Abstract
ABSTRACT
Introduction
Curbing adolescent vaping is a public health priority and little evidence exists examining protective factors. Using a strength-based approach, this study explored the relationship between adolescent vaping health perceptions and vaping use.
Methods
Cross-sectional data from 9000 Australian adolescents aged 14–17 years recruited via multiple online panels as part of the Generation Vape Study were used. Logistic regression compared never vs ever vaping, and inversed multinomial logistic regression compared never vaping to four lifetime vaping categories (ranging from use on a few to >100 occasions) for eight health perceptions.
Results
Overall, 66% (5948/9000) of participants reported never vaping. Within all vaping categories, most agreed that vapes are unsafe, can harm the lungs and brain and can cause addiction, and disagreed that nicotine is harmless. Compared with those who disagreed/strongly disagreed, the odds of never vs ever vaping were greater among those who agreed/strongly agreed that vapes are unsafe to use (adjusted OR=2.67; 95% CI 2.17 to 3.27), can harm the developing brain (2.61; 2.05 to 3.33), can damage the lungs (1.61; 1.23 to 2.10), can cause addiction (2.32; 1.79 to 3.00) and that they are unsafe to use around others (2.94; 2.48 to 3.49). Compared with those who agreed/strongly agreed that nicotine is harmless, there were greater odds of never use (vs ever use) among those who disagreed/strongly disagreed (1.75; 1.44 to 2.11). The protective relationship remained across different lifetime vaping categories. Neither agreeing nor disagreeing was not generally a factor protective against vaping.
Conclusion
Perceptions of vape harms appear protective against experimental and regular vaping. Young people vape despite the majority of users being aware of harms, suggesting knowledge alone is an unlikely driver of behaviour. Comprehensive control efforts that embrace a suite of actions including education, policy, enforcement and monitoring activities are needed to best protect adolescent health.
Keywords: Adolescent, Public Health, Cross-Sectional Studies, Epidemiology
WHAT IS ALREADY KNOWN ON THIS TOPIC
Globally, adolescent vaping prevalence is increasing. While harmful vaping perceptions are assumed to be protective against vaping, evidence is limited and focuses mainly on vaping harms relative to cigarette use and assesses broad perceptions of harm and addiction among ever vs never vapers.
WHAT THIS STUDY ADDS
This study shows that perceptions of vaping harms are also protective among adolescents, with greater odds of being a never vaper among those who perceive vaping to be unsafe, causes addiction and harms the lungs and brain. This relationship holds true for all patterns of vaping, ranging from experimental to more regular use. However, most users are aware of vaping harms, indicating knowledge alone is likely to be insufficient to guide behaviour and that other factors contribute to adolescent vaping.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
While important, education cannot be the only prevention strategy to curb adolescent vaping. Instead, health education should be a component of comprehensive vaping control, acting alongside regulatory and enforcement efforts to restrict access, limit exposure to vaping marketing and promotion, and reduce product appeal.
Introduction
In 2022/2023, 30% of Australian adolescents aged 14–17 years reported ever having used vapes (e-cigarettes), up from 14% in 2017.1 This increase occurred despite national laws and regulations that prohibited the sale or supply of vapes to minors.1 2 The international market is saturated with large volume, high nicotine delivering devices many of which are specifically designed and marketed towards adolescents.3 Several vaping health risks have been identified, including addiction, poisonings both intentional and accidental, nicotine toxicity from inhalation, burns and injuries, lung injury and increased smoking uptake in non-smokers, although many health effects remain unknown.4 5 Adolescents are particularly vulnerable to the impacts of nicotine due to its potential to disrupt critical brain development that occurs during this period.6 Preventing vaping exposure among adolescents is a public health priority.7
Globally, many countries are grappling with high vaping prevalence among adolescents with efforts to curb population exposure to vaping and youth access modelled on traditional tobacco control strategies and policies.2 Historic tobacco control activities—underpinned by strategies of denormalisation—deliberately position smoking as undesirable and unacceptable, and have been attributed to declines in smoking prevalences.8 However, this negative framing risks the stigmatisation of smokers, potentially affecting their mental health.8 9 While an unintentional outcome of denormalisation, the potential to stigmatise vapers is likely if similar strategies are implemented to curb growing vaping prevalence. An alternative approach to negative framing or deficit discourse is one of strength, underpinned by principles of salutogenic theory, whereby stigmatisation and subsequent health harms may be mitigated, and growth and development opportunities are pursued and self-empowerment is key.10,12 Salutogenic theory or salutogenesis centres on the origins of health and the pursuit of optimal health (as opposed to the origins and absence of disease in pathogenesis).12,14 Embracing this tenant, strength-based approaches seek to reframe research and policy agendas to emphasise individual and community strengths that support and promote optimal health without minimising issues or ignoring inequalities.12
A common strength-based approach is the analysis of protective factors often generated by changing the reference group in standard risk calculations.12 Using this measure, several potential protective factors against vaping have been identified in the literature15 including positive family environments and practices,16,19 and academic achievement and involvement.17,19 Health perceptions, and particularly the perceived addictiveness of the products, have also been commonly investigated; however, evidence regarding the relationship between health perceptions and vape use is unclear, as it focuses predominantly on vaping harms relative to cigarettes, includes broad health perception statements and considers only binary categories of vaping (ie, ever vs never). A 2022 systematic review identified nine studies comparing harm perceptions of e-cigarettes compared with cigarettes—six studies found that perceiving vaping as less harmful than cigarettes was associated with vaping and three found no association.20 Another systematic review from 2022 did include meta-analyses pooling data from 11 studies and found greater odds of being an ever vaper among those who perceived vapes as less addictive or harmful than cigarettes (compared with those who saw them as equally addictive or harmful).21 However, this review also found greater odds of ever vaping among those who perceived vapes as more addictive than cigarettes compared with equally addictive.21
Considering the absolute harm of vaping, as opposed to the relative harm to cigarettes, all six studies identified in the review by Hans and Son reported that disagreeing that vaping is harmful was associated with increased likelihood of ever vaping.20 The meta-analysis also found greater odds of being an ever-vaper among those who disagree that vapes are harmful compared with those who agreed (seven studies), and no significant difference between those who agree or disagree that vaping is addictive (five studies).21 Overall, Alys et al concluded that the evidence on vaping perceptions and vaping use was of very low or low certainty21 with both reviews noting limitations due to significant heterogeneity in populations and measures, and dominance of cross-sectional evidence.20 21 Only one study was located that adopted a positive-outcome approach whereby the outcome lies in the direction of optimal health (ie, non-use) rather than the adverse outcome (vaping) and found greater perceived risk that vapers were harming themselves by vaping was associated with greater likelihood of non-vaping.19 While the evidence is broadly suggestive that health perceptions may be protective against vaping, there is a need to more closely examine how different and specific health perceptions relate to various vaping use patterns.
