Young adults and e-cigarettes: a qualitative exploration of awareness, experience and attitudes

10 Knowledge and information

10.1 Chapter 4 of this report looked at young adults' general awareness of e-cigarettes. This chapter explores in more detail what young adults know about e-cigarettes, what they would like to know, the information sources they are using and their views on those sources. The first part of the chapter focuses on knowledge, while the second part focuses on information sources.

What young adults know about e-cigarettes

10.2 The research explored what young adults know about (i) e-cigarettes and how they work, and (ii) e-liquids and their ingredients. The comments from participants indicated varying levels of knowledge and understanding, both within and across groups. The most knowledgeable young adults - perhaps not surprisingly - were regular vapers; however, the research also included regular vapers who said they knew 'nothing, literally nothing' about how e-cigarettes worked, and non-vapers who demonstrated at least a basic level of knowledge about e-cigarettes and e-liquids. Knowledge levels appeared to be lowest among non-smokers, who were also least likely to use or have ever tried an e-cigarette.

10.3 All the research groups included participants with some basic knowledge about e-cigarettes and liquids. These participants had a general understanding that e-cigarettes were battery powered, and worked by applying heat to a liquid to create 'steam' or 'vapour', and that newer e-cigarette devices (mods) incorporated additional functionality. It was also commonly understood that e-liquids contained 'oils', nicotine (participants often knew that liquids containing different levels of nicotine were available), water and flavourings, and that they did not contain tar. Younger participants, in particular, speculated as to the extent to which e-cigarettes contained unspecified 'chemicals' or other ingredients.

10.4 The most knowledgeable participants (all of whom were regular e-cigarette users) talked at length about how e-cigarettes worked and what e-liquids contained. Some were comfortable with terms such as VG (vegetable glycerine) and PG (propylene glycol), wattage and voltage, and had a sophisticated understanding of the more advanced types of e-cigarette devices and the effects of varying the proportions of PG and VG in their e-liquids. Some in this group were building their own e-cigarettes and buying ingredients and creating their own liquids. Some had spent time seeking out information on e-cigarettes (see paragraph 10.10), and others explained how their own scientific or technical education helped with their understanding of e-cigarettes. It was, however, clear that this level of knowledge was exceptional, and that not everyone who vaped was familiar with - or interested in - the technical detail recounted by these participants.

What young adults would like to know about e-cigarettes

10.5 When asked what they would like to know about e-cigarettes, smokers and vapers were largely in agreement about wanting more information about two related issues:

• The ingredients of e-liquids
• The health effects of using e-cigarettes - particularly the long-term health effects, and the relative effects compared to tobacco cigarettes.

10.6 Regarding health effects, some vapers and smokers drew comparisons with the wide availability of information on cigarettes. They commented that information was routinely available on cigarette packs about contents and health risks; others noted health education provided in schools as a source of information on smoking.

10.7 Less often, vapers also suggested that they would like more practical information on how e-cigarettes worked, the different options available to them, and how they should be used. Discussion in groups involving vapers indicated that the absence of easily accessible information on using e-cigarettes was an issue that others had also encountered, particularly when they had first taken up vaping:

'It's not very easy to find information if you don't know anything about vaping. If you type in [an internet search] "What is vaping?", like, you find, like, "This is this type", like, mechanical mods, and you're, like, "Whoa, I don't understand anything!" It's too much information at the start. No-one gives like a short explanation of everything. It's very hard to understand all the types of devices, all the liquids, what's inside the liquids, it's too much information for people.' ( FG3, Male, vaping group, aged 18-23, in higher / further education)

10.8 However, not all e-cigarette users expressed interest in getting more information. Some were happy with the information they had or indicated that they preferred not knowing what was in their e-cigarettes.

10.9 Non-smokers and non-vapers in general had less interest in getting more information about e-cigarettes.

Steps taken to improve their knowledge of e-cigarettes

10.10 Some vapers had actively sought to improve their knowledge about e-cigarettes and e-liquids. This included carrying out internet searches, visiting vaping chat rooms and websites, and requesting information in shops and from suppliers of e-liquids. Some reported that they had carried out some research before making their first purchase, or because they wanted to improve their knowledge as they became more interested in vaping as an 'activity'. One vaper explained as follows:

'I remember when I was starting getting into it, I basically was just, like, I want to know a general amount of information before I go to the vape shop and start buying expensive liquids, so I went on a website. They basically just said this is the difference between this and this, and actually taught me quite a lot.' ( FG6, Male, aged 16-19, vaping group, in employment )

10.11 This, however, was not the case for all e-cigarette users: one admitted to 'never having looked into it', and another said, 'It's terrible we are smoking these things and we don't know what they are'.

