Vaping – Youth perceptions and attitudes: evidence briefing

Annex – Analysis of the existing evidence

Attractiveness

Several systematic reviews/meta-ethnographies and primary studies examined for this briefing suggest that young people find vaping attractive due to vaping products’ design (e.g. small size and possibility to customise them, for example by choosing different nicotine contents); enjoyment in experimenting with a variety of flavours; exposure to brightly coloured packaging; and easy accessibility of vaping products in terms of cost and purchasing options (i.e. from multiple illegal sources, including physical stores, online or through proxies). More details on each of these aspects are presented below.

Product design

The sources examined for this briefing suggest that young people tend to perceive vaping products as appealing due to their novel design and function, customisability in terms of flavours and nicotine contents, small size and lack of unpleasant smell compared to conventional cigarettes.

• A meta-ethnography on young adults’ experiences and perceptions of e-cigarette use (2021) concluded that e-cigarettes were viewed as youth-oriented in design and function, and as reflecting the younger generation’s relationship with technology. A more recent Scottish focus group study (2023) also supports these findings.
• A systemic review on consumer preference for e-cigarette attributes (2019) and a meta-ethnography on young adults’ perceptions and experiences of e-cigarette use (2021) concluded that young people were drawn to the customisability of vaping products, namely the possibility of choosing a variety of flavours and nicotine contents.
• Two meta-ethnographies on emerging norms of e-cigarette use among adolescents (2021) and on young adults’ experiences and perceptions of e-cigarette use (2021) concluded that youths perceived vaping products as more appealing than conventional cigarettes due to their customisable characteristics (e.g. possibility to mix e-liquids) and variety of flavours. Additionally, young people were attracted to their discrete size and lack of unpleasant smell, which make them easy to conceal from disapproving authoritative figures such as parents or teachers. These findings are supported by a more recent US study on adolescent vaping experiences (2023).

Flavours

The sources examined for this briefing suggest that flavours increase willingness to try/continue vaping, due to the enjoyment in experimenting with different flavours and the sensory appeal of flavours both in terms of taste, and appeal of names and designs.

• Three systematic reviews on young people's consumer preferences for e-cigarettes attributes (2018), youth perceptions and use of non-menthol flavours in e-cigarettes (2019) and youth use of e-liquid flavours (2022), and a number of more recent primary research studies^[2], found that flavours (especially fruit or sweet flavours) increased product appeal, and willingness to initiate vaping and use vaping products. Flavours were cited by young people as the second most common reason (after curiosity) encouraging them to try vaping in a number of papers^[3].
• A systematic review on youth use of e-liquid flavours (2022) concluded that young people found enjoyment in experimenting with new flavours and preferred to switch between different flavours rather than sticking to a single one. A more recent Scottish focus group study (2023) concurs that the variety of flavours available plays an important role in attracting the youths.
• A systematic review on youth use of e-liquid flavours (2022) concluded that the sensory appeal of vaping flavours may extend beyond taste and include additional aesthetic elements, such as distinct flavour names and descriptions, packaging colours and designs.

Packaging

The sources examined for this briefing highlight mixed findings on whether young people notice vaping products’ packaging, with the most recent evidence revealing that youths feel constantly exposed to bright and colourful packaging, would find plain packaging unattractive and believe products labelled as “tobacco-free nicotine” to be safer and less addictive.

• There is mixed evidence on the extent to which youths notice vaping products’ packaging. A UK qualitative study on e-cigarette emergence and the potential for renormalisation of smoking (2020), and a GB mixed-method study on young people’s use of e-cigarettes (2020) concluded that adolescents were not always exposed, hence influenced by packaging. This was because vaping devices were often passed between peers in social gatherings or obtained through informal supply chains. However, a more recent qualitative study by Cancer Research UK (2023) reported that youths noted the high visibility of e-cigarette packaging throughout daily life (e.g. in shops, schools, online and as litter on the street) and were able to name different brands. Participants also mentioned their attraction to the brightly coloured packaging, which was often positioned in contrast with the regulated, plain packaging and limited visibility of conventional cigarettes.
• Findings from an international randomised online experiment (2023) and a GB experimental study (2023) revealed that plain packaging might diminish the appeal of vaping products. The international randomised online experiment further suggested that plain packaging might be associated with higher health risk perceptions. A qualitative study by Cancer Research UK (2023) also found that plain packaging was perceived as particularly unattractive, while brightly coloured packaging contributed to youth perception that vaping products were less harmful than conventional cigarettes.
• A US experimental study on vaping products and labelling (2023), found that labels’ wording can cause confusion on health harms of vaping. The authors reported that youth exposed to flavoured disposable nicotine vaping products labelled as “tobacco-free nicotine” was more likely to believe that the devices did not contain nicotine, and were less addictive and safer compared to products with “nicotine” or “nicotine from tobacco” labels.