Given the paucity of evidence, the vulnerability of adolescents to e-cigarette health harms and the present opportunity to reframe vaping rhetoric from deficit to strength, this study aims to assess the relationship between vaping health perceptions and vaping use behaviour (focusing on never vaping) using a strength-based approach.
Materials and methods
This study uses data from the Generation Vape research project,22,34 a 4-year (2021–2025) study examining e-cigarette use among young Australians. The current study includes data from waves 2–5 (inclusive) involving online cross-sectional surveys of 14–17-year-olds across Australia. Data were collected from April 2022 to October 2023 at 6-month intervals and the survey was pretested for clarity prior to administration.
Recruitment
Participants who had heard of e-cigarettes with a self-reported age of 14 to 17 years (inclusive) and living in Australia were eligible to participate. Selection was independent of e-cigarette use and no other selection criteria applied. Australian adolescents were recruited by a professional research recruitment agency via multiple online panel providers through repeated cross-sectional surveys. Quotas were applied for age, sex, location of residence (eg, metropolitan or rural) and average household income, to reflect the general population geographical distribution. Both parental and participant consent were obtained after they had received a Participant Information Statement.
Outcome
Using the same measure as the Australian Secondary Students’ Alcohol and Drug (ASSAD) survey,1 participants were asked “How many times have you used a vape?” with five possible responses: I’ve never vaped; just a few puffs; I have vaped on fewer than 10 occasions in my life; I have vaped on more than 10 but fewer than 100 occasions in my life; and I have vaped more than 100 times in my life. Binary classification included never use or ever use; ever use was defined as those reporting in the affirmative to any type of lifetime e-cigarette use including a few puffs, a few puffs but less than 10 occasions, more than 10 occasions but less than 100 occasions and more than 100 occasions.
Exposure
The exposures were based on survey responses to perceptions about health harms of vaping. The survey includes eight statements relating to health perceptions with participants asked to indicate their agreement using a five-point Likert scale (1=strongly agree; 2=agree; 3=neither agree nor disagree; 4=disagree; 5=strongly disagree). Responses were grouped into three categories for analyses: ‘strongly agree or agree’, ‘neither agree nor disagree’ and ‘strongly disagree or disagree’.
The statements were (a) Vapes are unsafe to use, (b) Vaping can harm the developing brain, (c) Vaping can damage the lungs, (d) Vaping during adolescence can cause addiction, (e) Vapes are healthier than smoking tobacco cigarettes, (f) Vapes help smokers to quit, (g) It is unsafe to use vapes around others and (h) Nicotine is harmless.
Statistical analysis
Cross-sectional surveys were pooled and survey data for repeat respondents (n=4030 surveys) removed except for their initial survey. Each model was restricted to only those with complete outcome, covariate and exposure data.
Summary statistics were used to describe characteristics of sample, overall and by lifetime vaping use. Response proportions (%) by lifetime vaping use for each health perception were presented. Applying the positive outcomes approach12 in the assessment of exposure-outcome relationships, ‘never use’, based on the response “I’ve never vaped”, was chosen as the main outcome category of interest (as it represents the optimal health state); the exposure category that is likely to be a protective for well-being (eg, those who ‘strongly agree/agree’ that vapes are unsafe or those who ‘strongly disagree/disagree’ that nicotine is harmless) was chosen as the main exposure of interest and the category that is likely to be a risk factor was chosen as the reference (eg, those who ‘strongly disagree/disagree’ that vapes are unsafe). Logistic regression was used to estimate ORs and 95% CIs of never use of vapes compared with ever use for each health perception. Multinomial logistic regression models were inversed to estimate odds of never use vs each lifetime vaping category (‘a few puffs’, ‘>few but <10 occasions’, ‘10–100 occasions’ and ‘>100 occasions’) for each health perception, modelling vape use as a nominal outcome. Nominal p values are shown for each statistical test with no adjustments made for multiple comparisons and estimates are presented with 95% CI rather than focusing on p values.