Information sources

10.12 The research explored where the young adults in the research had got their information about e-cigarettes. It was clear that informal sources of information were important to participants who often mentioned learning about e-cigarettes from family and friends who already used them or via word-of-mouth. More formal sources mentioned most frequently by participants included: retailers and producers, the internet, social media, and, very occasionally, health agencies and professionals. Participants offered mixed experiences and views on each of these sources.

Retailers and suppliers

10.13 Participants had used both high street and online retailers as sources of information and reported a variety of experiences, both positive and negative:

'People in the shops don't really have a clue what they are. They are just selling them. Anything I ask them, like, what's different with that one, they don't have a clue.' ( FG2, Male, smoking group, aged 16-21, in further education)

'I trust the people in the shops to be honest. I like to speak to people face to face. If I've got any questions I'll ask them.' ( FG6, Female, vaping group, aged 16-21, in employment)

10.14 Participants were, however, keen to distinguish between specialist and non-specialist shops and websites as reliable sources of information:

'I'd go to a specialist store, I'd assume they'd all have to know what they're talking about when it comes to certain products and stuff, so that's probably your best bet.' ( FG7, Male, vaping group, aged 19-25, unemployed)

10.15 Others were generally sceptical about retailers and suppliers as sources of information because, as one participant put it, 'they are trying to sell you a product'.

10.16 Those who had used vaping shops as a source of information also referred to picking up product leaflets as well as consulting with staff.

The internet and social media

10.17 It was common for participants to report that they had used the internet to find information about e-cigarettes - through social media sites such as Facebook and YouTube and internet searches. However, they frequently, questioned the reliability of the internet as an information source. One said, 'There's a lot of misinformation about [e-cigarettes] online, so I'm not really sure what's right and what's wrong'; another said the internet 'was so full of garbage, that you don't know what to trust'.

10.18 Those who reported the greatest level of satisfaction with using the internet to access information were often more experienced vapers. They referred to researching products, reading reviews and reports online, and some said they had accessed academic research papers. They also referred to vaping forums and websites.

Health agencies and professionals

10.19 Occasionally, participants said that they had got information from health professionals or agencies in a range of different contexts which had included:

• Talking to family or acquaintances who worked as health professionals
• Being advised to try e-cigarettes by a doctor as a smoking cessation method
• Receiving information when being treated for an e-cigarette related injury
• Consulting NHS websites.

10.20 Although some saw medical professionals and health websites as trustworthy sources of information, participants were more often doubtful about how much doctors would know about e-cigarettes. Other participants did not regard health professionals as a potential source of information because they did not a have a particularly positive or ongoing relationship with their doctor, or because it was simply not convenient or 'too much effort' to visit a doctor.

Trustworthy sources of information

10.21 When asked directly about the information sources they would trust, participants offered a range of suggestions. These included:

• Doctors and scientists (including those with a media presence)
• Public sector organisations, such as the NHS, Health Scotland and 'the government'.

10.22 Less common suggestions included:

• Third sector organisations such as Chest, Heart and Stroke Scotland
• Published studies and research by 'respected' organisations - the World Health Organisation was a specific example put forward.

10.23 Despite the misgivings frequently expressed, some participants also saw e-cigarette producers, shops, and websites as potentially trustworthy sources of information. Participants often stressed that they would look to 'legitimate' sites, but were not always clear about how they would identify such sites.

Overall views on available information

10.24 With the exception of those regular vapers who were confident about the knowledge they had about e-cigarettes, participants generally expressed a dissatisfaction or frustration with information available on e-cigarettes. Two participants commented as follows:

'The government doesn't even know what's in it, so how are we meant to know.' ( FG4, Female, smoking group, aged 16-19, unemployed)

'It would seem that it would be safer because of what it is, but at the same time, you don't actually know because there's not been any proper testing on it, so you don't really know, you're just kind of going off of what people are saying essentially.' ( FG12, Male, non-smoking group, aged 19-25, in employment)

10.25 Comments such as these were not untypical and suggest that young adults would welcome accessible, reliable and evidence-based information provided by credible sources.