Accessibility

The sources examined for this briefing suggest that young people find vaping attractive as vaping products are relatively cheap, especially when compared to tobacco products, and easy to obtain.

• A meta-ethnography on young adults’ e-cigarette perceptions and experiences of e-cigarette use (2021) and the Surgeon General Report (2016) concluded that young people perceived vaping products as cheap, particularly in relation to conventional cigarettes. Two more recent primary studies, a qualitative study conducted by Cancer Research UK (2023) and a Scottish focus group study (2023), also found that low price of vaping products was part of their appeal, especially with regard to disposables.
• A number of meta-ethnographies/systematic reviews and primary studies reported that young people found vaping products easy to obtain, both online and in physical stores (from retailers who would sell to underage customers) and/or through proxies such as family members, friends or strangers^[4].

Risk perception

Systematic reviews and meta-analyses examined for this briefing reveal how young people’s risk perception of vaping is influenced by beliefs in absolute harm (e.g. long-term harms), addictive nature of vaping products, relative harm compared to conventional cigarettes; and by the warning labels on packaging. More details on each of these aspects are presented below.

Absolute harm

The sources examined for this briefing suggest that there are diverse perceptions on the absolute harm of vaping coming from mixed and false information. Young people are concerned about the unknown long-term risks of vaping and second-hand vapour/aerosol (SHV/A), and believe that flavoured vaping products are less harmful than unflavoured or tobacco-flavoured ones.

• A systematic review on adolescents’ health perceptions of e-cigarettes (2021) and two meta-ethnographies on emerging norms of e-cigarette use among adolescents (2021) and on young adults’ e-cigarette perceptions and experiences of e-cigarette use (2021) revealed mixed perceptions regarding the absolute harm of vaping. Some young people expressed concerns about the safety of vaping products, citing unknown long-term risks, harmful chemicals and addiction potential, while others believed vaping posed no health harms^[5]. These contrasting views derived from mixed messages from online sources and from what was perceived as a lack of research and a lack of consensus within public health (i.e. sometimes promoting vaping as a cessation tool). The systematic review and the meta-ethnography on emerging norms of e-cigarette use among adolescents also found that some young people reported using e-cigarettes only under the assumption of safety and expressed willingness to quit if they learned that vaping posed health harms.
• Several systematic reviews and primary studies concluded that adolescents generally perceived flavoured vaping products as less harmful than unflavoured or tobacco-flavoured vaping products^[6].
• A systematic review on adolescents’ health perceptions of e-cigarettes (2021) and a meta-ethnography on emerging norms of e-cigarette use among adolescents (2021) found that many young people expressed concerns about the unknown harms of SHV/A, while others simply considered SHV/A as “water vapour” or “flavoured smoke”.
• Many of the reviewed sources highlighted differences in perceptions of absolute harm by vape user status, with those who vaped more likely than those who did not vape to perceive vaping in general^[7], flavoured vaping products and SHV/A^[8] as less harmful.

Relative harm to conventional cigarettes

The sources examined for this briefing suggest that overall vaping is perceived as less harmful than smoking, mostly as a result of young people’s beliefs in lower addictiveness of vaping products, absence of harmful chemicals in the e-liquids and reduced health risks from SHV/A compared to second-hand smoke.

• Two meta-ethnographies on emerging norms of e-cigarette use among adolescent (2021) and on young adults’ e-cigarette perceptions and experiences (2021), a systematic review on adolescents’ health perceptions of e-cigarettes (2021) and the Surgeon General Report (2016) concluded that young people generally regarded vaping products as less harmful than conventional cigarettes. However, the ASH youth vaping report (2023) found that since 2013, the number of young people across Great Britain considering vaping as less harmful than smoking has been gradually decreasing, while the number of those considering vaping as more harmful than smoking has been increasing. Based on these findings and given the upward trend in vaping prevalence in Great Britain, ASH suggested that perceptions of harm may not influence uptake. Some of the reviewed sources also identified a relationship between relative harm perceptions and user status, reporting that current users and dual users were more likely to perceive vapes as less harmful compared to non-users^[9].
• A systematic review on adolescents’ health perceptions of e-cigarettes (2021), a systematic review and meta-analysis on youth risk perceptions of e-cigarettes (2022), and two meta-ethnographies on emerging norms of e-cigarette use among adolescents (2021) and on young adults’ e-cigarette perceptions and experiences of e-cigarette use (2021) collectively revealed that reduced perception of relative harm was linked to the lack of combustion in vaping products and to misbeliefs in the lower addictiveness of tobacco-free nicotine, absence of harmful chemicals and reduced health risks from SHV/A. These beliefs stemmed from misinformation from advertising and marketing (particularly from social media), and lack of critical thinking at a young age. Additional studies reviewed for this briefing confirmed these misconceptions in young people deriving from a lack of clear messaging on vaping^[10].

