Vaping and smoking in adolescents 14 and under in Aotearoa New Zealand: cross-sectional study of e-screening data

Introduction

Electronic cigarettes (e-cigarettes), a type of electronic nicotine delivery system, have been promoted to assist with smoking cessation. Because e-cigarettes heat liquid containing nicotine and flavourings rather than burn tobacco, users inhale nicotine in a vapour (known as vaping) rather than in smoke. This means that users are not exposed to the same levels of chemicals that can cause diseases in people who smoke conventional cigarettes, and evidence suggests that e-cigarettes can increase smoking quit rates.¹

There has been a striking uptake of vaping in adolescents, calling into question the relationship between vaping and smoking in this demographic. For instance, US data indicate a significant year-on-year increase in vaping from 2017 to 2019, with a concerning increase in youth who are physically addicted to nicotine being noted.² For Aotearoa New Zealand (NZ), data from the Action for Smokefree 2025 (ASH) Year 10 Survey indicate a similar upward trend in vaping indicators from 2014 to 2019 for students aged 14–15 years.³ Students who were Māori, Pacific, gender diverse, or from low-decile and mid-decile schools were more likely to vape or smoke daily, and males were more likely to vape daily but less likely to smoke daily than females. However, the authors note that daily use of vapes was low (3.1%) and lower in non-smokers (0.8%), which combined with observed declines in smoking, suggests vaping may be replacing smoking in adolescents. Conversely, while vaping may assist in smoking cessation in some cases, it has become an activity taken up by non-smoking young people, with evidence that it can paradoxically lead to smoking initiation.⁴

To provide further insight into adolescent vaping and smoking in NZ, we analysed data from YouthCHAT (Youth electronic Case-Finding and Help Assessment Tool), a web-based application developed in NZ to assess lifestyle and mental health issues in young people in primary care settings.^5,6 This is a self-report questionnaire with modules addressing smoking, alcohol and drug use, anxiety, depression, external stressors, abuse, conduct and behavioural disorders, anger control, eating and body image, physical activity, gambling and gaming, and sexual health and identity. Branching logic means that the number of questions in a module may increase depending on positive responses. Where there are positive responses, youth are asked whether this is an issue with which they would like help, either immediately or later (see Supplementary Table S1 for the full list of questions).⁷ Initially YouthCHAT asked young people about smoking or vaping in a single question, but in February 2023, a separate series of questions around vaping, parallel to those about smoking, were introduced, including asking whether they have taken up vaping to quit smoking.

YouthCHAT differs from a conventional research survey in that users are participating in electronic screening (e-screening) by invitation of a health provider, with the understanding that the provider will be reviewing the responses to inform a one-on-one consultation. Moreover, the help-assessment questions on positive screening provide an element of patient-preference/self-direction for the consultation and, in the context of the present study, provide novel data. The aim of this paper is to assess proportions of adolescents who report vaping and/or smoking in this e-screening cohort, with particular attention to patterns in gender and ethnicity, and to provide insights around vaping reason and interest in help with vaping or smoking.

Methods

A counter-balanced randomised trial found that YouthCHAT performed as well as a face-to-face Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety (HEEADSSS) interview to detect psychosocial issues in Year 9 students.⁸ An initial YouthCHAT screen can reduce the time taken to conduct a HEEADSSS (required for all Year 9 students in low-decile secondary schools).⁹ YouthCHAT data can self-populate the MedTech (Practice Management System) advanced HEEADSSS form. Presumably due to these features and results, field use of YouthCHAT is highly concentrated on adolescents aged 14 years and under, consistent with Year 9. The resulting e-screening cohort consists of young people who received care from primary care nurses and doctors in NZ, predominantly at clinics based in low-decile schools and public health services.

Following extensive research projects in a variety of settings, concluding in 2019,^10–12 YouthCHAT is now operated by NZ-based company Kekeno under licence to the University of Auckland. Under this contract, Kekeno provides de-identified data extracts to the University of Auckland named inventors for research purposes.

In 2024, YouthCHAT researchers received a de-identified extract of data from June 2019 to the end of February 2024 containing 11,593 completed YouthCHAT surveys after data cleaning. YouthCHAT questionnaire response data were exported from the SQL Server databases of the operational system, removing personal identifiers, but retaining age, gender, and ethnicity. To form the dataset for analysis, the data were pivoted from long to wide format, yielding a single row per participant with questionnaire responses converted into columns in a Microsoft Excel spreadsheet. Random sampling checks were conducted to ensure data conversion was accurate. Questionnaires with incomplete data were removed, and the dataset limited to questionnaires that included the separate vaping question. Analysis was conducted using Python with open-source libraries (pandas, NumPy, and SciPy).

