 Dec; 45(6):546-53.
2) Action for Smokefree 2025 (ASH). ASH Year 10 Snapshot Survey 2021: Topline - Youth smoking and vaping. Available from: http://ash.org.nz. Online, 2022.
3) Li J, Newcombe R, Walton D. The prevalence, correlates and reasons for using electronic cigarettes among New Zealand adults. Addict Behav. 2015 Jun;45:245-51. doi: 10.1016/j.addbeh.2015.02.006.
4) Wamamili B, Wallace-Bell M, Richardson A, et al. Electronic cigarette use among university students aged 18–24 years in New Zealand: results of a 2018 national cross-sectional survey. BMJ Open. 2020 Jun 22;10(6):e035093. doi: 10.1136/bmjopen-2019-035093.
5) Sapru S, Vardhan M, Li Q, et al. E-cigarettes use in the United States: reasons for use, perceptions, and effects on health. BMC Public Health. 2020 Oct 9;20(1):1518. doi: 10.1186/s12889-020-09572-x.
6) Bold KW, Kong G, Cavallo DA, et al. Reasons for trying e-cigarettes and risk of continued use. Pediatrics. 2016 Sep;138(3):e20160895. doi: 10.1542/peds.2016-0895.
7) Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: characterizing youth, young adult, and adult users. Prev Med Rep. 2016 Nov 11;5:33-40. doi: 10.1016/j.pmedr.2016.11.001.
8) Wilson N, Summers JA, Ait Ouakrim D, et al. Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking. BMC Public Health. 2021 Nov 8;21(1):2038. doi: 10.1186/s12889-021-12103-x.
9) Marques P, Piqueras L, Sanz M-J. An updated overview of e-cigarette impact on human health. Respir Res. 2021 May 18;22(1):151. doi: 10.1186/s12931-021-01737-5.
10) McDonald CF, Jones S, Beckert L, et al. Electronic cigarettes: A position statement from the Thoracic Society of Australia and New Zealand. Respirology. 2020 Oct;25(10):1082-1089. doi: 10.1111/resp.13904.
11) Bals R, Boyd J, Esposito S, et al. Electronic cigarettes: a task force report from the European Respiratory Society. Eur Respir J. 2019 Jan 31;53(2):1801151. doi: 10.1183/13993003.01151-2018.
12) Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J. 2018 May 30;51(5):1800278. doi: 10.1183/13993003.00278-2018.
13) O’Brien D, Long J, Quigley J, et al. Association between electronic cigarette use and tobacco cigarette smoking initiation in adolescents: a systematic review and meta-analysis. BMC Public Health. 2021 Jun 3;21(1):954. doi: 10.1186/s12889-021-10935-1.
14) Chatterjee K, Alzghoul B, Innabi A, et al. Is vaping a gateway to smoking: a review of the longitudinal studies. Int J Adolesc Med Health. 2016 Aug 9;30(3):/j/ijamh.2018.30.issue-3/ijamh-2016-0033/ijamh-2016-0033.xml. doi: 10.1515/ijamh-2016-0033.
15) Wang X, Zhang X, Xu X, et al. Electronic cigarette use and smoking cessation behavior among adolescents in China. Addict Behav. 2018 Jul;82:129-134. doi: 10.1016/j.addbeh.2018.02.029.
16) Pearson JL, Hitchman SC, Brose LS, et al. Recommended core items to assess e-cigarette use in population-based surveys. Tob Control. 2018 May;27(3):341-346. doi: 10.1136/tobaccocontrol-2016-053541.
17) Wamamili B, Coope P, Grace RC. Cigarette smoking and e-cigarette use among university students in New Zealand before and after nicotinecontaining e-cigarettes became widely available: results from repeat cross-sectional surveys. N Z Med J. 2021 Oct 8;134(1543):90-102.
18) Stats NZ. 2018 Census ethnic group summaries. Online: Statistics New Zealand, 2018.
19) Ministry of Health. New Zealand Health Survey: Annual Data Explorer - Tobacco use 2021 [updated November 2020. Accessed 12 April 2022. [Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2020-21-annual-data-explorer/_w_8ea33faa/#!/explore-topics].
20) Chaplin MD, Brogie J, Burch A, et al. Effectiveness of an educational intervention on health risks of vaping for high school–aged adolescents. J Am Pharm Assoc (2003). Nov-Dec 2020;60(6):e158-e161. doi: 10.1016/j.japh.2020.05.008.
21) 21. Leslie FM. Unique, long-term effects of nicotine on adolescent brain. Pharmacol Biochem Behav. 2020 Oct;197:173010. doi: 10.1016/j.pbb.2020.173010.
