E-cigarette use among young people in Ireland has risen dramatically and now stands at 37% ever-use and 17.3% current use (used in last 30 days). Initially, this rise occurred in tandem with a continuing trend of decreasing smoking prevalence, but latest figures for smoking in Ireland show that this decline in smoking has halted overall and, among boys, smoking has risen from 13% in 2015 (Taylor et al. 2016) to 16% in 2019 (Sunday et al. 2020). Boys are also more likely than girls to use e-cigarettes. Smoking combustible cigarettes and using e-cigarettes are risk activities that are closely aligned. Respondents in our survey who smoked were much more likely to use e-cigarettes. The apparent reversal in smoking prevalence, together with the great increase in prevalence of e-cigarette use, has implications for tobacco control policies, including, in particular, health education, regulation, and cessation services for young people (Hanafin and Clancy 2019).
Socio-demographic influences: age, gender, social class, and household composition
E-cigarette use, like smoking, is a gendered activity. Boys are now more likely to be at risk of both smoking and of e-cigarette use, and gender remains a predictor when covariates have been adjusted for. Smoking is well-established as a classed activity, but findings about e-cigarettes and social class have been ambivalent (Kapan et al. 2020). Recent Irish research found that, in a sample in which smoking was patterned by social class, e-cigarette use (ever- or current) was not (Költő et al. 2020). The prevailing consensus in the sociology of health is that higher socioeconomic status (SES) lowers illness risk (Martin 2019). Therefore, better-off families and having higher-educated parents might be expected to be protective variables but, as with other studies (Kapan et al. 2020), our findings about social class and e-cigarette use are inconsistent. When covariates were adjusted for, perceiving that one’s family was better off considerably reduced the odds of current e-cigarette use but having parents who were college/university educated increased the odds. This suggests some differences in young people’s views and motivations with regard to e-cigarettes compared with combustible cigarettes, as the association between smoking and lower socio-economic status is well-established. The association between SES and use of other addictive substances is also ambivalent. For example, young adults with the highest family background SES have been found to be most prone to alcohol and marijuana use, even after controlling for covariates (Patrick et al. 2012). They are also more likely to use other drugs, and to use alcohol and other substances to cope with stress (Martin 2019). Our findings may indicate that e-cigarette use has more in common with alcohol and other drug use than it has with smoking. Familial support was negatively associated with current use (AOR = 0.78, 95% CI: 0.64–0.95, p = .015) suggesting that, as familial support increases, the odds of being an e-cigarette current user decrease.
Polysubstance use is highly prevalent among adolescents who use e-cigarettes (Gilbert et al. 2020) and, in our study, the strongest associations with e-cigarette use were found to be with other substance use. Current use of e-cigarettes was strongly associated with current smoking and current cannabis problem use, and to a lesser extent, current heavy episodic (‘binge’) drinking.
Our initial descriptive analyses suggested that particular individual behaviours were associated with either lower e-cigarette use (being active in sports, reading books for enjoyment, having hobbies such as art and music) or more e-cigarette use (truancy, early tobacco or alcohol initiation (aged 13 years or younger), using alcohol to get high, problem or compulsive internet/social media/gambling behaviours). When we adjusted for covariates, most of the individual behaviour variables were not significantly associated, but early smoking initiation remained associated with e-cigarette current use. Actively participating in sport showed a 2.2 increased odds of e-cigarette current use pointing again to differences in how adolescents view e-cigarettes compared with combustible cigarettes, perhaps considering them a “healthier” substance.
Adolescents are more likely to engage in risky behaviors in the presence of peers (Gardner and Steinberg 2005; Chein et al. 2011). In our study, we report very strong correlations between all peer substance use and e-cigarette current use. However, we observe that once covariates are adjusted for, peer risk activities are largely not predictive of e-cigarette current use, with the single exception of having peers who “get drunk”.
E-cigarette users in our survey were more likely to be current users of combustible cigarettes, to have increased odds of problem cannabis use and ‘binge’ drinking, perhaps indicating problems with substance dependency and they may, therefore, have difficulty quitting e-cigarettes (Wills et al. 2017).
We agree with others (Gilbert et al. 2020) that e-cigarette screening should include the assessment of other substances, with a view to identifying and implementing prevention efforts and improving population health.
Regulation of tobacco products
Smoking prevalence in Irish teens and adults declined significantly during the period 1995 to 2015, and Ireland’s very progressive tobacco control policies and legislation have been shown to account for a great deal of this decline (Li et al. 2018, 2020). A study estimating the impact of individual policies implemented between 1995 and 2015 on reduction of smoking prevalence in teenagers in Ireland (Li et al. 2020) examined seven tobacco control interventions: price, Smokefree legislation, health warning on packages, advertising ban, availability of cessation treatment, youth access, and mass media campaigns. For both male and female adolescents, real price increases and legislation banning smoking in workplaces were significantly associated with reductions in smoking.
Implications for regulation of e-cigarettes
Lack of full knowledge of the harms of e-cigarettes and also their potential role in smoking cessation in adults causes hesitancy in introducing regulations. Messaging might need to be more nuanced in terms of smoking cessation in adults, where e-cigarettes may have a role.
Further regulation of e-cigarettes is urgently required in Ireland in order to reduce e-cigarette use among young people and prevent the re-normalisation of tobacco products use in Irish society. The extension of existing regulation and legislation would be an expeditious approach, and there is a convincing argument for a re-framing of the paradigm about e-cigarettes. Re-framed as new tobacco products, they lend themselves to being regulated as are combustible cigarettes. Existing harm-reduction arguments in relation to e-cigarettes only have currency in relation to adult users, but they probably have none in relation to children. Indeed, e-cigarettes may come to represent another twist in the ‘safer cigarettes’ discourses that have been used by the tobacco industry for many decades (Hanafin and Clancy 2015).
If the effects of Tobacco Control interventions on e-cigarettes in young people mirrored effects on smoking, the greatest efficacy might be expected from price and taxation policies, and extension of Smokefree legislation to include use of e-cigarettes (Li et al. 2020). Price has been identified as a motivator for reduced e-cigarette use among young people (Pesko et al. 2018), with higher prices associated with reduced e-cigarette use among adolescents in the US. Current regulation of e-cigarettes in Ireland is largely confined to compliance with the EC Tobacco Products Directive 2014/40/EU (TPD) (European Parliament and Council 2014). An extension of the existing Irish Smokefree legislation to include e-cigarettes would mean that e-cigarettes would be prohibited in workplaces, enclosed public places, restaurants, bars, education facilities, healthcare facilities, and public transport. Proposed new tobacco control legislation policies by the Irish government, to include age restriction for e-cigarette purchase to over-18s, may have an impact on e-cigarette use among students, as support for tobacco control, including non-combustible products, is high (Wipfli et al. 2020).
Implications for health education and cessation
Future research surveys in adolescents should include intention and readiness to quit e-cigarettes. Health education may have a role in encouraging cessation as there is evidence from adults that learning about nicotine risk through fact sheets may lead to being motivated to re-evaluate the risks of e-cigarettes (Yang et al. 2020).
Perceiving slight or moderate risk in using e-cigarettes appears to be protective against current use, also suggesting a role for health education by providing clear, focused, up-to-date information for adolescents about the risks of e-cigarette use. It would seem that efforts could be stepped up in the junior cycle of post-primary schooling to develop health education curricula that are appropriate in terms of content, pedagogy, resources, and evaluation (Hanafin and Clancy 2019, Hanafin, Clancy, the SILNE R Partners 2020).