Addiction

The sources examined for this briefing suggest that there are mixed perceptions around the addictiveness of vaping, with a general perception that it is less addictive than tobacco smoking. At the same time, the sources indicate how the majority of young vapers consider themselves addicted or describe their urge to vape as moderate to strong.

• A systematic review on adolescents’ health perceptions of e-cigarettes (2021) and a meta-ethnography on emerging norms of e-cigarette use among adolescents (2021) agreed that there are mixed perceptions on the addictive quality of vaping products. While most young people saw vaping products as somewhat addictive, there was an overall generalised perception that they were less addictive than tobacco cigarettes. The authors of the meta-ethnography considered this to be a result of misconceptions around the nature and risks of addiction coupled with contrasting public health and commercial messaging, or lack of official advice. A more recent US experimental study on labelling and misperceptions (2023) also found that two fifths of youth in the sample believed that flavoured disposable nicotine vaping products labelled as “tobacco-free nicotine” were less addictive than products labelled as “nicotine from tobacco”.
• The systematic review also highlighted how a significant proportion of e-cigarette users believed they would not become addicted to e-cigarettes and that it would be easy to quit if they chose to. These findings are confirmed by an additional US study (2021) reviewed for this briefing which concluded that over half of teenagers were optimistically biased about their individual ability to quit vaping.
• A systematic review and meta-analysis on adolescents and youth risk perceptions of e-cigarettes (2022) found that ever users were more likely than non-users to perceive e-cigarettes as less addictive than tobacco cigarettes.
• The King's College London Vaping in England evidence review (2022), a study on adolescents’ experiences of vaping (2021) and the ASH SmokeFree GB Youth survey (2023) highlighted how the majority of young vapers considered themselves addicted or described their urge to vape as moderate to strong. Two US studies on vaping among teens (2021) and adolescents’ experiences of vaping (2021) also reported how participants said they experienced an unanticipated addiction. Additionally, a meta-ethnography on young adults’ perceptions and experiences of e-cigarette use (2021) found that the lack of natural “end point” of vaping products (compared to conventional cigarettes which burn to their end) led users to feel they were excessively consuming nicotine, due to the inability to quantify consumption and psychological addiction.

The role of warning labels on packaging

The evidence on the role played by warning labels on packaging is mixed with a systematic review concluding that warning labels are associated with increased harm perception among youth, but more recent primary studies suggesting that warning labels are not effective at influencing risk perceptions.

• A systematic review on the effectiveness of vaping regulatory strategies (2024) concluded that warning labels were associated with increased harm perception among youths, hence decreased intention to initiate vaping.
• A recent primary study on responses to textual warning labels on e-cigarette advertisements (2024) concluded that warning messages are ineffective at influencing youth risk perceptions or willingness to use/quit e-cigarettes. Additionally, the Cancer Research UK report (2023) shows how participants in the focus groups claimed not to pay attention to warning labels (despite noticing their presence) and were cynical about manufacturers’ reasons for including them (i.e. to protect themselves rather than the user).

Acceptability

Systematic reviews and meta-ethnographies examined for this briefing suggest that youth acceptability of vaping is linked to its normalisation (e.g. due to its popularity), its perception as a social activity and use of vaping products as a stress-management tool. Many young people approve of vaping products as cessation tools but they also recognise the environmental impact of plastic/batteries they contain. More details on each of these aspects are presented below.

Normalisation

No systematic reviews/meta-ethnographies existed on this theme. The primary research sources examined suggest that the normalisation of vaping is linked to its popularity, high exposure to packaging and lack of restrictions on vaping locations. A potential association between familial/peer behaviours and normative beliefs, and vaping has also been identified.