Estimates were adjusted for gender, age at time of completing survey (years), socioeconomic status (SES) of residence area, remoteness of residence, state/territory of residence, Aboriginal and Torres Strait Islander status, language spoken at home and smoking status. SES of residential area was determined using participants’ residential postcodes, which were linked to the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) using Postal Areas correspondence files provided by the Australian Bureau of Statistics (ABS).35 IRSAD is an area-level composite index based on Census variables including income, education, employment, occupation and housing. Scores are standardised (Australian mean ≈ 1000) and were grouped into quintiles, with 1 indicating the most disadvantaged areas and 5 the most advantaged. All analyses were conducted in Stata v18.
Patient and public involvement statement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Results
Sample characteristics
The sample included 9000 adolescents aged 14–17 years from across Australia of whom 66% (n=5948) reported never vaping, 15% (n=1323) a few puffs, 6% (n=568) vaping on <10 occasions, 7% (n=598) vaping on 10 to 100 occasions and 6% (n=563) had vaped on >100 occasions (table 1). The mean age for the overall sample was 15.4 years and the sample included 44% males, 54% females and 1.3% non-binary respondents. The majority of the sample (79%) were never-smokers. The fully adjusted model was restricted to 8974 participants due to missing covariate data (see online supplemental table 1 for details).
Table 1. Participant characteristics by lifetime vaping—number (percentage).
| Lifetime vaping | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Never (5948) | A few puffs (1323) | More than a few but <10 occasions (568) | 10–100 occasions (598) | >100 occasions (563) | Overall (9000) | |||||||
| Gender | ||||||||||||
| Male | 2766 | (46.5) | 541 | (40.9) | 221 | (38.9) | 234 | (39.1) | 203 | (36.1) | 3965 | (44.1) |
| Female | 3060 | (51.4) | 755 | (57.1) | 342 | (60.2) | 351 | (58.7) | 348 | (61.8) | 4856 | (54.0) |
| Non-binary | 76 | (1.3) | 19 | (1.4) | 3 | (0.5) | 8 | (1.3) | 11 | (2.0) | 117 | (1.3) |
| Prefer to self-describe | 17 | (0.3) | 2 | (0.2) | 1 | (0.2) | 3 | (0.5) | 1 | (0.2) | 24 | (0.3) |
| I would prefer not to say | 29 | (0.5) | 6 | (0.5) | 1 | (0.2) | 2 | (0.3) | 0 | (0.0) | 38 | (0.4) |
| Mean age (years) | 15.32 | 15.49 | 15.67 | 15.90 | 15.87 | 15.43 | ||||||
| State or territory | ||||||||||||
| NSW | 1837 | (30.9) | 393 | (29.7) | 162 | (28.5) | 163 | (27.3) | 169 | (30.0) | 2724 | (30.3) |
| VIC | 1440 | (24.2) | 342 | (25.9) | 108 | (19.0) | 142 | (23.7) | 133 | (23.6) | 2165 | (24.1) |
| QLD | 1243 | (20.9) | 290 | (21.9) | 168 | (29.6) | 154 | (25.8) | 132 | (23.4) | 1987 | (22.1) |
| SA | 466 | (7.8) | 95 | (7.2) | 43 | (7.6) | 43 | (7.2) | 43 | (7.6) | 690 | (7.7) |
| WA | 741 | (12.5) | 164 | (12.4) | 66 | (11.6) | 66 | (11.0) | 67 | (11.9) | 1104 | (12.3) |
| TAS | 119 | (2.0) | 21 | (1.6) | 12 | (2.1) | 18 | (3.0) | 9 | (1.6) | 179 | (2.0) |
| NT | 23 | (0.4) | 9 | (0.7) | 4 | (0.7) | 6 | (1.0) | 1 | (0.2) | 43 | (0.5) |
| ACT | 79 | (1.3) | 9 | (0.7) | 5 | (0.9) | 6 | (1.0) | 9 | (1.6) | 108 | (1.2) |
| Remoteness of residence | ||||||||||||
| Metro | 4808 | (81.1) | 1048 | (79.6) | 427 | (75.4) | 442 | (74.2) | 404 | (71.8) | 7129 | (79.4) |
| Inner regional | 811 | (13.7) | 186 | (14.1) | 97 | (17.1) | 108 | (18.1) | 117 | (20.8) | 1319 | (14.7) |
| Outer regional | 283 | (4.8) | 74 | (5.6) | 36 | (6.4) | 42 | (7.0) | 36 | (6.4) | 471 | (5.2) |
| Remote | 30 | (0.5) | 9 | (0.7) | 6 | (1.1) | 4 | (0.7) | 6 | (1.1) | 55 | (0.6) |
| SES of residence area | ||||||||||||
| 1—lowest SES | 686 | (11.5) | 168 | (12.7) | 76 | (13.4) | 71 | (11.9) | 82 | (14.6) | 1083 | (12.03) |
| 2 | 762 | (12.8) | 178 | (13.5) | 80 | (14.1) | 80 | (13.4) | 103 | (18.3) | 1203 | (13.37) |
| 3 | 1103 | (18.5) | 253 | (19.1) | 129 | (22.7) | 124 | (20.7) | 112 | (19.9) | 1721 | (19.12) |
| 4 | 1470 | (24.7) | 306 | (23.1) | 113 | (19.9) | 150 | (25.1) | 114 | (20.2) | 2153 | (23.92) |
| 5—highest SES | 1913 | (32.2) | 413 | (31.2) | 168 | (29.6) | 171 | (28.6) | 152 | (27.0) | 2817 | (31.30) |
