Participant Characteristics
Similar numbers of children were recruited from each year group: aged 6-7 years (33.3%); 8-9 (37.4%) and 10-11 (29.3%) and 27.8% reported that they spoke the Welsh language at home. Two schools were in urban areas, 5 were rural and 1 semi-rural. Two schools were in the most deprived and 2 schools in least deprived deprivation category (44) (Table 1).
Table 1 here
Awareness of e-cigarettes
Children across the 3 year groups demonstrated a general awareness of e-cigarettes. The vast majority (94.9%) could distinguish pictures of e-cigarettes from tobacco cigarettes in the questionnaire (year 2, 89%; year 4, 96.7%; year 6, 100%: p<0.001). Most thought electronic and tobacco cigarettes looked different from each other (93.3%) and that the internal components were different (82.5%). Around half reported they smell different (51.1%) and the smoke was different (48.0%) (Table 2).
Table 2 here
Awareness of e-cigarettes was evident in the peer discussions as well. Children across all 3 year groups were able to discern the difference between tobacco and e-cigarettes from a series of photograph, discussed them using appropriate terminology such as ‘e-cigarettes’, ‘e-cigs’, ‘electric fags’ and ‘vapes’ and recognised they were different from tobacco cigarettes.
”They look like different from normal fags” (Male, Age 7, School 4)
“They [e-cigarettes] don’t have any tobacco in” (Male, Age 9, School 7)
The youngest children were of the opinion that e-cigarettes were comprised of ‘metal and oil’ or ‘plastic’ and ‘glass’. Some said they contained ‘chemicals’, were reusable and more durable:
“They might be stronger longer and you don’t throw it away.’” (Female, Age 7, School 1)
“I think they’re better for you, you can charge them back up, you don’t have to throw them out and that could start a fire.” (Male, age 7, School 6)
The older children, particularly those exposed to people who vape had a more nuanced understanding of e-cigarettes and were better able to discuss their composition, how they are used and the differing nicotine levels:
“It’s like a vape, you put liquid in them, because my step dad has one, you put liquid in them and then that burns out. It’s got nicotine in it, some of them have” (Male, Age 11, School 4)
“E-cigarettes can have nicotine and also not because my dad is down to zero nicotine now, he doesn’t use nicotine in his vape at all and you can customise the flavour and that, he prefers peach” (Male, Age 11, School 5)
In the questionnaire, a higher proportion of children thought tobacco cigarettes were used more (59.9%) and were easier to purchase (57.8%), than e-cigarettes. 73.7% reported seeing tobacco
cigarettes more often than e-cigarettes (14.5%). Over six in ten (61.8%) also reported that e-cigarettes were safer to use than tobacco cigarettes (Table 2). This was evidenced in the qualitative findings with some of the younger children in particular highlighting that e-cigarettes did not need to be lit and therefore would not be a fire hazard:
“I think the electronic one is more safer than the other [tobacco] one because if we blow it too hard and we drop it and it is still flaming it might cause a forest fire or a house fire” (Male, Age 7, School 3)
“With the other ones [tobacco cigarettes] if you light it and drop it on the carpet it can cause a fire” (Female, Age 9, School 5)
Several of the older children brought up the fact that e-cigarettes can explode ‘in your pocket’ or ‘in your face’ and stressed the importance of getting ‘…a proper one from special shops’ (Female, Age 11, School 6).
Flavours featured widely in children’s views of e-cigarettes. Of the 401 D&W responses that describe what children see and smell when near e-cigarettes, 22.9% (n=94) specifically mentioned ‘sweet, scented smoke’, ‘nice smells’ and fruit flavours (year 2, n=23; year 4, n=24, year 6, n=47) (Table 3).
Table 3 here
In the peer discussions, awareness that e-cigarettes ‘got fruit flavours inside of it’ was commonplace and there was a general consensus across all age groups that sweet and fruit flavoured e-liquids were more likely to appeal to young people and could ‘entice’ and ‘encourage’ them to vape:
“The young ones might be encouraged to use it, the electronic one, because they love fruit and they might not know that it is really unhealthy” (Female, Age 7, School 3)
“I think that the younger people will want to do it because with all the different flavours, they just want to try them” (Female, Age 9, School 1)
“…to encourage younger people like 15 year olds because of the flavours like cherry, chocolate...” (Female, Age 11, School 6)
Interestingly, a couple of the older children also considered the aesthetic appeal of e-liquid flavours: ‘because their breath doesn’t smell’ (Female, Age 11, School 7) and their commercial potential: ‘I think they’re trying to make it more appealing to children by making the like bubble gum flavoured and candy flavoured… so they have more buyers’ (Male, Age 11, School 1).
