Vaping among pupils in South African high schools is sky high, say researchers of a study into the use of e-cigarettes, data for which is limited in developing countries.
In the United States, write Sam Filby and Richard van Zyl Smit from the University of Cape Town in The Conversation, e-cigarettes are the most commonly used tobacco product among middle and high school students aged 12 and older, with 5.9% of students reporting use.
They write:
Surveys from Britain indicate that 20.5% of children (aged 11–17) have tried vaping, and that 7.6% of children currently vape. Similar usage rates ranging from 3.3% to 11.8% have been found in south-east Asia. Evidence on vape use among adolescents living in Africa is more scarce.
We are public health researchers who have studied the phenomenon in South Africa. Our latest study, published in The Lancet’s eClinical Medicine, found that vaping among South African pupils is sky high. We surveyed more than 25 000 South African high school students across 52 schools in eight of the country’s nine provinces, and found that 16.8% of the sampled pupils currently use e-cigarettes.
Research has shown conclusively that children should not use these products because of the health risks.
Our findings show that high rates of adolescent vaping are not restricted to high-income countries.
Harmful impact on young minds and bodies
In a 2016 report, the US Surgeon-General called vaping among young people an “urgent public health problem”.
One reason for this is that these products commonly deliver nicotine. Nicotine use during adolescence harms the developing brain, with potential long-term effects on learning, memory and attention.
Nicotine is also an addictive substance. Addictive behaviour in general is associated with the development of mental illness, further fuelling the mental health problems experienced by some adolescents. Substance abuse can lower their inhibitions, leading to increased high-risk behaviours.
Non-nicotine vapes are also bad for health. The chemical composition of specific flavours like cherry, cinnamon and vanilla have also been shown to cause damage to the lung lining and blood vessels.
The rising popularity of e-cigarette use among adolescents globally should make helping young people quit vapes a priority.
Surveying South African schools
We approached schools predominantly in major centres like Cape Town, Johannesburg, Pretoria and Durban. All were “fee-paying” schools. We were not able to include less well-resourced schools without easy internet access, or non-fee-paying schools.
We categorised the schools into three brackets:
• lower-fee schools: annual fees between R20 000 and R40 000;
• medium-fee schools: annual fees between R40 000 and R90 000; and
• high-fee schools: annual fees more than R90 000
Around 17% of pupils in our sample attended lower-fee schools, 64% attended mid-fee schools, and 19% attended high-fee schools. Around 31% attended co-ed schools, 41% attended all-boys’ schools, and 29% attended all-girls’ schools.
Students were asked about their use of four products in the 30 days preceding the survey: e-cigarettes, tobacco cigarettes, cannabis and hookah pipes.
Those who indicated that they currently vaped were asked additional questions about their vaping history and habits. We also asked about their reasons for starting and continuing to vape.
Using this data, we studied e-cigarette use, nicotine dependence, and the mental health and social stressors associated with vaping among a large sample of pupils.
Alarming rates
Our study found that 16.8% of high school pupils we surveyed were currently using e-cigarettes. There were far lower rates of tobacco cigarette use (2%), cannabis use (5%) and hookah pipe use (3%).
The proportion of children reporting e-cigarette use increased by grade: around 9% of grade 8 students reported using vapes, but this rose sharply to an average of 29.5% among grade 12 pupils (who will turn 18 in their final school year). Some schools had usage rates as high as 46% among grade 12 pupils.
Among those who indicated that they vaped, 38% vaped daily, and more than half of those in our sample reported that they vaped four or more days per week.
Around 88% of pupils reported using vapes that contained nicotine. About 47% reported that they vaped within the first hour of waking up – this is highly suggestive of nicotine addiction. We estimate that up to 61% of high school teens who vape could be seriously addicted to nicotine.
Why adolescents start and continue vaping
We found that the primary reasons for starting vaping differed from the main reasons for continuing to vape.
• Just more than half (50.6%) of those who vaped cited social influences (family, friends, peer pressure, the need to fit in) as reasons for starting. Around 20% indicated that they’d started vaping to cope with stress and anxiety, while 16.2% said they had started out of general curiosity.