• A qualitative study by Cancer Research UK (2023) found that youths perceive vaping as more normalised than tobacco smoking due to the popularity of e-cigarettes, increased exposure to e-cigarette packaging and fewer restrictions on vaping locations (especially when compared to stricter regulations on conventional cigarette displays and smoke-free spaces). This study, together with research on adolescent use and perceptions of vaping products (2021) and on vaping among teens (2021), revealed a widespread perception of high vaping prevalence, which further contributed towards perceived indirect peer pressure to partake in vaping.
• Three primary studies suggest a potential positive association between familial and peer behaviours, normative beliefs, and the use and perceptions of vaping products among youth. A primary study on home e-cigarette rules and youth behaviours (2022) concluded that strict home rules were significantly associated with young people’s perceptions of parental disapproval and higher perceptions of harmfulness. A Canadian qualitative study (2023) also found that participants who vaped held approving behavioural and normative beliefs on vaping, including that it makes you look cool and is endorsed by peers. On the other hand, participants who didn’t vape reported being influenced in that by disapproval from their familial and social networks. Finally, a US qualitative study on regular e-cigarette users’ behaviours, attitudes and familial norms (2019) revealed how many participants reported that their family members knew they were e-cigarette users and received implicit and explicit messages with neutral or positive attitudes (which may have encouraged initiation and continued use according to the researchers).

Social acceptability

The sources examined for this briefing suggest that young people deem newer models of vaping products more socially acceptable than older models. Young people also think that vaping products are bad for the environment as they are non-recyclable.

• Several papers identified a hierarchy of vaping and smoking products among the youth. A meta-ethnography on young adults’ perceptions and experiences of e-cigarette use (2021) and a Scottish focus group study on youth’s engagement and perceptions of disposable e-cigarettes (2023) agreed that young people deemed smaller and newer models (e.g. disposables) as more socially acceptable than older and larger models (seen as bulky and ostentatious), or conventional cigarettes. A US focus group study (2021) also found that young people had distinct understandings of vapes, e-cigarettes and cigarettes, where vapes were positively associated with smaller models, fun flavours, young people, school environment, social activity and social popularity; e-cigarettes were understood as the older versions of these models, used by older people and for smoking cessation^[11]; and conventional cigarettes were negatively associated with health harms, bad smell, second-hand smoke and old people. Similarly, the young people participating in a UK qualitative study (2020) widely rejected the term “e-cigarette” in favour of “vape”, given its association with older models designed to mimic the appearance of conventional cigarettes.
• Two meta-ethnographies on emerging norms of e-cigarette use among adolescents (2021) and on young adults’ e-cigarette perceptions and experiences (2021) concluded that youth perceptions of vapes often varied by user status. The researchers found that vapers were more likely to have positive perceptions of vaping as “cool”, “fun” and “fashionable”, whereas non-vapers were more likely to have negative perceptions of vaping as “uncool”, a “fad” or a passing “trend”, and saw their peer vapers as “wannabe” or “embarrassing”. Non-vaping youths in a US focus group study (2021) also criticised their peer vapers, claiming they thought they were “invincible” and not subject to potential harms. Several studies^[12] agreed that the perceived “coolness” of vaping was associated to the experimentation with different flavours and vapour clouds/tricks (often shared on social media), and that many young people saw vaping as a social activity to “fit in” with friends.
• A UK qualitative study on e-cigarette emergence and the potential for renormalisation of smoking (2020) and a GB mixed-method study on young people’s use of e-cigarettes (2020) found that, irrespective of user status, adolescents approved of vaping when used socially, but disapproved of regular use.
• A meta-ethnography on emerging norms of e-cigarette use among adolescents (2021) found that discreetly purchasing vapes in shops and online was seen as a transgressive behaviour to test and push boundaries.
• A meta-ethnography on young adults’ perceptions and experiences of e-cigarette use (2021) found that young people had a perceived conscientiousness when vaping as they believed SHV/A was better for the environment compared to tobacco smoke. However, two more recent primary studies on youth’s engagement and perceptions of disposable e-cigarettes (2023) and on factors influencing decision- making in both youth who vape and don’t vape (2023) also concluded that young people understood vaping products as bad for the environment, due to the waste (i.e. batteries and plastic) they generate.

Cessation

The evidence examined for this briefing suggests that young people approve of vaping products when used for cessation purposes and believe they are effective smoking cessation tools.

• A meta-ethnography on young adults’ e-cigarette perceptions and experiences (2021) and the Nicotine vaping in England report (2022) found that young people perceived vaping products as effective cessation tools. The findings from the meta-ethnography also reflect the conclusion of a meta-ethnography on emerging norms of e-cigarette use among adolescents (2021) that young people approved of vapes when used for cessation purposes, but not when used without a history of smoking. Furthermore, the meta-ethnographies revealed that approval of vaping products as cessation tools from authoritative figures, such as parents, contributed to a reduced perception of relative harm and to the normalisation of vaping.

Stress relief

The evidence examined for this briefing suggests that adolescent vapers perceive vaping products as an effective tool for managing stress and anxiety.

• A systematic review on adolescents’ health perceptions of e-cigarettes (2021) and primary studies reviewed for this briefing revealed that many youths perceived vaping as a coping mechanism to manage stress and anxiety^[13].