| Not known | 14 | (0.2) | 5 | (0.4) | 2 | (0.4) | 2 | (0.3) | 0 | (0.0) | 23 | (0.26) |
| Aboriginal or Torres Strait Islander | ||||||||||||
| No | 5734 | (96.4) | 1247 | (94.3) | 520 | (91.5) | 550 | (92.0) | 493 | (87.6) | 8544 | (94.9) |
| Yes—Aboriginal descent | 160 | (2.7) | 60 | (4.5) | 37 | (6.5) | 43 | (7.2) | 55 | (9.8) | 355 | (3.9) |
| Yes—Torres Strait Islander descent | 10 | (0.2) | 2 | (0.2) | 3 | (0.5) | 1 | (0.2) | 1 | (0.2) | 17 | (0.2) |
| Yes—both Aboriginal and Torres Strait Islander descent | 21 | (0.4) | 8 | (0.6) | 5 | (0.9) | 1 | (0.2) | 7 | (1.2) | 42 | (0.5) |
| I would prefer not to say | 23 | (0.4) | 6 | (0.5) | 3 | (0.5) | 3 | (0.5) | 7 | (1.2) | 42 | (0.5) |
| Language spoken at home | ||||||||||||
| English only | 4979 | (83.7) | 1152 | (87.1) | 513 | (90.3) | 556 | (93.0) | 514 | (91.3) | 7714 | (85.7) |
| Another language only (specify) | 145 | (2.4) | 22 | (1.7) | 7 | (1.2) | 6 | (1.0) | 4 | (0.7) | 184 | (2.0) |
| English and another language (specify) | 824 | (13.9) | 149 | (11.3) | 48 | (8.5) | 36 | (6.0) | 45 | (8.0) | 1102 | (12.2) |
| Lifetime cigarettes or other tobacco product use | ||||||||||||
| Never-smoker | 5760 | (96.8) | 760 | (57.4) | 258 | (45.4) | 233 | (39.0) | 92 | (16.3) | 7103 | (78.9) |
| A few puffs | 167 | (2.8) | 496 | (37.5) | 143 | (25.2) | 125 | (20.9) | 97 | (17.2) | 1028 | (11.4) |
| More than a few puffs but <10 cigarettes | 13 | (0.2) | 50 | (3.8) | 114 | (20.1) | 89 | (14.9) | 98 | (17.4) | 364 | (4.0) |
| 10 to <100 cigarettes | 7 | (0.1) | 10 | (0.8) | 41 | (7.2) | 120 | (20.1) | 162 | (28.8) | 340 | (3.8) |
| 100+ cigarettes | 1 | (0.0) | 7 | (0.5) | 12 | (2.1) | 31 | (5.2) | 114 | (20.2) | 165 | (1.8) |
ACT, Australian Capital Territory; NSW, New South Wales; NT, Northern Territory; QLD, Queensland; SA, South Australia; SES, socioeconomic status; TAS, Tasmania; VIC, Victoria; WA, Western Australia.
Perceptions of harm according to lifetime vaping
The majority of participants within each lifetime vaping category either agreed/strongly agreed that vapes are unsafe to use, vapes can harm the developing brain, vapes can damage the lungs and vaping during adolescence can cause addiction and across all lifetime vaping categories, ≤20% disagreed/strongly disagreed with these health perceptions (figure 1A–D). Vapes can damage the lungs and vaping during adolescence can cause addiction had the greatest proportions that agreed/strongly agreed across all lifetime vaping categories ranging from 71%–90% and 68%–88% respectively (figure 1C,D). For these health perceptions, the proportion of participants that agreed/strongly agreed was highest among never vapers (range of 82%–90%) and generally declined with greater lifetime vaping.
Figure 1. Responses by lifetime vaping (%).
Although more never vapers disagreed/strongly disagreed that vapes are healthier than cigarettes (41%), there were also substantial proportions that neither agreed nor disagreed (32%) and that agreed/strongly agreed (27%). Within each other lifetime vaping category, the inverse occurred with the largest proportion of participants agreeing/strongly agreeing that vapes are healthier than cigarettes (ranging from 42% to 51%) with 26%–32% of participants neither agreeing nor disagreeing and 17%–30% disagreeing/strongly disagreeing (figure 1E). The proportion of never vapers that disagreed/strongly disagreed (40%) that vapes help smokers quit was similar to those who neither agreed nor disagreed (37%). Between 20% and 27% from other lifetime vaping categories disagreed/strongly disagreed, 28%–35% neither agreed nor disagreed and 38%–52% (figure 1F).
The majority of never vapers and those who had vaped just a few puffs agreed/strongly agreed that it is unsafe to use vapes around others (71% and 55% respectively). Only 37%–42% of the other vaping categories agreed/strongly agreed with this statement, 33%–38% neither agreed nor disagreed and 24%–30% disagreed/strongly disagreed (figure 1G).
Irrespective of lifetime vaping category, more than 68% in each group disagreed/strongly disagreed that nicotine was harmless with <15% in each group agreeing/strongly agreeing (figure 1H).