Responses to ever-smoked and ever-vaped questions were tallied, as were follow-up responses for those who reported ever-smoking or ever-vaping. Ever-smoking and ever-vaping responses were cross-tabulated and tested for independence across the range of options (4 × 3) and for the hypothesis of difference in frequency of ever-smoking and ever-vaping (2 × 2), each by chi-squared (χ²). Sub-totals of combinations of ever-vaped and ever-smoked responses were tallied by gender and ethnicity. Hypotheses of gender and gender-by-ethnicity differences were tested by χ² of independence of variables for females versus males and for Māori and Pacific versus NZ European ethnicity within males and within females for frequency of reporting having ever-vaped and of having vaped but never-smoked. Bonferroni correction for multiple comparisons was applied across the set of gender and gender-by-ethnicity hypotheses by multiplying P-values by 10. Responses to smoking and vaping help questions were tallied by gender and ethnicity.

Ethical approval was granted by the Auckland Health Research Ethics Committee, reference AH26667.

Results

There were 3625 YouthCHAT screens completed where separate smoking and vaping questions were asked between 9 February 2023 and 29 February 2024. The age distribution was dominated by 13 and under (2436, 67.2%) and 14 years (28.3%), with only 100 (2.8%) aged 15, 30 (0.8%) aged 16, and 33 (0.9%) aged 17 years or older. Further analysis was restricted to the 3462 cases with ages 14 years and under, consistent with Year 9.

Twenty-two percent of cases had ever-vaped and 12% ever-smoked (Table 1), with only 2% currently smoking. Less than 1% were daily smokers in the last 3 months as compared to nearly 5% daily vapers in the same period. Forty-nine percent of smokers and 68% of vapers reported having felt a need to cut down, with 28% of smokers and 22% of vapers wanting help, today or later (Table 2). The majority, 77%, had never smoked nor vaped; none reported smoking but never vaped, whereas 11% vaped but never smoked and 11% had done both (Table 3). Among current smokers, 38% reported vaping to help give up cigarette smoking (see Supplementary Table S2 for correlation between vaping and smoking status).

Girls were more likely to have vaped (25%) and have vaped but never smoked (13%) compared to boys (19 and 9%, adjusted P = 0.002 and 0.004 respectively) – Table 4. The rate of having ever-vaped and of vaping having never-smoked was higher in both Māori (adjusted P < 0.001) and Pacific girls (adjusted P = 0.005 for vaping and 0.001 for vaping never-smoked) compared with NZ European girls. For boys, rates of having ever-vaped were higher for Māori than NZ European (adjusted P < 0.001), but differences of ever-vaped, vaped but never-smoked, and vaped and smoked in the past were insignificant between Pacific and NZ European (Table 5). The numbers wanting help with smoking were small, but suggest that this is greater in girls than boys (35 versus 7%) and in NZ Europeans compared to Māori (30 versus 12%) – Supplementary Table S3. Many more wanted help with vaping – 20% of girls versus 15% of boys, and 23 and 27% respectively for Māori and Pacific versus 20% for NZ Europeans.

Discussion

This study provides insight on smoking and vaping responses of a young adolescent cohort in the context of lifestyle and mental health e-screening on invitation from clinicians. The data were based on an opportunistic cross-sectional study cohort that reflects the predominant use of YouthCHAT in schools as a precursor for Year 9 HEEADSSS assessments and includes responses to help-assessment questions. For these young adolescents, vaping was reported as a more familiar and common experience than smoking, with 22% having ever-vaped compared to 12% ever-smoked, and less than 1% daily smoking in the last 3 months as compared to nearly 5% daily vaping in the same period. This is consistent with the ASH Year 10 Survey results, suggesting vaping is largely replacing smoking in young people.³

Some gender and ethnicity patterns in smoking and vaping were present at significant levels in the cohort. Girls were more likely to have ever-vaped and to have vaped but never-smoked as compared to boys. Both Māori and Pacific girls were more likely to have ever-vaped and to have vaped but never-smoked than their NZ European counterparts. While the pattern for boys was less consistent, Māori were more likely than NZ European boys to have ever-vaped. Since the 1980s more girls aged 15–19 years have been smokers than boys. Māori rates of smoking have been higher than other ethnic groups, although socioeconomic factors have been shown to account for a significant amount of the ethnic inequities in tobacco use between Māori– Pacific and non-Maori–Pacific.¹³ Our study shows a similar pattern of increased rates among girls and Māori, but with vaping replacing smoking.

