The New ‘Cool’? A Qualitative Study of E-Cigarette Perceptions and Experience Among Irish Adolescents

Abstract

Background

E-cigarette use among young people has increased significantly in recent years, and their health impact is a concern. Countries are challenged to define an effective regulatory and public health response. In Ireland, information is limited in terms of access, knowledge, and the context in which e-cigarettes are used. The study aims to provide an in-depth understanding of these factors to help develop policies and interventions to combat e-cigarette use among young people.

Method

Focus groups of children aged 15-16 years (n = 76) were conducted in three schools. A topic guide was utilised to facilitate discussion. Topics were introduced using a third person technique, asking participants to discuss them in terms of schoolchildren in general. Focus groups were recorded, transcribed, and thematically analysed.

Results

E-cigarettes are popular, with the emergence of a sub-culture of young users. Risk awareness of nicotine, or the health effects of e-cigarettes was unclear. Few had seen e-cigarette warning labels. There was a lack of school education about e-cigarettes. E-cigarettes were used in locations where they can be concealed. There was an awareness of the e-cigarette flavours, with sweet and fruity flavours being popular. E-cigarettes were easy to access, particularly by using social media, with online buying and selling online between schoolchildren. Pop up adverts with discount codes were common plus social media was used to view videos of ‘vape tricks’. Smoking, alcohol consumption, and use of e-cigarettes were interlinked; participants felt that those who smoked or vaped also consumed alcohol, which would often be consumed at the same time. Alcohol may influence the decision to experiment with e-cigarettes and other substances.

Conclusions

The study highlights the urgent need for further policy action, including better education for children and parents, regulating social venues and advertising, and restricting flavours and product placement of e-cigarettes.

Keywords

e-cigarettes smoking schoolchildren adolescents focus groups

Introduction

E-cigarette use by young people has risen significantly in the last decade in many countries and remains a major concern.^1–5 In Ireland, current use among 15-24-year-olds has increased from 1% in 2015 to 18% in 2023.⁶ Among those aged 12-17 years the 2022 HBSC survey found that 18% had ever used e-cigarettes, with 13% reporting current use.⁷ A key factor in this worldwide trend is the growing popularity of disposable vapes, which are inexpensive, easy to use and conceal, and are available in youth-appealing flavours. ^8–10

While there is some debate regarding the potential role of e-cigarettes in terms of helping adults to quit traditional smoking,¹¹ studies suggest that they still pose long term cardiovascular and pulmonary risks.¹² The balance of risks and benefits for children and young people requires careful appraisal. A particular concern for young people is the heightened risk associated with exposure to nicotine and a range of other chemicals. The US Surgeon General report that nicotine may harm the developing adolescent brain more than the adult brain, exposing users to several chemicals known to have adverse health effects.¹³ Evidence also indicates that youth who use e-cigarettes and e-cigarettes combined with other tobacco products have a higher risk of developing respiratory conditions such as bronchitis, pneumonia or chronic cough.¹⁴ In addition, emerging trends such as young people’s use of e-cigarettes containing cannabis can expose them to acute and long-term health risk, particularly with the emergence of high potency cannabis and synthetic cannabinoids.^15–17 Another concern is that e-cigarette use may lead to smoking initiation among young people. A number of reviews have found a ‘gateway effect,’ showing an association with e-cigarette use and subsequent cigarette smoking.^18–21

Despite evidence confirming a rise in adolescent e-cigarette use in Ireland, the regulatory and public health response has been slow; at the time of this study, sales to under-18 s were still permitted. While there is some epidemiological information, there is limited insight in terms of how young people perceive and experience vaping. Increased understanding of access patterns, motivations, and social contexts would be valuable in terms of developing policy responses and interventions to combat the upward trend in e-cigarette use by children. This study addresses a knowledge gap by providing an in-depth understanding of current knowledge, attitudes and behaviour of schoolchildren in terms of e-cigarette use.

Method

Background and Rationale

A qualitative approach using focus groups was employed to provide an in-depth understanding of e-cigarette use among schoolchildren, as this would complement quantitative approaches^7,22 by providing the depth and context necessary to capture important issues of relevance to policy-makers. Ethical approval was obtained from the HSE Sligo and HSE Northeast Hospital Research Ethics Committees (Application 674).

Sampling

Focus groups were conducted in 2019 on schoolchildren aged 15-16 years (transition year). A convenience sample of three schools in three Irish counties across single-sex and mixed-gender schools was selected. This approach aimed to capture a broad range of perspectives and reduce gender-related participation bias.^23,24 Children aged 15-16 (transition year) were selected based on evidence indicating that this is a key period for the onset of smoking, with marked increases typically observed from age 15 onward.⁷ As this was a qualitative study, power analysis calculations to determine sample size were not undertaken. Instead, the study was guided by qualitative methodology, with three groups conducted at each school (giving a total of nine focus groups) which supported the thematic saturation of data.²⁵

Families of all transition year students in selected schools were contacted, and written informed consent was obtained from parents and written assent was provided by the participating schoolchildren. Eligibility was based solely on being a transition year student; vaping or smoking status was not an inclusion or exclusion criterion. To maintain manageable focus group size, a maximum of 36 students per school were selected, with 12 participants assigned to each focus group.²⁶ Random sampling was conducted when consent exceeded this limit. Participants received a ‘goodie bag’ as a gratuity. In total, 38 male and 38 female transition year students took part in the focus groups.