• Common reasons cited for continuing vape use were to cope with anxiety, depression or stress (28.4%), or because they were addicted (14.9%).
Some explicitly stated addiction in their reasoning:
It’s an addiction, no matter what I try I can’t stop. (female, 17)
Others described it more as a habit:
It has become a habit. I have to consume something constantly. (female, 18)
Less than 10% of students identified social influences as the reason they continued to vape.
Around 46% of students did not list addiction as a reason for continuing to vape, although their reported habits aligned with patterns typically seen in individuals who are highly addicted. This suggests that many pupils in our sample may lack awareness of what constitutes addiction.
What needs to be done
Our research underscores the urgent need for a co-ordinated public health response to address the vaping crisis among high school pupils.
The government must pass the Tobacco Products and Electronic Delivery Systems Control Bill. This legislation will ensure that vapes cannot be sold near schools or online.
The restrictions on the advertising of vaping products provided for in the Bill may aid with this as well as the deglamorisation of vaping among young people – reducing the general curiosity that leads many young people to begin in the first place.
The dangerous myth that “vaping is safe” also needs to be debunked.
Finally, we need to help addicted teenagers to stop vaping. Punishing students for vaping is unlikely to be an effective strategy. Parents must be more aware of the signs of vaping and the underlying issues driving it.
Healthcare professionals should ask young people about their vape use during routine check-ups, and school counsellors should teach coping strategies to help teens navigate life’s challenges.
Sam Filby – Research Officer, Research Unit on the Economics of Excisable Products, University of Cape Town.
Richard van Zyl Smit – Associate Professor and Consultant Pulmonologist , University of Cape Town.
Study details
Electronic cigarette usage amongst high school students in South Africa: a mixed methods approach
Richard van Zyl-Smit, Samantha Filby, Gurveen Soin, Jacqueline Hoare, Asya van den Bosch, Sebastian Kurten.
Published in The Lancet eClinical Medicine in December 2024
Summary
Background
The WHO has highlighted that: “promotion of e-cigarettes has led to marked increases in e-cigarette use by children and adolescents.” The long-term neuropsychiatric and psychological consequences of substance abuse in adolescence is well recognised. Limited data exists on the adolescent burden of vaping-related nicotine addiction and behavioural and/or psychological dependence to guide pharmacological or behavioural interventions to stop electronic cigarette usage.
Methods
A self-administered brief electronic survey was provided to a large, sample of high school students from January to October 2023 in South Africa. Questions on vaping usage, initiation, reasons for continuation and indicators of physical and psychological dependence were asked. A mixed methods approach was used to obtain and analyse quantitative and qualitative responses.
Findings
25,149 students from 52 South Africa schools completed the survey. 45.8% identify as female, 51.7% male, 0.3% transgender, 2.1% do not identify with a gender. Current vaping was reported by 16.83% (95% CI: 16.47–17.30), with 36.71% reporting ever using a vaping product (95% CI: 26.06–37.36). The odds of vaping increased by grade but not with increasing school affluence. 47% vaped within the first hour of waking suggesting high nicotine addiction. Vaping initiation reasons of: ‘social influences’ and ‘curiosity’, changed significantly to ongoing motivations of: ‘enjoyment’, ‘managing mental distress’ and ‘addiction’ to nicotine. Paired quantitative/qualitative responses regarding stress and dependence showed inconsistencies at the individual student level.
Interpretation
Vaping in the schools surveyed was high and increased by grade but was not associated with school level affluence. Drivers for vaping initiation change significantly to persistence drivers with significant nicotine addiction. Adolescent perceptions (qualitative/quantitative) are frequently incongruent suggesting that mixed methods evaluations are required to understand individual level drivers of vaping. Urgent interventions tailored to this population are required. Nicotine addiction may require “off-label” pharmacotherapies alongside tailored behavioural interventions utilising the expressed concerns, psychological and dependence measures elicited from adolescents.
See more from MedicalBrief archives:
SA study finds high school vaping ‘off the charts’
Vaping among teens at SA’s affluent schools ‘a significant problem’
Researchers expose the ‘pitiful quality’ of highly cited vaping studies
What proposed Tobacco Bill means for vaping in South Africa
Vaping scourge among children prompts long-term health effects study