Understanding and Preventing Youth Vaping in the UK

‍Authors and affiliations: Ananya Ananya^1, Sterling Rippy¹, Buvana Ailoo¹, Jun Nakagawa² (1. London Borough of Hounslow; 2. London Borough of Camden)

Acknowledgements: Piers Simey, London Borough of Camden; Kelly O’Neill, London Borough of Hounslow

Abstract

Despite the Department of Health and Social Care guidance advising against vaping for non-smokers and people under 18, there has been a significant rise in vaping among children in the UK. Local authorities can play a major role in addressing youth vaping, but research on the behavioural drivers of youth vaping and effective interventions are still limited. The aim of this rapid review is to summarise the evidence on the behavioural determinants of youth vaping using the Theoretical Domains Framework (TDF) and what interventions have been tested in the field to prevent youth vaping.

Adhering to the PRISMA guidelines, the rapid evidence review search yielded 217 studies, with 32 meeting the inclusion criteria. Thematic analysis identified six important TDF domains:

• Environmental Context and Resources
• Social Influences
• Knowledge
• Memory, Attention and Decision Processes
• Beliefs about Consequences
• Reinforcement.

Key enablers that promote vaping behaviour among youth included socialisation, peer influence, availability, and appealing product design, while barriers that prevent or reduce youth vaping included stigma from non-vaping peers and parental attitudes.

Only seven papers that recommended strategies and interventions to prevent youth vaping were identified, which included educational programmes, peer-led education, and social media campaigns. Although these interventions showed promise, there is limited evidence on their effectiveness. The review highlighted the need for interventions addressing environmental influences, such as regulatory measures and access restrictions.

This rapid evidence review underscores the complex influences on youth vaping and provides insights for future research and intervention development. Addressing social and environmental factors is essential for designing effective policies and health interventions to prevent youth vaping.

Introduction

The UK Department of Health and Social Care recommends that young people and those who have never smoked should not vape or be encouraged to vape (DHSC, 2024). However, research suggests there has been an increase in young people who have tried vaping from 13.9% in 2020 to 20.5% in 2023, and regular vaping use was more common than regular tobacco smoking (ASH, 2023, Williams et. al, 2023). Whilst long term effects are not yet known, short term effects such as throat or mouth irritation, headache, cough, and nausea have been identified (Hartmann-Boyce et al., 2022). The outcome of a recent UK Government Call for Evidence highlighted the limited research available on the evidence to prevent youth vaping (Office for Health Improvement and Disparities, 2023).

Local authorities in the UK are responsible for commissioning stop smoking services, as well as the enforcement of regulations in retail providers. In response to the increase in youth vaping, many local authorities have implemented interventions to prevent and limit uptake by children. Developing a thorough understanding of the influences on youth vaping is necessary to ensure interventions are effective and provide value for money. The field of behavioural sciences offer a range of evidence and theory-based approaches to understanding influences on behaviour to inform intervention design. The Theoretical Domains Framework (TDF) is one validated behavioural framework which can be mapped to the Behaviour Change Wheel (BCW) ( Atkins et al., 2017). The TDF is a comprehensive tool that provides a refined understanding of a behaviour. The framework was first developed by synthesising 128 theoretical constructs from 33 different theories.

To the authors’ knowledge, no studies have been identified that review the influences on youth vaping behaviours using the TDF.

The aim of this review was to summarise the latest evidence on preventing take up of vapes amongst children and young people under the age of 18.

The review aimed to answer the following research questions:

• What are the primary influences on vaping behaviours among Children and Young People (CYP) in the UK?
• What themes emerge when applying the TDF to identify barriers and enablers of youth vaping?
• What is the role of key stakeholders involved in addressing vaping behaviours among CYP?
• What interventions have been implemented to address vaping behaviours among CYP, and what is their effectiveness?

Methods

PRISMA guidelines (Page et al., 2021), originally tailored for systematic reviews and meta-analyses, were adapted to suit time constraints by limiting the search to a select number of databases and focusing on more recent publications (from 2020 onwards) while ensuring an explicit and transparent process.

Study Design

The inclusion criteria for the review focused on studies examining the behavioural determinants of vaping among CYP under 18 years of age and studies assessing the effectiveness of interventions to address youth vaping. Table 1 specifies the inclusion and exclusion criteria based on the standardised tool, PICOS (Methley et al., 2014). Recognising the scarcity of available peer-reviewed literature around social and behavioural influences on youth vaping, the scope of the study was expanded to encompass grey literature, including policy documents and commentaries.