Data Collection

Development of a ‘topic guide’ was informed by: consultation with Environmental Health Service stakeholders, a review of relevant international research, and findings from a preliminary pilot group. It consisted of open-ended and detailed probe questions (see supplement 1). The main topics included vaping among Irish schoolchildren, attitudes to e-cigarettes/vaping, the accessibility and availability of products, health effects of vaping, and the combined use of vaping, smoking and alcohol. Participants were encouraged to speak openly, with confidentiality emphasised. Since schoolchildren might be reluctant to discuss personal behaviour, a third person technique was used,²⁷ whereby participants were asked to discuss topics in terms of schoolchildren generally (eg, “Is vaping popular among schoolchildren?”). The focus groups were administered by two members of the study team at each of the schools selected for the study. Teachers or parents were not present during the focus groups. On average each focus group lasted 37.32 min (SD = 7.16 min).

Analysis

Transcripts of the focus group discussions were analysed using grounded theory.²⁸ The process began with open coding to identify key patterns and ideas, which were then refined into broader thematic groupings. Similar categories were then grouped together to form a coding framework to identify response categories. The transcripts were then coded using the framework, from which a number of key themes were identified through a process of pattern coding, consistent with the phased approach to qualitative analysis outlined by Bingham (2023).²⁹

The qualitative data analysed in this study formed part of a Health Service Executive (HSE) report on adolescent vaping in Ireland.³⁰ The current paper presents a re-analysis of this dataset with new interpretation, updated contextualisation, and adapted descriptions of selected methods and results.

Results

Profile

A total of 76 Transition Year students aged 15-16 years (38 male and 38 female) took part in the focus groups, including 35 from Sligo, 22 from Cavan, and 19 from Dundalk. The key themes that emerged were:

Youth Perceptions of Vaping in Ireland

Some respondents felt vaping was popular among certain groups of schoolchildren, particularly younger ones, though most said the majority did not vape. Reasons for use included peer influence and wanting to be seen as ‘cool’ and wanting to fit in, attraction to flavours which makes them “trendier” than traditional cigarettes and the ability to do “tricks” shared on social media. Others mentioned vaping as a way to relieve boredom, act rebellious, or because it was perceived as less harmful than smoking:

“…a stereotype may be that it’s not as bad as smoking but still looks so cool smoking apparently.”

“When you see other people doing it they would think it was cool.”

“They think it’s cool because their friends do it.”

“They do tricks; this is big on YouTube as well…..They blow shapes with smoke.”

What Schoolchildren Think E-Cigarettes Contain

The majority of participants across the focus groups thought that e-cigarettes contained nicotine, although some were uncertain. Others pointed out that nicotine-free options are available. Many were unsure about other ingredients; several thought they contained water, or flavourings, and two mentioned chemicals:

“I am unsure like what they contain.”

“Well they contain nicotine so that’s why they are addictive.”

When asked about the safety of inhaling e-cigarettes, most thought they were “probably” not safe. Some felt e-cigarettes were safer or healthier than traditional cigarettes, while two thought they might be safe with no side effects. One participant had concerns about the effects on the throat; another about lungs, and two felt vaping had similar effects to smoking. One participant mentioned a lack of education about e-cigarettes, while another noted greater awareness of smoking dangers due to stricter smoking regulations compared to vaping:

“Probably not….but I think a lot of people see it as a healthier option to cigarettes and they don’t think there are any side effects with it.”

“E-cigarettes are not as bad as cigarettes because that’s the point of them I suppose.”

Contexts and Settings of E-Cigarette Use

Locations frequently mentioned for adolescent vaping included teenage discos and school toilets or bathrooms. Discos were often held in adult venues with smoking areas, which participants reported that children used to smoke or vape. While security staff checked for and confiscated alcohol, cigarettes, and e-cigarettes as children entered, several participants noted that once inside, staff did not prevent children from accessing smoking areas or using them to smoke or vape. Bathrooms and dimly lit areas within discos were also identified:

“The main disco we have here, there’s like an outside smoking area in it because it’s an adults’ nightclub and a lot of people sneak their cigarettes in with them, in their tops or whatever…..It was absolutely packed with people just out there smoking.”

“You walk into the bathroom and a big cloud hits your face.”

School toilets were reported as being popular due to the lack of cameras. Some noted the strong smell of e-cigarettes in the toilets. Few mentioned other school areas, as cameras made it harder to vape at school:

“Yeah if they are doing it in the school it will be in a bathroom.”

“There are cameras outside so it’s more likely they will do it in the bathroom.”

Other locations included a variety of public and private spaces such as the local garage or shops, shopping centres, parks and forests, travelling to school, waiting for the school bus, walking the dog, and at home- particularly in bedrooms or bathrooms. It was felt that schoolchildren vaped in any areas without cameras where they would not be seen:

Awareness of E-Cigarette Flavours

Several participants mentioned a wide range of e-cigarette flavours, with strawberry and other fruit flavours most common. Sweet flavours like cotton candy, chocolate, and bubble gum were also mentioned. Some were unaware of flavour options. Several noted that children experiment by mixing e-liquids to create new flavours; one participant reported not being sure if this was harmful:

“There are loads of different flavours you can use to experiment. You just mix them up to see what happens.”