22) 22. New Zealand Government. Smokefree Environments and Regulated Products (Vaping) Amendment Act 2020 2020 [updated August 2020]. [Available from: https://www.legislation.govt.nz/act/public/2020/0062/latest/LMS313857.html accessed 13 April 2022].
Contact diana@nzma.org.nz
for the PDF of this article
E-cigarette use patterns, brand preference and knowledge about vaping among teenagers (13–16 years) and parents of children attending Christchurch Hospital
View Article PDF
E-cigarette use (vaping) has been increasing rapidly both among adults and teenagers in New Zealand. A 2019 study which investigated smoking and vaping in high school students (n=7,721) found 10% of students vaped at least monthly and 6% vaped weekly or more often.[[1]] The ASH year 10 Snapshot Survey in 2021[[2]] found that vaping had increased since 2019, and daily vaping was 9.6% overall and up to 19% among Māori teenagers. Unlike adults who often vape as a means to reduce tobacco use or quit smoking,[[3]] most teenagers are attracted to e-cigarettes because of simple curiosity,[[4]] flavours, friends, and ability to use vape products discreetly.[[5–7]]
There is general consensus among the scientific community that vaping is less harmful than smoking conventional cigarettes, but not harmless.[[8]] However, there remains disagreement among policymakers internationally on the role of vaping in tobacco control, owing to limited evidence.[[9]] Concerns about e-cigarette use have been raised by the major international respiratory societies.[[10–13]] These include known and unknown long-term health risks, and the potential for vaping to serve as a gateway to smoking, especially among adolescents and young adults. Several studies have shown an association between e-cigarette use and subsequent onset of smoking among teenagers,[[13,14]] while one study reported an association between vaping and attempted smoking cessation although the success rate was only 13.5%.[[15]]
Currently in New Zealand, patients are asked about whether they smoke on admission to hospital, but information is lacking whether vaping is also asked. Understanding the e-cigarette use habits and knowledge of patients about vaping presenting to hospital can enable clinicians to provide relevant information to help patients make informed decisions. We sought to explore these areas in a pilot study to test the validity and acceptability of research tools before deployment to a wider study of vaping knowledge and brand preference in high school students.
Method
Data was collected as part of a summer studentship between 9 December 2021 and 23 February 2022 at Christchurch Hospital. Teenagers aged 13–16 years and parents of children presenting in the paediatric outpatient department were eligible to participate. The study was approved by the Human Ethics Committee (Health) of the University of Otago (H21/169), and locality authorisation was provided by the Canterbury District Health Board. Information about the study was provided to prospective participants in the waiting area and they were invited to take part. Written or online consent was obtained before completing the survey (for teenagers aged 13–15 years old we required their parental as well as their own consent).
The questionnaire included previously validated questions as well as new questions. The methods including these new questions were piloted for use in a wider study on vaping in high schools. Most questions on e-cigarette use (ever-use, frequency of use, reason for use, nicotine use, type of vaping device, and harm perception) were adapted from Pearson and colleagues.[[16]] The question on gender was adapted from previous research on smoking and vaping among university students in New Zealand.[[17]] The ethnicity question was based on the question in the New Zealand census.[[18]]
Participants could complete the survey online or on paper. Digital devices (iPads) were provided for participants to scan a QR code and complete the questionnaire anonymously. Participants were asked to complete the survey independently, without parents or teenagers viewing or influencing each other’s responses and no issues were reported. We reassured teenagers that the study was anonymous, and that there were no repercussions on them, to encourage them to answer questions about smoking and vaping openly. Information was provided for participants to contact Quitline for support if they were concerned about their smoking or vaping. All participants completed the survey online and the questionnaire took five minutes on average.
Survey measures
Demographic information
For the purpose of analysis, participants aged 13–16 years were categorised as teenagers and participants aged 17 years or older were categorised as parents. Participants could identify their gender as male, female, other and “prefer not to say”; however, only male and female options were selected by participants. Participants indicated the ethnicities they identified with, and these were categorised as New Zealand European, Māori, Pasifika (included Samoan, Cook Island Māori and Tongan), Asian (included Indian and Chinese) and Other, consistent with previous research.[[17]]
E-cigarette use
Participants were asked if they had ever used an e-cigarette or vaping device (ever-use); whether they currently vaped at least monthly (current use); how often they vaped “in home” or “in car” when other people were present (never/almost never vs other); the primary reason for using an e-cigarette/vaping device; and whether their usual e-cigarette/vaping device contained nicotine. Additionally, participants were asked about the type of e-cigarette (disposable pod, rechargeable pod, mod system, large modular system); brand of the vaping device that they used the most and the main reason for choosing the brand; their favourite e-liquid/e-juice; and the main source of vaping supplies. Participants were asked about their perceptions of the harmfulness of e-cigarettes compared with tobacco cigarettes.