Search Strategy and Study Selection Process

The search strategy was developed using a combination of search terms and relevant synonyms which can be viewed in Appendix I. Initially, all titles underwent screening against the predefined inclusion and exclusion criteria, followed by abstract screening of the selected papers. Following this process, any duplicate entries were manually removed, and papers deemed relevant were selected for full-text screening. The data was initially searched, screened, and extracted by a single reviewer, with the screening and extraction subsequently reviewed by two additional reviewers.

Data Extraction and Analysis

Data extraction was performed using Microsoft Excel. Selected studies underwent excerpt extraction, which were deductively coded to their corresponding TDF domain (Atkins et al., 2017). This was followed by inductive analysis conducted on the top two domains with the highest number of studies, for generating broader sub-themes within each of the two TDF domains within the limited time frame. Studies focused on interventions were further analysed to identify effectiveness and were used to inform recommendations.

Results

The literature search yielded a total of 271 studies. After abstract screening, 32 articles were identified. Thematic analysis identified six key TDF domains. These were Environmental Context and Resources; Social Influences; Knowledge, Memory, Attention and Decision Processes; Beliefs about Consequences; and Reinforcement (Table 2).

Barriers and Enablers to Uptake of Vaping Behaviour among Youth

Inductive themes were identified within the top two TDF domains: Social Influences and Environmental Context and Resources. Barriers were defined as those influences which reduce the likelihood of vaping whereas enablers were defined as those influences which increase likelihood of vaping.

Enablers to Uptake of Vaping Behaviour among Youth

Social Influences:

1. Socialisation/Bonding (Enabler): Vaping was commonly described as a social activity among young people, often occurring in group settings such as parties or social gatherings. Peer influence, social media, and the desire to bond with peers through shared experiences like “tricks” (Brown et al., 2020) become an aspect of socialisation among CYP.
   
2. Desire to Fit-in (Enabler): Many CYP associated vape use with a desire to fit in with their peers, often justifying their own use based on the perceived high prevalence of vaping among their social circles. They felt compelled to use e-cigarettes because “everyone else” does and viewed vapes as “cool” or “trendy” (Smith et al., 2023; Watts et al., 2022).
3. Familial (Parental) Influences (Enabler and Barrier): Although peers play a predominant role, research shows that parents may also influence children’s perceptions and use of vapes. Children who lived with someone who vaped were more knowledgeable and accepting of vaping products and were more likely expressed intention to vape as adults (Egger et al., 2024; Porcellato et al., 2020).
4. Social Setting Influence (Enabler): Vaping purchases primarily occur in social settings where individuals may buy vapes through their friends (Watts et al., 2022, Moore et al., 2020), potentially influencing decision-making processes in social contexts.

Environmental Context and Resources:

1. Availability and Accessibility (Enabler): The availability and accessibility of vapes particularly online and in retail shops with lax age verification measures, enables ease of underage access (Public Health Wales, 2023).
2. Packaging and Presentation (Enabler): Vape packaging designed with bright colours, resembling sweet brands, and appealing flavours like fruit and candy contribute to the attractiveness of vaping to young people (Balogun, 2024; Arnott, 2023).
3. Unregulated Sale (Enabler): The unregulated sale of vapes, particularly those not meeting quality and safety standards, was highlighted as an enabler for youth vaping. Illicit products flooding the market further were another issue, as they are often sold in unregulated marketplaces and small retail shops, making regulatory oversight challenging (Public Health Wales, 2023; Department of Health and Social Care, 2024).
4. Point of Purchase (Enabler): CYP commonly obtained vaping products from newsagents, corner shops, and off licences, highlighting the ease of access from various retail outlets (Department of Health and Social Care, 2024).
5. Ease of Concealment (Enabler): E-cigarettes are often designed to be small in size, making them easily concealable and allowing teens to use them discreetly in home or school settings. The lower risk of detection compared to traditional cigarettes enhances their appeal among adolescents (Grebenau, 2020).
6. Social Media Advertising (Enabler): Social media ads may influence young peoples’ decision-making processes and guide their impressions of vapes by driving narratives and social norms around an adolescent identity (Yazidjoglou et al., 2024). In addition, social media has been associated with an encouragement in vape use and social approval (Grebenau, 2020).