How Schoolchildren Obtain E-Cigarettes

Social media was the method mentioned most to access e-cigarettes. Snapchat was highlighted in particular, with individuals promoting e-cigarettes through their “stories,” with purchases taking place during or after school. Other platforms referred to included Instagram and Facebook:

“Yeah, they advertise like on the social media and yeah they have them up for sale and they could actually sell it in school.”

Several participants mentioned that e-cigarettes were purchased online, often using a parent’s or the child’s own debit card. Deliveries were made via parcel collection services or sent to a friend’s address. Shops were another common source, particularly discount shops and vape stores.” One person noted that the placement of e-cigarettes at shop counters made them easy to steal. Other sources included corner shops, pop-up stands in shopping centres, and off licences. Several noted that age restrictions were easily bypassed using fake ID or by asking older siblings, friends, or relatives to buy them. Participants felt shopkeepers were generally not strict about checking age:

“Some shops even if you clearly look under-18 you can just go in and buy them.”

“You just need to have some form of ID; it doesn’t even have to look remotely like you.”

Parental Awareness and Communication About E-Cigarettes

Few adolescents had discussed vaping with parents, and many perceived a lack of parental knowledge about e-cigarettes and their risks (such as contents, addictiveness, how they differ from smoking). Several also noted that schools provided little or no education on the health risks of e-cigarette use:

“I think parents don’t really know too much about e-cigarettes and I think we are taught about smoking in school but we’re not taught about e-cigarettes at all.”

“We have learned about like the facts of smoking, what I should do, but you wouldn’t learn about vaping. I don’t think that the teachers know.”

Social Media Exposure and E-Cigarette Promotion

Social media was one of the main platforms where participants reported seeing e-cigarette advertisements. Several noted that schoolchildren promoted e-cigarettes to their peers by posting on their Snapchat ‘stories:’

“You know on Snapchat is someone just taking a picture e-cigarettes and put them on the stories that they are for sale.”

Some participants noted that Instagram sometimes recommended accounts promoting e-cigarettes. Others mentioned that some individuals were paid to post photos or videos of themselves vaping, often endorsing specific products:

“It will kind of give you a picture or video of them using it and then I’ll give you a discount code to get like 10% off or something, they’re promoting the product.”

Several participants also stated that e-cigarettes were advertised by the shops that sold them, particularly vape shops. Adverts would be in shop windows and also on the e-cigarette display stands, and on store delivery vehicles:

“If you just go around town there will be a shop on nearly every road. Yeah that’s where you see them.”

“You know when you go into your shop then there’s a big stand there.”

Several participants reported seeing e-cigarette advertisements online, including pop-up ads and promotions. Other sources of e-cigarette advertising mentioned included word of mouth, observing peers using them, and seeing people use them in general.

Awareness and Visibility of Health Warnings

Warning labels were largely overlooked or deemed less visible than those on cigarette packaging, with participants showing limited awareness of health messaging, believing people generally ignored the warnings:

“I don’t think I have seen any about the actual effects.”

“I don’t think it says how it can affect your health.”

“Not as much as smoking. Smoking has all images on the back now, clearly showing you that it will destroy your lungs.”

E-Cigarettes and Other Risk Behaviours

Participants were asked whether vaping took place at the same time as smoking and drinking alcohol. Many said that people who vape also tend to drink alcohol and smoke cigarettes, with some using all three simultaneously. Others believed e-cigarette users mainly consumed alcohol, while some thought they smoked at the same time. A few felt that users would only vape. One participant noted that if e-liquids or nicotine were unavailable, vapers might turn to cigarettes instead:

“Yeah, I’d say that people who would vape would smoke and drink alcohol as well. Anybody that I know that vape, they smoke and they drink as well.”

“I think most of them smoke as I think they have all at least tried smoking, like cigarettes. They tried it at least once or twice.”

Discussion

By employing a qualitative approach, this study provides an in-depth insight into the knowledge, attitudes and behaviours of Irish schoolchildren regarding e-cigarettes. It highlighted the emergence of a subculture of schoolchildren that use e-cigarettes with many participants lacking awareness of health risks and often perceiving vaping as less harmful than smoking. By contrast schoolchildren were aware of a wide variety of e-cigarette flavours, particularly sweet and fruit-based options. It was reported that vaping took place in concealed areas such as school toilets and underage discos. At discos they were closely linked with smoking and alcohol use. E-cigarettes were accessible through social media, and retail outlets where age restrictions were perceived as easy to bypass. It is important to interpret these findings within the historical context of data collection in 2019. Since then, there has been increasing awareness of the risks of vaping among schoolchildren in Ireland,⁴ meaning that the findings may not be fully generalisable. However, it is worth noting that while 79% of students in 2024 viewed regular e-cigarette use as a moderate or great risk, 38% still saw no risk from trying e-cigarettes occasionally.⁴ This suggests that experimentation remains normalised among some young people and underscores the need in Ireland to progress an overdue and more comprehensive regulatory framework, including product names, design, flavour and promotion.