Knowledge about vaping
Participants were asked how much they agreed or disagreed with four statements about vaping: (1) e-cigarettes can be helpful in smoking cessation; (2) e-cigarettes can be dangerous to children; (3) vaping can be addictive; and (4) vaping is a healthy habit. The responses were agree (agree/strongly agree), neutral, and disagree (disagree/strongly disagree). The primary sources of information about vaping were also assessed and the options included vape shops, social media, friends/relatives, healthcare providers, commercials, and other.
Data analysis
Data was analysed descriptively using IBM SPSS Statistics V.28 and results reported as overall proportions by participant group (teenagers vs parents). Contingency table tests were used to compare the responses of teenagers and parents on knowledge about vaping and two-sided p<0.05 was considered statistically significant.
Results
Participants
A total of 102 participants took part and 95 were included in analysis (Table 1). Of those excluded, four were aged 12 or younger and three did not provide their age. Eight participants (8.4%) smoked conventional cigarettes at least monthly (4.8% of teenagers, 11.3% of parents).
E-cigarette use
Table 2 shows e-cigarette use characteristics of participants, harm perception, reasons for choosing their preferred vaping device, and favourite flavours.
Ever e-cigarette use was similar in teenagers and parents (33.3% vs 30.8%), but current use (i.e., vaping at least once a month) was higher in parents than in teenagers (15.1% vs 7.1%).
The common reasons for vaping in teenagers included curiosity (38.5%), enjoyment (30.8%), and to socialise or fit in with friends (15.4%), whereas most parents reported vaping to quit smoking (50.0%), reduce smoking, and to avoid returning to smoking (25.0%). Other reasons given by parents were vaping when unable to smoke, and curiosity (25.0%).
Teenagers were less likely than parents to report vaping in home (21.4% vs 46.7%) or in car (7.1% vs 28.6%) when others were present. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%). Half of teenagers used a mod system with a tank that they refilled with vape juices/liquids, whereas a similar proportion of parents used a rechargeable e-cigarette or pod system that uses prefilled cartridges.
The sample of e-cigarette users was too small (13 teenagers, 16 parents) to provide useful information about brand preference, but there was no dominant brand for either group. Price (23.1%) and available flavours (23.1%) were the most common reasons that influenced the choice of preferred vaping device among teenagers, while recommendation from friend (26.7%), and price (20.0%), had the greatest influence among parents. Overall, fruit was the most preferred flavour (46.2% of teenagers, 40% % of parents). The primary source of vaping supplies for teenagers was friends/peers (53.8%) and vape shop for parents (40.0%).
Knowledge about vaping
Parents were significantly more likely than teenagers to agree that e-cigarettes can be dangerous to children (p=0.042); there were no statistically significant differences between parents and teenagers in other knowledge questions. Almost all (96.7%) agreed that e-cigarettes can be addictive, and 84.6% disagreed with the statement that “vaping is a healthy habit” (Table 3).
Table 4 displays the primary sources of information about vaping. Overall, friends/peers (for 46.3% of teenagers and 31.4% of parents), social media (16.3% overall) and “Other sources” (17.4% overall) were the most commonly reported sources of information about vaping.
View Tables 1–4.
Discussion
To the best of our knowledge, this is the first study in New Zealand to assess the patterns of e-cigarette use, brand preferences, and knowledge about vaping in an outpatient setting. We estimate the prevalence of ever-use vaping, current vaping and current cigarette smoking of 33.3% vs 30.8%, 7.1% vs 15.1% and 4.8% vs 11.3%, respectively, among teenagers compared to parents. Parents were also more likely than teenagers to vape in home or car when other people were present. All teenagers who vaped used nicotine-containing e-liquids/juices, compared with 86.7% of parents. Overall, fruit was the most preferred flavour and friends/peers were the primary sources of information about vaping. All participants appeared to have a good understanding of the potential benefits and harms of vaping.
Our finding of current smoking among teenagers is consistent with a finding of a 2019 New Zealand Youth19 survey (4% smoked at least monthly),[[1]] but current vaping was lower in our study (7.1% vs 10%). This may be explained by our small opportunistic sample, and potential differences in sample characteristics and environmental factors. Teenagers in the current study were in hospital for follow-up of health conditions, including respiratory illnesses which might have influenced their reporting of vaping and smoking, whereas the 2019 New Zealand Youth19 survey was conducted in a general student population.
The prevalence estimates of current smoking among parents (11.3%) in our sample are comparable to estimates in the general population (10.9%), but current vaping was much higher in the current study (15.1% vs 8.2% in the general population).[[19]] It is possible that some parents may have chosen to vape rather than smoke while around children. This appears to be supported in part by a finding of higher rates of use of e-cigarettes by parents versus teenagers in the home (46.7% vs 21.4% respectively) or in the car (28.6%% vs 7.1%) when other people were present.