Relation of vaping harm perception of never versus ever use
Compared with those who disagreed/strongly disagreed, the odds of never use were greater among those who agreed/strongly agreed that vapes are unsafe to use (adjusted OR (aOR): 2.67; 95% CI: 2.17 to 3.27), can harm the developing brain (aOR: 2.61; 95% CI: 2.05 to 3.33), can damage the lungs (aOR: 1.61; 95% CI: 1.23 to 2.10), can cause addiction (aOR: 2.32; 95% CI: 1.79 to 3.00) and are unsafe to use around others (aOR: 2.94; 95% CI: 2.48 to 3.49). The odds of never use were significantly lower among those who agreed/strongly agreed compared with those who disagreed/strongly disagreed that vapes were healthier than cigarettes (aOR: 0.34; 95% CI: 0.29 to 0.39) or that vapes help smokers to quit (aOR: 0.37; 95% CI: 0.32 to 0.43). Compared with those who agree/strongly agree that nicotine is harmless, there were greater odds of never use among those who did not perceive nicotine as harmless (aOR: 1.75; 95% CI: 1.44 to 2.11) (table 2).
Table 2. Adjusted ORs for never vaping, compared with ever vaping by health perception.
| Proportion of never users % (n/N) |
aOR* (95% CI) | aOR† (95% CI) | ||
|---|---|---|---|---|
| Vapes are unsafe to use | ||||
| Strongly disagree/disagree | 42.6 | (337/791) | 1 | 1 |
| Neither agree nor disagree | 47.7 | (716/1502) | 1.31 (1.09 to 1.57) | 1.09 (0.86 to 1.38) |
| Strongly agree/agree | 73.0 | (4894/6706) | 4.11 (3.51 to 4.81) | 2.67 (2.17 to 3.27) |
| Vaping can harm the developing brain | ||||
| Strongly disagree/disagree | 39.2 | (217/554) | 1 | 1 |
| Neither agree nor disagree | 47.6 | (691/1451) | 1.38 (1.12 to 1.69) | 1.07 (0.82 to 1.40) |
| Strongly agree/agree | 72.1 | (5039/6993) | 4.31 (3.58 to 5.19) | 2.61 (2.05 to 3.33) |
| Vaping can damage the lungs | ||||
| Strongly disagree/disagree | 50.2 | (208/414) | 1 | 1 |
| Neither agree nor disagree | 44.4 | (413/930) | 0.79 (0.62 to 1.01) | 0.71 (0.52 to 0.97) |
| Strongly agree/agree | 69.6 | (5327/7655) | 2.46 (2.00 to 3.03) | 1.61 (1.23 to 2.10) |
| Vaping during adolescence can cause addiction | ||||
| Strongly disagree/disagree | 43.6 | (197/452) | 1 | 1 |
| Neither agree nor disagree | 49.8 | (506/1017) | 1.25 (0.99 to 1.58) | 1.24 (0.91 to 1.67) |
| Strongly agree/agree | 69.7 | (5245/7530) | 3.22 (2.63 to 3.94) | 2.32 (1.79 to 3.00) |
| Vapes are healthier than smoking tobacco cigarettes | ||||
| Strongly disagree/disagree | 76.7 | (2463/3214) | 1 | 1 |
| Neither agree nor disagree | 68.4 | (1880/2748) | 0.65 (0.57 to 0.73) | 0.64 (0.55 to 0.74) |
| Strongly agree/agree | 52.8 | (1604/3036) | 0.32 (0.29 to 0.36) | 0.34 (0.29 to 0.39) |
| Vapes help smokers to quit | ||||
| Strongly disagree/disagree | 76.2 | (2360/3096) | 1 | 1 |
| Neither agree nor disagree | 69.0 | (2177/3178) | 0.67 (0.60 to 0.75) | 0.68 (0.59 to 0.78) |
| Strongly agree/agree | 51.8 | (1410/2724) | 0.32 (0.29 to 0.36) | 0.37 (0.32 to 0.43) |
| It is unsafe to use vapes around others | ||||
| Strongly disagree/disagree | 43.4 | (511/1177) | 1 | 1 |
| Neither agree nor disagree | 55.5 | (1218/2196) | 1.59 (1.38 to 1.85) | 1.42 (1.18 to 1.72) |
| Strongly agree/agree | 75.0 | (4219/5626) | 3.97 (3.47 to 4.54) | 2.94 (2.48 to 3.49) |
| Nicotine is harmless | ||||
| Strongly disagree/disagree | 69.9 | (5072/7254) | 2.07 (1.79 to 2.40) | 1.75 (1.44 to 2.11) |
| Neither agree nor disagree | 45.3 | (376/831) | 0.69 (0.57 to 0.84) | 0.67 (0.52 to 0.86) |
| Strongly agree/agree | 54.6 | (499/914) | 1 | 1 |
Adjusted for gender, age.
Adjusted for gender, age, SES of residence area, remoteness of residence, state/territory of residence, Aboriginal and Torres Strait Islander status, language spoken at home and smoking status.
aOR, adjusted OR.
Compared with those who disagreed/strongly disagreed, the odds of never use among those who neither agreed nor disagreed were greater for the perception that vaping is unsafe around others (aOR: 1.42; 95% CI: 1.18 to 1.72) and lower for the health perceptions that vaping can damage the lungs (aOR: 0.71; 95% CI: 0.52 to 0.97), that vapes were healthier than cigarettes (aOR: 0.64; 95% CI: 0.55 to 0.74) and that vapes help smokers to quit (aOR: 0.68; 95% CI: 0.59 to 0.78). There was no statistical difference for all other health perceptions (table 2). See online supplemental table 2 for unadjusted results.