A number of quantitative studies in Ireland and elsewhere demonstrate the popularity of e-cigarettes among adolescents.^6,31,32 This is especially concerning as the younger the age of initiation can lead to greater addiction.³³ Our findings add qualitative depth describing common and shared attitudes among younger e-cigarette users (aged 13-15) that may drive these trends. Although there was an awareness that e-cigarettes contained nicotine, knowledge of the addictiveness and health risks was unclear. This is in contrast to conventional cigarettes, where risk awareness is well established in children and young people.³⁴ Nicotine has been shown it to be harmful to the cardiovascular, respiratory, renal, and reproductive systems.³⁵ Additionally, accidental ingestion of liquid nicotine poses a serious risk and can be fatal.³⁶ Addiction may also lead to schoolchildren smoking cigarettes and also put them at risk of smoking related diseases. Indeed e-cigarette use among youth is associated with increased risk of cigarette initiation and use.³⁷ Schoolchildren need to be better informed about both the health risks and the addictive properties of nicotine in e-cigarettes.

Underage discos emerged as key venues for experimenting with vaping, smoking, and alcohol. Despite security checks, participants reported that substances could be concealed and used, often in smoking areas or toilets with minimal staff intervention. This raises concerns about supervision and child safeguarding. Other Irish research suggests that underage discos may normalise risky behaviours.^38,39 The regulations for underage discos should be reviewed to ensure that venues intended as safe spaces do not instead facilitate substance use. While these events are intended to provide school-aged children with a safe and supervised social setting, our study suggests that the opposite is often the case. This concern is reflected in media reports of incidents at underage discos.⁴⁰ In terms of other locations, it appears that e-cigarettes are used at a variety of locations such as school toilets where their use can be concealed. Detection devices that can identify e-cigarette fumes have been developed⁴¹and such devices could be installed in hidden locations such as school toilets.

Participants were aware of a wide variety of e-cigarette flavours, particularly sweet and fruit-based options. Studies show that these flavours are perceived as more novel and attractive, with children more susceptible to trying them. The attractiveness is enhanced by colourful packaging, often resembling sweets.^42,43 Several participants were aware of mixing e-liquid flavours, which may sustain use by keeping novelty.^44,45 The use of flavourings to target children, combined with the fact that some flavourings can form harmful compounds⁴⁶ highlights the importance of monitoring and regulation. While many countries, including Ireland, ban flavours in tobacco products,⁴⁷ regulations for e-cigarettes remain limited. In Ireland, the government has approved the drafting of legislation to restrict the range of e-cigarette flavours.⁴⁸ This is a welcome step and it is hoped that this will be expedited and extended to align with existing tobacco legislation.⁴²

E-cigarettes appear to be relatively easy for schoolchildren to access, with social media and local shops particularly popular. In Irish shops, e-cigarettes are often displayed in prominent locations such as the main point of sale⁴⁹ Although point-of-sale was only mentioned by one participant in the context of encouraging theft, evidence shows that point of sale promotion is associated with adolescent e-cigarette use,⁵⁰ while studies of tobacco have found that point of sale bans reduce youth exposure and purchasing.^51,52 This supports the Irish government’s proposed legislation to introduce restrictions on e-cigarette product placement and point-of-sale advertising.⁵³

Although many participants thought you had to be 18 to purchase e-cigarettes, there were no mandatory age restrictions on the sale of e-cigarettes at the time of the study. However, many retailers set their own age limits, and it was reported that these could easily be bypassed. In 2023 the Irish Government enacted legislation⁵³ prohibiting e-cigarette sales to under-18 s which is a welcome step. Ongoing monitoring is essential to assess the impact of this new law and ensure it meets its goals.

Although EU legislation bans e-cigarette advertising on TV, radio, and print, restrictions are weaker at points of sale, billboards, and on social media platforms.⁵⁴ Participants described exposure to advertising in retail shops, pop up online advertisements and vape trick videos. This exposure highlights the need to review e-cigarette advertising regulations, a step which has also been recommended by the Irish Cancer Society and the Irish Heart Association.⁵⁵ This point is also reinforced by studies that show that exposure to e-cigarettes advertisements increases the likelihood of e-cigarette use^56,57 In Ireland, legislation is being developed which will help to restrict point-of-sale advertising exposure to children.⁴⁸ In addition, the Online Safety and Media Regulation Act 2022⁵⁸ provides scope to restrict online advertisements for nicotine and tobacco inhaling products. These could make a significant contribution to reducing children’s exposure to such products.