In peer discussions, many children were aware of a legal age of purchase for tobacco and e-cigarettes, although the majority were unsure of the exact age. Some thought that “anyone over the age of 16” could buy them. Many were uncertain about where to access e-cigarettes as well. Across all year groups, those with relatives who vaped were better able to identify places of purchase including specialist shops, supermarkets and online.
“My dad has these ones [e-cigarettes], you can buy them from shops. (Male, Age 7, School 5)
“You can’t go to the shop, well I dunno, my father buys all of his vape juice online… He gets his all off the internet, he gets them from Amazon because it’s the best price for them.” (Male, Age 11, School 5)
There was some misunderstanding of the legal consequences of purchasing tobacco and e-cigarette underage, with some of the younger children believing that children or their parents could go to prison if they were found to be smoking or vaping.
“They could get in prison” (Male, Age 7, School 4)
“The parents might get in jail because they’re letting their children smoke” (Female, Age 7, School 4)
Some comprehension of addiction and, to a lesser extent the role of nicotine was evident, primarily amongst the older children. Questionnaire responses identified that two-thirds of the children (66.7%) thought it would be hard to stop smoking tobacco cigarettes once started whilst nearly half (46.9%) felt the same for e-cigarettes. There were significant differences in responses across year groups for both tobacco (year 2, 66.5%; year 4, 66.8%; year 6, 68.3%: p<0.001) and electronic cigarettes (year 2, 53.7%; year 4, 48.1%; year 6, 38.0%: p<0.001).
In the D&W exercise, the word addicted was mentioned 103 times, almost exclusively with regard to how tobacco smokers feel and why they smoke tobacco cigarettes. Addiction in relation to tobacco smoking was mentioned in all year 6 peer discussions but rarely with reference to e-cigarettes. Nicotine was also referred to less frequently by the older children when discussing either electronic or tobacco cigarettes. Few of the younger children actually used the terms addiction or nicotine when discussing smoking or vaping but discussions did convey some recognition of the concepts:
“Because when you start it [smoking] it’s like a habit and then you can’t stop” (Female, Age 7, School 7)
“If people still want to smoke…but they know the tobacco is affecting their lungs they just use those [e-cigarettes] cause it’s got the nicotine in” (Female, Age 7, School 6)
“Yeah, but if you smoke and give it up, you’ll feel sick for a couple of weeks, but then you’ll feel better because you’re getting used to no nicotine and you need the nicotine” (Male, Age 7, School 8)
Only a couple of the older children made the connection between nicotine and addiction:
“ They can also be really bad as well because say they had a flavour in them and they had nicotine then because the flavour could be addictive and then there is nicotine in it so could be then it could be the same as a normal cigarette” (Male, age 11, School 5)
Notably a few of the children across the discussion groups knew the amount of nicotine in e-cigarettes was variable and could be altered to aid smoking cessation. Generally these were children exposed to someone who vaped:
“And with them [e-cigarettes]…You can cut down….you can get ones with no nicotine at all”
(Male, Age 9, School 2)
“My father stopped smoking about 3 years ago now, he’s been on vapes since then. He has been lowering the nicotine and he is down to zero now” (Male, Age 11, School 5)
Health harms of e-cigarettes
In general, children in the study had poor understanding of any health harms related to e-cigarettes, often associating vaping and smoking with similar levels and types of harms. D&W responses for perceived health harms (n=385) ranged from considering e-cigarettes to be as bad for health as tobacco cigarettes (n= 17 (4.4%); year 2, n= 4; year 4, n=5; year 6, n=8) and/or causing death (n=14 (3.6%); year 2, n= 6; year 4, n=4; year 6, n=4) to considering e-cigarettes to be healthier and less harmful than tobacco cigarettes (n=28 (7.3%); year 2, n= 10; year 4, n=12; year 6, n=6) or not harmful at all (n=26 (6.8%); year 2, n= 8; year 4, n=12; year 6, n=6). Interestingly, three times as many older rather than younger children stated they did not know any health harms associated with e-cigarettes (n=116 (30.1%); year 2, n= 22; year 4, n=32; year 6, n=62).