Relation of vaping harm perception to never versus individual lifetime vaping categories
Overall, findings broadly resembled the never vs ever use analysis above. Among those who agreed/strongly agreed with statements, there were generally greater odds of never use compared with each of the four individual lifetime vaping categories for perceptions indicating vaping harm (unsafe to use, harm the developing brain, can cause addiction, unsafe to use around others and can damage the lungs) and generally lower odds for perceptions indicating vaping benefits (healthier than cigarettes and help smokers quit), and there were also generally lower odds of never use among those who disagreed/strongly disagreed that nicotine was harmless, noting a few non-significant results (table 3).
Table 3. Adjusted OR of never use compared with each lifetime vaping group by health perception.
|
|
A few puffs vs never | More than a few but <10 occasions vs never | 10–100 occasions vs never | >100 occasions vs never | ||||
|---|---|---|---|---|---|---|---|---|
| Never | Never | Never | Never | |||||
| (%) | aOR* (95% CI) | (%) | aOR* (95% CI) | (%) | aOR* (95% CI) | (%) | aOR* (95% CI) | |
| Vapes are unsafe to use | ||||||||
| Strongly disagree/disagree | 69.2 | 1 | 78.0 | 1 | 77.8 | 1 | 74.9 | 1 |
| Neither agree nor disagree | 72.2 | 1.14 (0.87 to 1.48) | 80.4 | 1.06 (0.75 to 1.48) | 79.6 | 0.98 (0.69 to 1.37) | 82.5 | 1.27 (0.85 to 1.88) |
| Strongly agree/agree | 84.5 | 2.08 (1.66 to 2.62) | 94.2 | 3.64 (2.69 to 4.93) | 93.9 | 3.49 (2.56 to 4.76) | 94.3 | 3.92 (2.75 to 5.59) |
| Vaping can harm the developing brain | ||||||||
| Strongly disagree/disagree | 67.2 | 1 | 75.3 | 1 | 72.8 | 1 | 73.3 | 1 |
| Neither agree nor disagree | 71.6 | 1.05 (0.78 to 1.43) | 82.3 | 1.18 (0.80 to 1.72) | 80.0 | 1.05 (0.71 to 1.53) | 80.8 | 0.96 (0.62 to 1.49) |
| Strongly agree/agree | 84.2 | 2.03 (1.54 to 2.68) | 93.6 | 3.32 (2.36 to 4.68) | 93.6 | 3.73 (2.63 to 5.29) | 94.0 | 3.48 (2.34 to 5.19) |
| Vaping can damage the lungs | ||||||||
| Strongly disagree/disagree | 71.2 | 1 | 85.6 | 1 | 80.9 | 1 | 84.6 | 1 |
| Neither agree nor disagree | 69.8 | 0.82 (0.58 to 1.17) | 78.1 | 0.54 (0.34 to 0.88) | 76.8 | 0.68 (0.43 to 1.07) | 81.0 | 0.60 (0.34 to 1.06) |
| Strongly agree/agree | 83.4 | 1.57 (1.16 to 2.11) | 92.8 | 1.55 (1.01 to 2.38) | 92.6 | 2.03 (1.38 to 3.01) | 92.6 | 1.28 (0.77 to 2.11) |
| Vaping during adolescence can cause addiction | ||||||||
| Strongly disagree/disagree | 66.1 | 1 | 77.6 | 1 | 78.8 | 1 | 81.7 | 1 |
| Neither agree nor disagree | 73.7 | 1.33 (0.95 to 1.86) | 80.6 | 1.18 (0.77 to 1.80) | 80.8 | 1.08 (0.69 to 1.69) | 85.2 | 1.27 (0.75 to 2.16) |
| Strongly agree/agree | 83.4 | 2.13 (1.60 to 2.83) | 93.1 | 3.07 (2.12 to 4.47) | 92.5 | 2.48 (1.68 to 3.66) | 92.4 | 1.76 (1.12 to 2.75) |
| Vapes are healthier than smoking cigarettes | ||||||||
| Strongly disagree/disagree | 86.5 | 1 | 95.1 | 1 | 95.1 | 1 | 94.6 | 1 |
| Neither agree nor disagree | 83.2 | 0.77 (0.65 to 0.92) | 92.0 | 0.41 (0.32 to 0.54) | 92.0 | 0.52 (0.40 to 0.69) | 92.8 | 0.60 (0.44 to 0.83) |
| Strongly agree/agree | 74.1 | 0.45 (0.38 to 0.53) | 83.9 | 0.21 (0.17 to 0.28) | 83.7 | 0.23 (0.18 to 0.29) | 85.3 | 0.25 (0.19 to 0.33) |
| Vapes help smokers to quit | ||||||||
| Strongly disagree/disagree | 86.7 | 1 | 94.6 | 1 | 94.6 | 1 | 95.4 | 1 |
| Neither agree nor disagree | 82.7 | 0.75 (0.64 to 0.89) | 92.1 | 0.56 (0.44 to 0.72) | 62.1 | 0.61 (0.47 to 0.79) | 93.2 | 0.59 (0.43 to 0.81) |
| Strongly agree/agree | 73.6 | 0.45 (0.38 to 0.53) | 85.4 | 0.31 (0.25 to 0.40) | 83.7 | 0.28 (0.22 to 0.36) | 82.8 | 0.21 (0.16 to 0.29) |
| It is unsafe to use vapes around others | ||||||||
| Strongly disagree/disagree | 69.9 | 1 | 78.4 | 1 | 78.4 | 1 | 75.5 | 1 |
| Neither agree nor disagree | 76.5 | 1.33 (1.07 to 1.66) | 84.5 | 1.58 (1.20 to 2.09) | 84.5 | 1.33 (1.00 to 1.75) | 86.6 | 1.85 (1.34 to 2.54) |
| Strongly agree/agree | 85.3 | 2.22 (1.82 to 2.72) | 94.8 | 3.94 (3.04 to 5.10) | 94.8 | 4.00 (3.06 to 5.23) | 95.3 | 5.20 (3.83 to 7.06) |
| Nicotine in harmless | ||||||||
| Strongly disagree/disagree | 84.1 | 1.89 (1.54 to 2.33) | 92.5 | 1.60 (1.18 to 2.17) | 92.5 | 1.63 (1.18 to 2.25) | 92.7 | 1.29 (0.89 to 1.87) |
| Neither agree nor disagree | 68.6 | 0.77 (0.58 to 1.02) | 82.3 | 0.64 (0.43 to 0.96) | 77.0 | 0.48 (0.33 to 0.72) | 80.7 | 0.48 (0.30 to 0.77) |
| Strongly agree/agree | 72.3 | 1 | 87.1 | 1 | 86.6 | 1 | 87.2 | 1 |
Adjusted for gender, age, SES of residence area, remoteness of residence, state/territory of residence, Aboriginal and Torres Strait Islander status, language spoken at home and smoking status.