The focus groups demonstrated an awareness that e-cigarettes contained nicotine, but knowledge appeared limited in terms of what else e-cigarettes contained and their health effects. Overall e-cigarettes were perceived as less harmful than traditional cigarettes, echoing findings from US studies.^59–61 Evidence suggests that exposure to e-cigarette marketing can lower harm perception which may exacerbate this issue.⁶² Parents expectations are also important in influencing adolescents decisions,⁶³ yet although smoking was widely discussed, few participants had engaged in a conversation about e-cigarettes with their parents. There is some evidence that parents view e-cigarettes less negatively than traditional cigarettes, which influences use by adolescents.⁶⁴ This emphasises the importance of enhancing parental knowledge of the health risks of e-cigarettes, so that they can communicate about the health risks of e-cigarettes to adolescents which may help prevent e-cigarette initiation.⁶⁵ In addition to nicotine, e-cigarettes contain a number of toxic substances that have short and long term health effects.^66,67 Emerging risks have also been identified in relation to Cannabinoid vaping.^15,68 In Ireland, young people have developed mental health-related problems after vaping the semi-synthetic cannabinoid Hexahydrocannabinol (HHC).⁶⁹ It is essential that children are made aware of these specific, additional risks with cannabinoid-vaping so that they can make informed decisions. The recent enactment of legislation to prohibit import, export, production, possession, sale, and supply of products containing HHC in Ireland will help reduce this risk.⁷⁰ Best practice communication techniques (similar to those used for tobacco education)^64,71 should be employed to raise awareness. School-based smoking education programmes should ensure students receive accurate, evidence-based information that supports informed decision-making and reduces the risk of initiation. Recent updates to the Social, Personal and Health Education (SPHE) school curriculum in Ireland are a welcome development.⁷²

European Union Regulations^47,54 require e-cigarette packaging to display nicotine health warnings, ingredient lists, and a leaflet outlining adverse effects, addictiveness, toxicity and at risk groups. The study found that there was a low level of awareness of these warnings, and among those who had seen them, there was inconsistency in terms of message content. Similar findings have been reported by Sontag et al.⁷³ Warning labels need to be prominently placed, clearly visible and impactful. Research shows that visible warnings can raise awareness of harm and reduce the intention to use e-cigarettes.⁵⁷ Given packaging constraints, it is difficult to display prominent warnings, suggesting a need for alternative approaches. One proposed solution is to mandate health warning posters at all retail outlets selling e-cigarettes. Point-of-sale warnings have been effective in tobacco control, increasing awareness and quit attempts.^74,75 The FDA in the U.S. is already using such e-cigarette warning posters in retail settings. ⁷⁶ Making this a licensing condition for retailers could help standardise practice. Under the Tobacco Products Directive (Recital 48),⁴⁷ individual countries can legally introduce mandatory point of sale health warnings. Such measures offer a practical way to address the limitations of packaging space while improving consumer awareness and encouraging cessation, as demonstrated in existing tobacco control efforts.

In terms of other lifestyle behaviours, focus group discussions suggested that young people who vaped were also likely to smoke and consume alcohol, particularly in the context of teenage discos where alcohol consumption may have contributed to the decision to experiment with traditional cigarettes and e-cigarettes This clustering of risk behaviours has also been observed in other studies.^19,77 Hughes et al⁷⁸ for example found that adolescents who binge drink or regularly consume alcohol are significantly more likely to access e-cigarettes, including those who have never smoked. This suggests that preventative strategies should consider vaping within the wider context of smoking and alcohol use among schoolchildren. They also highlight the need to review the regulation and management of underage discos. Measures such as smoke- and vape-free policies could be enforced through dance licence conditions set by legislation.

Since the time of data collection, e-cigarette use has continued to evolve in Ireland and internationally. Among 15-16-year-olds, past-30-day use increased from 14% to 22% across Europe between 2019 and 2023^3,4 while in Ireland it decreased slightly, from 18% in 2019 to 16% in 2023, although daily use remains notable at 7%.^34,79 In the United States, current use among high school students has also declined, from 27.5% in 2019 to 7.8% in 2024.^1,80 Over this period, perceptions of health risks associated with vaping have increased, with a rise in the proportion of 15-16-year-olds who consider occasional e-cigarette use to carry moderate or great risk, both in Ireland^34,79 and across Europe^3,4 This shift may reflect intensified media coverage and public debate about harms. For example, the 2019 outbreak of e-cigarette or vaping-associated lung injury (EVALI) was linked to a marked increase in risk perceptions among 16-19-year-olds in several countries.⁸¹ In addition, regulatory reform such as Ireland’s 2023 Public Health (Tobacco Products and Nicotine Inhaling Products) Act,⁵³ and educational initiatives, including the integration of e-cigarette content into the SPHE curriculum⁷² may also have affected risk perception. Collectively, these trends demonstrate the impact that regulatory reform and targeted initiatives can have. The need for reform needs to be regularly reviewed, as products continue to evolve.

A key strength of the study is the employment of a qualitative methodology which provides meaningful insights into the attitudes and perceptions of schoolchildren, that would have been difficult to determine with a quantitative approach. Although the sample size was sufficient for thematic analysis,²⁵ the study was only conducted in three schools across three counties and are not statistically generalisable to all schoolchildren in Ireland. It was also restricted to 15-16-year-olds. Whilst this is a critical age in terms of the onset of smoking,⁷ other age groups may have had differing experiences that may have been important to ascertain. Furthermore, the qualitative design and use of a third person questioning technique also meant that a detailed socio-demographic profile of participants was not obtained. This makes it difficult to assess the generalisability of findings. Despite these limitations, the study does provide an in-depth understanding of factors affecting e-cigarette use which can inform prevention efforts and policy responses.