Barriers to Uptake of Vaping Behaviour among Youth

Social Influences:  

1. Stigma among Non-Vaping Peers (Barrier): While vaping is often perceived as a social activity among adolescents, some acknowledged a stigma against vaping among their non-vaping peers. This stigma may prevent individuals’ decisions to vape openly or disclose their vaping behaviour to others (Groom et al., 2021).
2. Familial (Parental) Influences (Mixed-Barrier): Children with parents who viewed vapes as harmful or had strict home rules such as vape bans were less likely to use vapes (Greenhalgh et al., 2024).

Environmental Context and Resources:

1. Regulatory Measures (Barrier): Previous recommendations have been made to strengthen regulations on product labelling and implement bans on vapes under the Tobacco Products Directive (TPD) to prevent uptake among children (Health Policy Team, 2023).

Past and Current Interventions: Successes and Challenges

To date, there have been limited interventions targeting vaping behaviours among young people. Only seven studies were identified (see Table 3) which suggested interventions or potential approaches which may be used to develop interventions with one study contributing to more than one approach, leading to eight entries in the table. Interventions targeting youth vaping behaviour have previously involved e-Health approaches, peer-led education, and social media-based campaigns.

To summarise, current interventions employ a multicomponent approach that may integrate various components like digital platforms, peer networks, and social media-based campaigns to target youth vaping behaviour. While these interventions show promise in reducing knowledge and intentions for e-cigarette use among adolescents, few studies have measured change in behaviour as an outcome. For example, the "SOLVE Mystery Toolkit" (Hollis et al, 2022), aimed to assess the effectiveness of an educational program or toolkit in reducing youth e-cigarette use through interactive lessons, videos, and quizzes to increase knowledge and awareness about the risks of e-cigarette use. The effectiveness of the intervention was evaluated through feedback surveys assessing knowledge levels which suggested that 87% of the students who filled the optional feedback forms reported their knowledge levels regarding the health consequences of e-cigarette use to be excellent, good of satisfactory after using the toolkit. It is important to note that recent implementation of the program and optional survey completion may limit the current understanding of effectiveness. Peer led prevention campaigns, such as the "Above the Influence of Vaping (ATI-V)" (Wyman et al., 2021), program aimed to assess the effectiveness of a peer-led prevention campaign in reducing e-cigarette use among adolescents. Findings suggested that student participants who had more peer leaders as friends were less likely to report e-cigarette use in recent times after the intervention. Some programs including the Our Futures Vaping Trial are still in early stages with post-intervention effectiveness still in study and thus, the extent of effectiveness is still to be determined.

Discussion

This rapid evidence review identified six key drivers of youth vaping, grouped mainly under Social Influences and Environmental Context and Resources, as outlined by the TDF. While the existing interventions focus on changing knowledge, attitudes, or intentions around youth vaping, there is a notable gap in strategies targeting the environmental factors that significantly contribute to vape use among youth. Future research should prioritise interventions that not only educate but also create barriers to access, especially in retail and online platforms, where underage individuals can easily obtain vapes. Retailers play a critical role in this landscape and must be included in efforts to restrict access, whether through stricter age verification processes or clear legal consequences for non-compliance.

Strengths and weaknesses of this review

To the authors’ knowledge, this is the first paper to conduct a rapid assessment of behavioural drivers specific to youth vaping, which fills a critical gap in the literature. The findings of this review are timely, aligning with the UK government’s introduction of the Tobacco and Vape Bill, which seeks to ban the marketing of vapes to children and reinforce enforcement to limit access (UK Parliament, 2024). These regulatory efforts, combined with behavioural insights from this review, can guide future policies to prevent youth vaping more effectively. For policymakers, this review underscores the importance of multi-layered approaches that combine education with environmental and social interventions. For example, regulations around retail practices, online marketing, and even the design or flavour of vape products should be revisited to ensure they are not inadvertently appealing to children. Local authorities may also have a unique opportunity to use these findings to shape public health initiatives that address youth vaping at the local level. For example, strengthening monitoring and enforcement of existing laws on vape sales, conducting targeted inspections, and running local awareness campaigns in schools and youth settings could help reduce youth access to vaping. Collaborations between local authorities, schools, and retailers could also foster a more holistic approach to restricting vape accessibility and reducing demand.

There are some limitations to this review. It was restricted to studies published between 2020 and 2024, meaning earlier findings may have been excluded. Another limitation is that studies conducted in non-English languages were not included, possibly overlooking relevant evidence from other cultural contexts. While grey literature was incorporated to provide a broader understanding, it lacks the rigorous peer review that would typically ensure the validity of findings. Furthermore, this review had a geographic focus on Western, Educated, Industrialised, Rich, Democratic (WEIRD) countries, which may reduce the applicability of these findings to more diverse global populations where vaping patterns and regulatory environments differ.

