Electronic cigarette usage amongst high school students in South Africa: a mixed methods approach.

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. Funding: This study was funded in part by research grant from the Cambridge-Africa ALBORADA Research Fund G12753.