Conclusion

In the relative absence of regulation, schoolchildren in Ireland have been exposed to e-cigarettes, potentially leading to experimentation and use alongside tobacco and alcohol. At the time of data collection in 2019, with limited information about their health effects many schoolchildren perceived e-cigarettes as healthier alternatives to regular cigarettes. While awareness of vaping risks has since increased, experimentation remains normalised among some young people, highlighting the ongoing relevance of this study. There is a clear need to address the current policy vacuum and formulate a way forward to tackle children’s use of e-cigarettes in addition to a range of health risk behaviours such as smoking and alcohol, which are all closely interlinked. This study informed the enactment of age-based restriction on retail of e-cigarettes and licensing of retailers through the Public Health (Tobacco Products and Nicotine Inhaling Products) Act 2023.⁵³ But the imperative for further action underlined by this study means that plans for further legislation in Ireland, particularly in terms of restrictions on flavours, product packaging, product placement, advertising regulations, and the governance of underage discos must progress.⁸²

Supplemental Material

Suppplemental Material - The New ‘Cool’? A Qualitative Study of E-Cigarette Perceptions and Experience Among Irish Adolescents

Suppplemental Material for The New ‘Cool’? A Qualitative Study of E-Cigarette Perceptions and Experience Among Irish Adolescents by David S. Evans, Paul Hickey, Eamon Keenan, Paul Kavanagh in Tobacco Use Insights

Footnotes

Acknowledgements

We wish to express our sincere thanks to all the schoolchildren who participated in the focus groups. We are also grateful to the staff at each of the participating schools and the Environmental Health Service for facilitating the research. Special appreciation goes to Claire Dunne, Fiona Kavanagh, and Patricia Opeoluwa (Department of Public Health, HSE West) for their valuable assistance throughout the project and for their help with proofreading.

ORCID iDs

David S. Evans

Eamon Keenan

Paul Kavanagh

Ethical Considerations

Ethical approval for the study was received from the HSE Sligo and HSE Northeast Hospital Research Ethics Committees.

Consent to Participate

Obtained from school principals, parents and adolescents.

Author contributions

DE and PH conceptualised the study. DE and PH conducted data analysis. All authors contributed to the writing of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Available from Department of Public Health, HSE West and North West, Merlin Park Hospital Campus, Galway, H91 N973.*

Supplemental Material

Supplemental material for this article is available online.

References

Cullen

Gentzke

Sawdey

, et al. e-Cigarette use among youth in the United States, 2019. JAMA. 2019;322(21):2095-2103. doi:10.1001/jama.2019.18387

Wang

Gentzke

Creamer

, et al. Tobacco product use and associated factors among middle and high school students—United States, 2019. MMWR Surveill Summ. 2019;68:1-22. doi:10.15585/mmwr.ss6812a1

ESPAD Group . ESPAD report 2019: results from the european school survey project on alcohol and other drugs. 2020. https://www.espad.org/sites/default/files/2020.3878_EN_04.pdf

Hanafin J, Sunday S, Fitzmaurice H, Clancy L . ESPAD Ireland 2024: Results from the European School Survey Project on Alcohol and Other Drugs. Dublin, Ireland: TobaccoFree Research Institute Ireland for the Department of Health; 2025. https://arrow.tudublin.ie/cgi/viewcontent.cgi?article=1001&context=tobacreports&utm

Tarasenko

Ciobanu

Fayokun

Lebedeva

Commar

Mauer-Stender

. Electronic cigarette use among adolescents in 17 European study sites: findings from the global youth tobacco survey. Eur J Publ Health. 2022;32(1):126-132. doi:10.1093/eurpub/ckab180

Brennan

Bowe

Sheridan

Doyle

Boland

Kavanagh

. Evolution of nicotine product use in Ireland 2015–2023, and associations with quit intentions and attempts: an analysis of nationally representative repeated cross-sectional surveys. Lancet Reg Health Eur. 2025;55:101352. doi:10.1016/j.lanepe.2025.101352

Gavin

Kolto

Lunney

, et al. The Irish health behaviour in school-aged children (HBSC) study 2022. 2024. https://www.universityofgalway.ie/media/healthpromotionresearchcentre/hbscdocs/nationalreports/HBSC-2022-National-Report.pdf

Wang

Neff

Park-Lee

Ren

Cullen

King

. E-cigarette use among middle and high school students—United states, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1310-1312. doi:10.15585/mmwr.mm6937e1

Tattan Birch

Jackson

Kock

Dockrell

Brown

. Rapid growth in disposable e cigarette vaping among young adults in Great Britain from 2021 to 2022: a repeat cross sectional survey. Addiction. 2023;118(2):382-386. doi:10.1111/add.16044

10.

Tattan-Birch

Brown

Shahab

Beard

Jackson

. Trends in vaping and smoking following the rise of disposable e-cigarettes: a repeat cross-sectional study in England between 2016 and 2023. Lancet Reg Health Eur. 2024;42:100924. doi:10.1016/j.lanepe.2024.100924

11.

Vyas

Bennett

Hamel

, et al. Effectiveness of e-cigarettes as a stop smoking intervention in adults: a systematic review. Syst Rev. 2024;13(1):168.

12.