aOR, adjusted OR.
Similarly, there were higher odds of never use among those who neither agreed nor disagreed that vaping is unsafe around others and lowers odds for the perception that vapes are healthier than cigarettes and that vapes help smokers quit. There was generally no statistically significant association of never use for all other health perceptions across lifetime vaping categories (table 3). See online supplemental table 3 for unadjusted results.
Discussion
Adolescents who abstain from vaping were more likely than vapers of any level of use (including ever use and use ranging from vaping on only a few occasions to more than 100 occasions) to perceive vaping as harmful and less likely to perceive them as beneficial. The magnitude of the effect was generally similar by perception and lifetime vaping use. Irrespective of lifetime vaping use, the majority of adolescents agree that vapes are unsafe, can harm the lungs and brain and can cause addiction with the majority also disagreeing that nicotine is harmless. Neither agreeing nor disagreeing about vaping health perceptions was not generally found to be a factor protective against vaping either finding no association or for some perceptions, a lower likelihood of never vaping (ie, at greater risk of vaping).
Our results are consistent with those of Ratcliff et al who also used a positive outcome approach and found that perceived risk of e-cigarette use was associated with greater odds of abstinence from e-cigarette use in the past 30 days among adolescents from the USA.19 Findings are also in agreement with other studies that specifically considered perceptions of e-cigarette addictiveness36 37 and general e-cigarette harm perceptions38 39 including from the systematic review and meta-analysis by Aly and colleagues.21 Our study contributes new understanding to the relationship between vaping health perceptions and vaping behaviours, finding that specific health perceptions beyond general measures of harmfulness and addiction used in other studies are associated with greater likelihood of never use. Furthermore, we were able to assess this association across a range of vaping use patterns, which to our knowledge, no other study has investigated in equal detail.
While some health perceptions appear to be well established among adolescents, with upwards of 70% in each lifetime vaping category agreeing that vaping can damage the lungs, others demonstrate large proportions that neither agreed nor disagreed. For example, approximately 20%–30% of participants in lifetime vaping category (excluding never users) neither agreed nor disagreed vapes can harm the developing brain or that vapes are unsafe to use. Responses for vapes are healthier than cigarettes and vapes help smokers to quit also had large proportions neither agreeing nor disagreeing. While perceiving vaping to be unsafe around others was associated with greater likelihood of never vaping (ie, protective) among those who neither agreed nor disagreed, there was no association for other perceptions (including addiction, harm to the brain and unsafe) and interestingly, they were even less likely to never vape (ie, had greater odds of vaping) than those who agree nicotine is harmless and disagree that vaping can damage the lungs (never vs ever comparison). Like those who agree vapes are healthier than cigarettes and can help smokers quit, those who neither agree nor disagree also have lower odds of never vaping but to a lesser extent. Thus, aside from not being a factor protective against vaping, several of these perceptions have the opposite relation and are associated with greater risk of vaping among this group—in some cases greater than those who overtly consider vaping harmful. As messages that convey uncertainty are linked to viewing vaping as less risky,40 it is possible this could be influencing vaping behaviour, or a rationalisation for it. Also, this group is likely to be heterogeneous in their interpretation and reasoning behind the selection of ‘neither agree nor disagree’ and may reflect ambivalence, lack of knowledge or conviction, not holding an opinion or uncertainty.41 The notion that vapers would quit once health effects become known may suggest that an absence of evidence is being rationalised, to some degree, as an absence of harm or inconsequential harm, or that adolescents do not adopt caution in the face of the unknown.42 43
Dialogue and media reporting advocating the safety of e-cigarettes relative to cigarettes and their use as smoking cessation aids has been relentlessly promoted by the e-cigarette industry to further their commercial interests.44,46 The impact and persuasiveness of this narrative is reflected in the uncertainty adolescents report regarding these perceptions. While recognising the complexity of these topics, the rapid evolution of evidence regarding e-cigarette risk and their potential efficacy as smoking cessation aids (noting that most adolescents are non-smokers), and industry interference, developing nuanced health messaging conveying harms rather than uncertainty relevant to adolescents is needed. Adolescents with undecided e-cigarette health perceptions are an important target audience for health education and campaigns. They present an opportunity whereby strengthening e-cigarette harm perceptions and capitalising on the protective nature of these perceptions may benefit large portions of the adolescent population.