Similar misperceptions emerged in the peer discussion groups. Younger children in particular thought e-cigarettes were healthier and less harmful than tobacco cigarettes because they contained fruit flavours:
“It’s strawberry flavoured and strawberries are healthy” (Female, Aged 7, School 1)
“I think the electronic one [is healthier] because it has fruits in” (Female, Aged 7, School 3)
One older child (age 11) felt ‘safer’ breathing in flavoured smoke rather than cigarette smoke, stating that: “I know someone that had one once and it was cherry flavour and every time they puffed it out it smelled really nice so it made me feel a bit better and safer that I’m not breathing in all the bad things” (Girl, Age 11, School 6).
Unsurprisingly, older children had a better grasp of the health consequences of tobacco smoking and whilst many were unsure how e-cigarettes impacted on health, many surmised that they would be better than or different to tobacco cigarettes, mainly because they of their composition:
“There is not tobacco in them so they can’t harm you as much” (Male, Age 11, School 7)
“They are ever so slightly better because they have no tar and stuff” (Male, Age 11, School 6)
“After looking at the fruit flavours, I think you would have different damage to the body because I think tobacco will have more damage to the body like lung cancer” (Male, Age 11, School 3)
There was also some appreciation by older children that potential health harms of e-cigarettes are still unknown and therefore caution is warranted:
“I think people get a bit like ‘Oh I want to try that’ but they don’t actually know the harms they [e-cigarettes] can do to you” (Female, Age 11, School 6)
In about 2 years’ time we could find out that they’re [e- cigarettes] even worse than the other ones but we don’t know yet” (Male, Age 11, School 1)
The notion that e-cigarettes were healthier than tobacco cigarettes prevailed throughout the study although e-cigarettes were still considered to be more harmful than not smoking or vaping at all. Questionnaire results showed that more than half believed that tobacco cigarettes were worse for smoker’s lungs (59.6%) and worse for other people’s lungs (55.4%) compared to e-cigarettes. This increased with age from 46% of children aged 7 years to 72.7% aged 11. More children (74.6%) thought smoking was never a good thing to do as compared to those who thought using an e-cigarette was never a good thing to do (57.5%). Children were less likely to feel that using an e-cigarette was never a good thing to do if they lived with somebody who used them (30.9%) compared to not living with someone using e-cigarettes (65.2% p<0.001) (Table 2). This view also featured in the peer discussions. Whilst children generally did not think it was okay to use e-cigarettes, some felt that people who wanted to be healthy would be more likely use e-cigarettes than smoke tobacco cigarettes.
“Well they don’t damage your lungs like tobacco ones because you don’t have the ash in it” (Male, Age 7, School 5)
“People class them as like a healthier way of using cigarettes, people think they are better but they’re not” (Female, Age 11, School 4)
Motivations for vaping
When asked why people vape, over a quarter of D&W responses (27.6% (n=102); year 2, n= 20; year 4, n=38; year 6, n=44) indicated that e-cigarettes are used primarily to stop smoking tobacco cigarettes (Table 3). Quitting was the main reason given in the peer discussions as well and an awareness of the role e-cigarettes play in smoking cessation was highlight by some:
“If they have the real fags, they are bad and they damage your lungs. If you have them ones [e-cigarettes], they stop them, they stop the real fags and then you won’t smoke them” (Male, Age 7, School 4)
“Because they want to stop smoking. They use it as bit of a jump. That’s what they are intended for I think. They are intended to be a bit of a stepping stone to stopping” (Male, Age 11, School 6)
“People who smoke normal tobacco, they wanted to quit so they started smoking the electronic” (Male, Age 11, School 3)
Notably, children who had family members who vaped or smoked were better able to discuss how using them helped parents and relatives to quit smoking:
“He [dad] has mostly stopped using them [tobacco cigarettes] and just uses those [e- cigarettes]” (Male, Age 7, School 5)
“My step-dad has one, you put liquid in them and then that burns out. It’s got nicotine in it, some of them have” (Male, Age 11, School 4)
Other reasons for using e-cigarettes mentioned in D&W responses (n=370) included: because they were better than smoking (12%; n=44) and because they are healthier than tobacco cigarettes (11%; n=39), because it is enjoyable and fun (11%; n=40), to look cool and popular (10%; n=38) or because their friends do (2%; n=7). In peer discussions some suggested that teenagers use e-cigarettes to look cool and fit in with peer groups, although these social motivations were more widely associated with tobacco cigarettes.