Glantz

Bareham

. E-cigarettes: use, effects on smoking, risks, and policy implications. Annu Rev Publ Health. 2018;39:215-235. doi:10.1186/s13643-024-02572-7

13.

US Department of Health and Human Services . E-cigarette use among youth and young adults. In: A Report of the Surgeon General. Atlanta, GA; 2016.

14.

Zavala-Arciniega

Cook

Hirschtick

, et al. Longitudinal associations between exclusive, dual and polytobacco use and respiratory illness among youth. BMC Public Health. 2024;24(1):2159. doi:10.1186/s12889-024-19582-8

15.

Chadi

Minato

Stanwick

. Cannabis vaping: understanding the health risks of a rapidly emerging trend. Paediatr Child Health. 2020;25(Supplement_1):S16-S20. doi:10.1093/pch/pxaa016

16.

Murray

Quigley

Quattrone

Englund

Di Forti

. Traditional marijuana, high potency cannabis and synthetic cannabinoids: increasing risk for psychosis. World Psychiatry. 2016;15(3):195-204. doi:10.1002/wps.20341

17.

Chung

Lim

Stjepanović

Hall

Connor

Chan

. Adolescent Cannabis vaping trends (2021–2023): Delta-9-Tetrahydrocannabinol, Cannabidiol, and synthetic cannabinoids. Am J Prev Med. 2025;107655. doi:10.1016/j.amepre.2025.107655

18.

SCHEER (Scientific Committee on Health Environmental and Emerging Risks) . Scientific opinion on electronic cigarettes. 2021. https://health.ec.europa.eu/document/download/50b3adac-5451-47c1-8427-ea67e874c970_en

19.

Soneji

Barrington-Trimis

Wills

, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr. 2017;171(8):788-797. doi:10.1001/jamapediatrics.2017.1488

20.

Khouja

Suddell

Peters

Taylor

Munafò

. Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis. Tob Control. 2021;30(1):8-15. doi:10.1136/tobaccocontrol-2019-055433

21.

O'Brien

Long

Lee

McCarthy

Quigley

. Electronic cigarette use and tobacco cigarette smoking initiation in adolescents. In: An Evidence Review; 2020.

22.

Sunday

Keogan

Hanafin

Clancy

. ESPAD 2019 Ireland, summary results from the european school survey project on alcohol & other drugs in Ireland. 2020.

23.

Bischoping

Dykema

. Toward a social psychological programme for improving focus group methods of developing questionnaires. J Off Stat. 1999;15(4):495-516.

24.

Heary

Hennessy

. The use of focus group interviews in pediatric health care research. J Pediatr Psychol. 2002;27(1):47-57. doi:10.1093/jpepsy/27.1.47

25.

Guest

Namey

McKenna

. How many focus groups are enough? Building an evidence base for nonprobability sample sizes. Field Methods. 2017;29(1):3-22. doi:10.1093/jpepsy/27.1.47

26.

Lasch

Marquis

Vigneux

, et al. PRO development: rigorous qualitative research as the crucial foundation. Journal article. Qual Life Res. 2010;19(8):1087-1096. doi:10.1007/s11136-010-9677-6

27.

Clow

James

Qualitative Research . Essentials of Marketing Research: Putting Research into Practice. Sage Publications; 2014:95-126.

28.

Burnard

. A method of analysing interview transcripts in qualitative research. Nurse Educ Today. 1991;11(6):461-466.

29.

Bingham

. From data management to actionable findings: a five-phase process of qualitative data analysis. Int J Qual Methods. 2023;22:16094069231183620.

30.

Evans

Hickey

. E-cigarette and smoking use among adolescents in Ireland: a focus group study. 2020. https://www.drugsandalcohol.ie/33759/

31.

Western Region Drug Alcohol Task Force and Youth p . Western Region Drug and Alcohol Task Force, Planet Youth. Growing up in the West, County Report Galway. 2019.

32.

Kong

Krishnan-Sarin

. A call to end the epidemic of adolescent E-cigarette use. Drug Alcohol Depend. 2017;174:215-221. doi:10.1016/j.drugalcdep.2017.03.001

33.

Morean

Krishnan-Sarin

O’Malley S

. Assessing nicotine dependence in adolescent E-cigarette users: the 4-item patient-reported outcomes measurement information system (PROMIS) Nicotine dependence item bank for electronic cigarettes. Drug Alcohol Depend. 2018;188:60-63. doi:10.1016/j.drugalcdep.2018.03.029

34.

Hanafin

JSS

Fitzmaurice

Clancy

. ESPAD Ireland 2024: results from the european school survey project on alcohol and other drugs. 2025. https://www.drugsandalcohol.ie/43291/1/ESPAD-Ireland-2024.pdf

35.

Mishra

Chaturvedi

Datta

Sinukumar

Joshi

Garg

. Harmful effects of nicotine. Indian J Med Paediatr Oncol. 2015;36(1):24-31. official journal of Indian Society of Medical & Paediatric Oncology .

36.

Govindarajan

Spiller

Casavant

Chounthirath

Smith

. E-Cigarette and liquid nicotine exposures among young children. Pediatrics. 2018;141(5):e20173361. doi:10.1542/peds.2017-3361

37.