This study found that young people vape despite the majority of vapers agreeing that vapes are unsafe, can damage the lungs and brain, and cause addiction, and do not agree that nicotine is harmless. This remains true across the range of vaping use patterns from experimental to more regular use. These findings reinforce that purely knowing or appreciating the health risks of e-cigarettes is insufficient to guide adolescent behaviour. This is not unique to e-cigarette use and well documented in research related to other adolescent health behaviours and demonstrates the balance of rationality, intentionality and unconsciousness in decision making.47 For example, social norms—the implicit and often unspoken rules that guide behaviour—have been identified as drivers behind adolescent e-cigarette use where overestimates of e-cigarette prevalence contribute to a perception of normality and acceptance in wider society and position use as necessary for adolescents to fit in with their peers.33 Thus, while education and increasing awareness of e-cigarette harms are inarguably important, it is critical these knowledge-building strategies do not become the activity on which all e-cigarette prevention efforts are hinged. To prevent adolescent e-cigarette use, a suite of policy and regulatory levers must be enforced including but not limited to, reduced access to products, lessening product appeal and restricting e-cigarette marketing and promotion.
This necessity to implement a range of activities to curb e-cigarette use was recognised by the Australian Government with the implementation of comprehensive e-cigarette legislative reforms throughout 2024.48 The primary objective of the reforms is to limit access and exposure of e-cigarettes to non-smokers, in particular adolescents, while enabling controlled access to e-cigarettes for those who smoke for the purpose of smoking cessation.48 49 In January, a ban on the importation of all disposable vapes (irrespective of nicotine content) was enforced and as of 1 July 2024, an additional ban on the retail sale of e-cigarettes outside pharmacies was enacted. Further, products supplied via pharmacies are required to adhere to quality standards including restrictions on nicotine concentration, flavours and packaging.50 Comprehensive tobacco and e-cigarette control must include simultaneous policy, education, enforcement and monitoring activities and, though these 2024 reforms are promising, without ongoing resources and coordination, they may fail to meaningfully restrict e-cigarette access to protect adolescent health. It will be crucial to evaluate the effectiveness of the reforms, quickly identify areas for improvement and continue to monitor both e-cigarette use, attitudes and beliefs and the e-cigarette/tobacco industry response.
Using a strength-based approach, this study provides the first analysis to examine the association of multiple and diverse e-cigarette health perceptions with never vaping among a large sample of adolescents. It was also able to demonstrate associations by four discrete categories of vape use ranging from experimental use to more regular use enabling a more nuanced analysis. The primary limitation of this analysis is that it was cross-sectional data; therefore, it is only possible to examine how factors are associated with never vaping at a single time point, and causality cannot be inferred. Nonetheless, our findings contribute valuable evidence on the relationship between e-cigarette health perceptions and e-cigarette use among adolescents. Although Generation Vape uses recruitment rather than random sampling, the study design accounts for potential confounding by adjusting for key demographic and geographic variables. This approach supports broader generalisation of findings to Australian adolescents. As noted in Mealing et al,51 random sampling and full representativeness are not required for valid estimates based on internal comparisons (eg, people who do and do not vape) in cross-sectional studies. It is also possible that e-cigarette use may have been under-reported due to potential negative stigma associated with e-cigarette use—particularly parental disapproval of vaping—and though parents were aware of the survey via the consent process, to our knowledge, the surveys were completed independently and without parental supervision or involvement. In the current study, we chose not to adjust for multiple comparisons as we believe that a better approach, as recommended by a number of authors,52,54 is to evaluate the results in the context of prior evidence, plausibility, the number of tests performed and the strengths of the observed associations. We do, however, acknowledge that while p values are nominal for individual tests, the Type I error rate is likely to be inflated for the family of tests.
Awareness of the health risks of e-cigarettes appears to be protective as adolescents with greater perceptions of e-cigarette harms are more likely to be never vapers. This association remains true for various health perceptions including those relating to lung and brain damage, addiction and nicotine and for all types of lifetime vaping from experimental to more regular use. Neither agreeing nor disagreeing was not generally a factor protective against vaping. Although many adolescents who vape perceive the harms of e-cigarettes, they continue to vape. While health education is important, in isolation, it is unlikely to be sufficient to prevent adolescent e-cigarette use and policy and public health efforts must embrace a suite of actions to more fully protect adolescent health.
Supplementary material
Acknowledgements
The authors would like to acknowledge and thank the members of the Generation Vape research team for their support of this research.
Footnotes
Funding: Generation Vape is led by Cancer Council NSW in partnership with the Daffodil Centre and the University of Sydney, funded by the Australian Government Department of Health (grant number: not applicable), Minderoo Foundation (grant number: not applicable), the NSW Ministry of Health (grant number: not applicable) and Cancer Institute NSW (grant number: not applicable). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funders. AY holds an Australian Research Development Training Program stipend (grant number: not applicable). EB is supported by an Investigator Grant from the National Health and Medical Research Council of Australia (grant number: 2017742).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: Ethical approval for the study was provided by The University of Sydney Human Research Ethics Committee (Project number: 2021/442) in July 2021. Participants gave informed consent to participate in the study before taking part.
Data availability free text: Data from surveys are unavailable for sharing due to ethical requirements.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
No data are available.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
No data are available.