An interesting finding of this study was that among teenagers who vaped, 53.8% obtained their vape products from friends or peers and 15.4% each from a family member, or online and none from vape shops or convenience stores. On the one hand, this finding suggests that vape shops and convenience stores are adhering to their retail obligations. On the other hand, it indicates that current restrictions on e-cigarette access that are focused on vape shops, while necessary as part of a comprehensive strategy, will not prevent access to e-cigarettes among young people aged under 18 years. Additional strategies, including targeted media and educational interventions,[[20]] should be explored to increase young people’s knowledge on vaping-related health effects and possibly increase vaping cessation. Public health communication could focus on educating adults about the impact of nicotine exposure, especially on adolescent brain development and the increased generalised risk of drug misuse.[[21]]
Our data show that teenagers state they understand that vaping isn’t a healthy habit, but they are still vaping. It suggests teenagers are not acting on the information they have about vaping. One reason might be response bias: they are giving what they think are the socially acceptable, expected or model answers to the questions about the effects of vaping. Another may be because their primary sources of information about vaping are also the main sources of vaping supplies for teenagers, hence, the need for independent information/education, from a third party (e.g., public health, health professional). A third party may be in a better place to help a teenager to understand the insidious nature of nicotine addiction.
The questionnaire was well received, and participants did not seek assistance to complete the survey online using Qualtrics. This validates our research tools and gives us the confidence to use them in the upcoming survey on vaping in high school students.
Policy implications
The implications of our findings are twofold. First, they suggest more work is needed to improve the general understanding of the potential harms of exposure to e-cigarettes in young people. While it might be less harmful than smoking,[[1]] vaping is not harmless.[[8]] It is not desirable that a new generation of young people should become regular recreational users of an addictive product with unknown long-term effects. Mass media campaigns can be used to reinforce this message. Secondly, there is need for the Government to refocus efforts to reduce e-cigarette uptake among children and young people. The current regulations, including the Smokefree Environments and Regulated Products (Vaping),[[22]] have not prevented teenagers from accessing these products.
Limitations
The small sample restricted most of the analysis to descriptive statistics and the results may not be generalisable to an outpatient hospital population. Further, the questionnaire did not ask about the reasons why the teenage participants were being seen in the outpatient department. Information about participants’ health status, for example, respiratory or other medical conditions that could be aggravated by vaping or smoking, is useful when counselling patients about vaping.
Conclusion
Vaping was common among teenagers and parents. More parents than teenagers vaped in home or in car when other people were present. Teenagers, most commonly, vaped for curiosity and flavour and obtained e-cigarettes from sources other than vape shops, suggesting current vape shop regulations are unlikely to prevent teenagers from accessing vape products. Further educative and regulatory input is needed to reduce e-cigarette use in young people.
Summary
Abstract
Aim
Parents attending hospital with children in New Zealand are routinely asked about tobacco use, but information about vaping is lacking. We assessed e-cigarette use, brand preferences, and knowledge during paediatric outpatient attendance at Christchurch Hospital.
Method
We undertook an anonymous online survey of teenagers and parents attending paediatric outpatient clinic in December 2021 to February 2022. The sample (n=95) were 16% Māori and 8.4% currently smoked (4.8% teenagers, 11.3% parents). We used descriptive and contingency table analysis.
Results
Ever vaping was reported in 33.3% of teenagers and 30.8% of parents, and current use in 7.1% vs 15.1%, respectively. Most teenagers selected “curiosity/just wanted to try them” as their reason for vaping, whereas parents selected vaping to quit or reduce/avoid smoking. More teenagers than parents used nicotine-containing e-cigarettes (100% vs 86.7%) and more parents vaped indoors (in home or car) when other people were present.
The most important reasons for choosing particular e-cigarette brands among teenagers were price and flavours, with fruit flavours preferred. No teenagers obtained their e-cigarettes from vape shops versus 40% of parents. The primary source of information about vaping for teenagers and parents was friends/peers.
Conclusion
Vaping was common among teenagers and parents; teenagers vaped for curiosity and flavours and obtained vape products from sources other than vape shops.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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E-cigarette use patterns, brand preference and knowledge about vaping among teenagers (13–16 years) and parents of children attending Christchurch Hospital
Currently in New Zealand, patients are asked about whether they smoke on admission to hospital, but information is lacking whether vaping is also asked. Understanding the e-cigarette use habits and knowledge of patients about vaping presenting to hospital can enable clinicians to provide relevant information to help patients make informed decisions.
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