“They [e-cigarettes] look safe and you want it to look cool and you look more cool with them” (Female, Age 9, School 6)
Future Intentions to vape
Few children expressed any intention to use e-cigarettes or smoke tobacco cigarettes when older (Table 2). Of the minority reporting future intentions, slightly more thought they would vape (3.9%) rather than smoke (1.8%). Intention to smoke was significantly more likely if the child lived with someone who smoked (p=0.02), and intention to vape was significantly more likely if they lived with an e-cigarette user (p<0.001) (Table 2). ). Older children were significantly less likely to say they would vape when older (age 10-11, 1.4%) than younger children (age 6-7, 6.7%) (p<0.001).
Almost all peer discussion participants were adamant that they would not smoke tobacco or use e-cigarettes in the future, primarily over concerns about the health consequences:
“I don’t want to breathe a drug into my body” (Female, Age 11, School 1)
“Because we know the harms and everything it can do, so we don’t want it doing it to our bodies – so we won’t do it” (Female, Age 11, School Powys)
A very small minority of children intimated they might experiment with vaping when older:
“If I like it or don’t like, I’m going to try it [e-cigarettes] once” (Male, Age 9, School 8)
“Because I want to taste them” [e-cigarettes] (Female, Age 9, School 6)
“If you had to smoke I would go for the vaporiser” (Male, Age 11, School 6)
Acceptability of vaping and smoking
In the questionnaire, almost half of the children reported it was okay for grown-ups to use e-cigarettes (49.6%) or tobacco cigarettes (46.2%). Results were age related, with acceptability decreasing with age for both tobacco smoking in adults (p<0.001) and vaping in adults (p=0.024). Acceptability in adults was influenced by exposure to e-cigarettes in the home. Over a fifth (22.4%) indicated that somebody who lives in their household uses e-cigarettes and 32.3% had somebody in their household who smoked tobacco (Table 2). Children who lived with an e-cigarette user were more likely to report that it was ok for grown-ups to use e-cigarettes (63.0%), compared with of those who did not live with someone who used e-cigarettes (45.5%) (p=0.03) (Table 2).
Subtle familial influences were noted in peer discussion data. Findings suggest that children who had family members that were e-cigarette users or smokers were much more knowledgeable about the products and could discuss how they were used and where they could be purchased. These children were also able to comment more broadly on the variety of fruit flavoured liquids available and the use of e-cigarettes to stop smoking. Some understanding of role modelling was evident as well:
“Also because sometimes if your mum or dad smokes they influence you because you’re trying to be like your mum or dad or grownups- so if you see somebody who inspires you smoking you kind of want to do that (Male, Age 9, School 8)
Acceptability of e-cigarette use in children was very low. Six (1.2%) participants thought it was okay for children their age to use e-cigarettes and only 1 (0.2%) to smoke tobacco cigarettes. There were no significant differences in acceptability of e-cigarette use by gender or age. It was also low for children who lived with e-cigarette users (1.8%) and those not living with e-cigarette users (1.0%) but this difference was statistically significant (p=0.005) (Table 2).
Many of the children in peer discussions thought it was more acceptable for adults to use electronic and tobacco cigarettes than children because of the legal age restriction. Furthermore, there was a perception that adults were better able to make decisions about behaviours that had potential risk. Some children suggested that the smoke from tobacco cigarettes was more harmful to children’s bodies because they were still developing:
“[Older people] they will be older then and their lungs won’t be damaged that much [compared to younger people]” (Male, Age 7, School 5)
“Maybe your veins go stronger [when you are older], so maybe your veins can handle it” (Male, Age 9, School 1)