The findings provide some insights on the relationship of vaping to smoking for young adolescents in NZ and how they perceive the two behaviours. No respondent indicated that they had smoked but never-vaped. Conversely, few respondents indicated that they vaped to help them give up smoking (only 7% of those who said they had ever-vaped). Many were contemplative and open to change in their smoking and vaping behaviour. Nearly half of reported current smokers reported having felt the need to cut down and over a quarter said they wanted help. For those who had ever-vaped, over two-thirds had felt the need to cut down (15% of the entire adolescent cohort), although only a fifth wanted help.

The findings suggest that the concept of vaping having a social licence as a smoking cessation tool needs updating to account for the experiences of young adolescents. It is currently against the law for people under the age of 18 to buy cigarettes and vaping products,¹⁴ yet we see that they (especially vapes) are commonly accessed by a population years under this limit.

The Smokefree Environments and Regulated Products (Vaping) Amendment Act 2020 (NZ) includes the requirement for all workplaces, including restaurants and bars, to be smoke and vape-free, prohibiting the sale of vaping products to anyone under the age of 18, with product safety standards that must be met before vaping products can be sold. The aims of the Act include preventing the normalisation of vaping; regulating and controlling the marketing, advertising, and promotion of regulated products in order to discourage people, especially children and young people, from taking up smoking; and discouraging non-smokers, especially children and young people, from taking up vaping or using smokeless tobacco products.¹⁵

The cost of cigarettes in NZ is $42 for a pack of 20, over $2 a cigarette. According to SmokeFree, vaping costs about 10% of the cost of smoking.¹⁶ The vape liquid contains different amounts of nicotine – standard levels are 3, 6, 12, 18, and 20 mg mL^–1.¹⁷ Vaping is viewed as a cool and glamorous thing to do. It is also possible to buy vaping liquids containing no nicotine with enticing flavours such as bubblegum, candy floss, and sherbet, which may be a young person’s entry point into vaping. Adolescent use of such ‘nontraditional’ flavours has been shown to be associated with increased likelihood of continuing to vape.¹⁸ Many young people in NZ report seeing vape product marketing on social media platforms.¹⁹

In 2022, NZ passed pioneering legislation, introducing a steadily rising smoking age to stop those born after January 2009 from ever being able to legally buy cigarettes. The law was designed to prevent smoking-related deaths and reduce health system costs, and was due to come into effect in July 2024. It would have also cut the nicotine content in tobacco products and reduced the number of retailers by more than 90%, although it would not reduce the nicotine in vaping products. However, the coalition government that came into power in November 2023 repealed the legislation, and the Prime Minister Christopher Luxon says the government will ‘encourage people to take up vapes as a cessation tool.’²⁰

Key limitations of this study relate to it being an opportunistic sample based on the current users of the YouthCHAT tool with a single cross-section of self-report data. As such, the smoking and vaping frequencies cannot be seen as a representative sample of NZ adolescents at large; but substantial numbers of Māori and Pacific (as well as NZ European) girls and boys are among the respondents. While the YouthCHAT questions adapt elements from established instruments (including ASSIST with respect to smoking and vaping), the questions were designed to support pragmatic workflow and goals for the clinicians using the tool, with generation of research data as a secondary consideration. One notable issue is the logical incompleteness of the ever-vaped question (Table 3), which lacked a response to cover those who have both vaped and smoked, while not vaping to help quit smoking. While this incompleteness elicits caution in interpreting rates of concurrent smoking and vaping from the data, we believe it is still credible that relatively few adolescents identified with the ever-vaped response ‘Yes, to help me give up smoking cigarettes.’ We see the responses about wanting help with smoking and vaping – in line with the help-assessment objective of YouthCHAT – as a strength of the study.

Conclusion

Vaping is more frequent than smoking among adolescents aged 14 years and under in NZ. Vaping shows gender and ethnicity patterns toward higher frequency in females and Māori and Pacific ethnicities. Relatively few adolescents say they are vaping to help give up smoking, and many are contemplative of vaping less and open to receiving help. While smoking cigarettes is likely to be much more harmful than vaping, vaping is not benign; its long-term effects are still unknown, and they may serve as a pathway for new smokers.⁴ Increased regulation is urgently needed, with tight controls of vaping products to prevent e-cigarette marketing from attracting non-smoking adolescents, while ensuring access for those who wish to use vaping to quit smoking.

Supplementary material

Supplementary material is available online.