Comparative findings: Youth vaping vs. Tobacco use

In comparing youth vaping with tobacco use among under-18s, several parallels can be drawn. Both behaviours are heavily influenced by access, peer pressure, and marketing strategies (ASH, 2024). However, the regulatory landscape is markedly different. Tobacco products face stricter marketing and sales regulations in the UK compared to vaping products, despite similar risk profiles in terms of addiction potential for young users (ASH, 2024). Policymakers can learn from tobacco control strategies, such as plain packaging and retail display bans, which have proven effective in reducing youth smoking rates, and adapt these for vaping prevention (ASH, 2024). Retailers could also be held to the same accountability standards as those for tobacco products, with penalties for violations.  Given this gap, local authorities could adapt tobacco control policies to the vaping context, particularly focusing on restricting advertising and increasing enforcement. The BCW framework offers various intervention and policy functions that could be explored to design more effective strategies (Michie et al., 2014).

Implications for practitioners

This review has several implications for practitioners. For clinicians, the findings of this review highlight the need for a nuanced approach to discussing vaping with young patients and their families. Clinicians should be aware that while vaping is often positioned as a harm reduction tool for smokers, its use among non-smoking youth presents a different set of risks. Conversations with young patients should include discussions about the social and environmental drivers that make vaping appealing and emphasize the long-term health risks, even in the absence of tobacco use.  Policymakers should consider expanding current tobacco control regulations to vaping products, especially considering the evidence suggesting that similar strategies could curb use among youth. A comprehensive approach that includes banning targeted advertising, limiting flavours that appeal to children, and enforcing stricter age verification processes in both physical and online stores is crucial. Retailers could be incentivised or required to adopt practices that make vapes less accessible to underage consumers, such as compliance audits and more stringent penalties for violations.

Unanswered questions and future research

This review raises several critical questions for future research. For instance, when considering the effectiveness of current harm reduction strategies for smoking, how can they be modified to prevent uptake by non-smokers and young people? More research is needed to explore the unintended consequences of promoting vaping as a safer alternative to smoking, particularly regarding youth exposure. Additionally, the APEASE criteria (Affordability, Practicability, Effectiveness, Cost-effectiveness, Acceptability, Side effects/safety, and Equity) could provide a useful framework for evaluating current interventions while measuring for unintended consequences (Michie et al., 2014). Future studies should apply these criteria to assess the long-term impact of different strategies, ensuring that they do not inadvertently contribute to increasing vape use among non-smokers and young people. Another key area for research involves understanding the role of retailers and online platforms in enabling youth access to vapes. Future studies should evaluate the effectiveness of current regulatory frameworks governing vape sales, particularly in how they are enforced at the point of sale and through digital platforms. Moreover, given that social influences are a major driver, understanding how peer networks and social media shape vaping behaviours among youth could provide new avenues for intervention. Lastly, cross-cultural research is needed to examine whether the behavioural drivers identified in this review hold true in non-WEIRD countries. Such research would inform the development of globally applicable strategies, ensuring that interventions are tailored to diverse social and economic contexts.

Conclusion

This review highlights important behavioural influences on youth vaping that can guide future interventions. Social and environmental factors play a central role in shaping vape use among young people, and these must be addressed through targeted policies and regulations. The introduction of the Tobacco and Vape Bill in the UK provides a timely opportunity to apply these insights, especially in retail and marketing contexts. Further research is necessary to understand how these findings can be effectively translated into both policy and clinical practice, ensuring that interventions strike the right balance between harm reduction and prevention.

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Appendix I

The search strategy for this rapid review was developed using the following search terms: (vaping* or vape* or e-cigarette*), (adolescents* or children* or young people* or youth* or teenagers* or minors*), (behaviour* or influence* or factor* or determinants* or social influence* or peers* or parental influence*), (U.K.* or United Kingdom* or London* or British youth* or England* or U.S.A* or Europe* or Australia* or New Zealand*), (regulation* or policy* or legislation* or law* or trading standards* or rule* or guideline* or compliance*). Boolean operators were used to combine the facets (e.g. “AND”; “OR”). Studies and grey literature were searched in the following databases: Applied Social Sciences Index and Abstracts (ASSIA), EMBASE, MEDLINE, PubMed, BASE, Policy Commons, Gov.uk and HMIC.