Berry

Fetterman

Benjamin

, et al. Association of electronic cigarette use with subsequent initiation of tobacco cigarettes in US YouthsElectronic cigarette use and subsequent cigarette smoking InitiationElectronic cigarette use and subsequent cigarette smoking initiation. JAMA Netw Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794

38.

Van Hout

MCA

. Youth alcohol and drug use in rural Ireland--parents’ views. Rural Remote Health. 2009;9(3):1171.

39.

Leonard

Katelaar

. Dancing at the disco. 2024. https://alcoholforum.org/wp-content/uploads/2024/05/AFI-Teenage-Disco-Digital.pdf

40.

Baker

. Underage discos face stringent conditions. Irish Examiner. https://www.irishexaminer.com/breakingnews/ireland/underage-discos-face-stringent-conditions-876236.html Accessed 16th August 2019.

41.

Evans

(2019, June 6). New AI device detects both vaping and bullying in schools. Psychology Today, June 2019. https://www.psychologytoday.com/ie/blog/the-future-brain/201906/new-ai-device-detects-both-vaping-and-bullying-in-schools. Accessed 10 Nov 2025.

42.

Walley

Wilson

Winickoff

Groner

. A public health crisis: electronic cigarettes, vape, and JUUL. Pediatrics. 2019;143(6):e20182741. doi:10.1542/peds.2018-2741

43.

Mc Caffrey N. E-cigarette Packaging and Flavour Research . Report undertaken by IPSOS on behalf of the Irish heart foundation and the Irish cancer society. Irish Heart Foundation. https://irishheart.ie/publications/e-cigarette-flavour-options/

44.

Morean

Butler

Bold

, et al. Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults. PLoS One. 2018;13(1):e0189015. doi:10.1371/journal.pone.0189015

45.

Schneller

Bansal-Travers

Goniewicz

McIntosh

Ossip

Oâ€™Connor

. Use of flavored electronic cigarette refill liquids among adults and youth in the US- results from wave 2 of the population assessment of tobacco and health study (2014-2015). PLoS One. 2018;13(8):e0202744. doi:10.1371/journal.pone.0202744

46.

Erythropel

Jabba

DeWinter

, et al. Formation of flavorant-propylene Glycol Adducts with Novel Toxicological Properties in Chemically Unstable E-Cigarette Liquids. Nicotine & Tobacco Research; 2018.

47.

L121. directive 2014/40/EU of the european parliament and of the council of 3 April 2014 on the approximation of the laws, regulations and administrative provisions of the member states concerning the manufacture, presentation and Sale of tobacco and related products and repealing directive 2001/37/EC. Off J Eur Union. 2014;L127: 1-38.

48.

Department of Health . Minister for Health Secures Government Approval to Introduce Greater Restrictions on Vapes. Government of Ireland. Updated 10 September 2024. https://www.gov.ie/en/department-of-health/press-releases/minister-for-health-secures-government-approval-to-introduce-greater-restrictions-on-vapes/

49.

Evans

Flanagan

Hickey

. An audit of the availability and accessibility of E-cigarettes- A case for considering regulation. NHIS Research Bulletin. 2018;8(1):50.

50.

Best

Haseen

van der Sluijs

, et al. Relationship between e-cigarette point of Sale recall and e-cigarette use in secondary school children: a cross-sectional study. BMC Public Health. 2016;16(1):310. doi:10.1186/s12889-016-2968-2

51.

Van Hurck

Nuyts

Monshouwer

Kunst

Kuipers

. Impact of removing point-of-sale tobacco displays on smoking behaviour among adolescents in Europe: a quasi-experimental study. Tob Control. 2019;28(4):401-408. doi:10.1136/tobaccocontrol-2018-054271

52.

McNeill

Lewis

Quinn

, et al. Evaluation of the removal of point-of-sale tobacco displays in Ireland. Tob Control. 2011;20(2):137-143. doi:10.1136/tc.2010.038141

53.

Government of Ireland . Public health (tobacco products and nicotine inhaling products) act 2023. 2023. https://www.irishstatutebook.ie/eli/2023/act/35/enacted/

54.

Government of Ireland . European Union (Manufacture Presentation and Sale of. Tobacco and Related Products) Regulations 2016 (S.I. No. 271 of 2016), as amended: Market developments concerning electronic cigarettes and refill containers (Article. 32). Irish Statute Book. https://www.irishstatutebook.ie/eli/2016/si/271/made/en/print (2016).

55.

Irish Cancer Society, Irish Heart Foundation . E-cigarettes and heated tobacco products: an evidence review by the Irish heart foundation and Irish cancer society. 2019.

56.

Vassey

Galimov

Kennedy

Vogel

Unger

. Frequency of social media use and exposure to tobacco or nicotine-related content in association with E-cigarette use among youth: a cross-sectional and longitudinal survey analysis. Prev Med Rep. 2022;30:102055. doi:10.1016/j.pmedr.2022.102055

57.

Collins

Glasser

Abudayyeh

Pearson

Villanti

. E-cigarette marketing and communication: how e-cigarette companies market e-cigarettes and the public engages with e-cigarette information. Nicotine Tob Res. 2017;21(1):14-24. doi:10.1093/ntr/ntx284

58.

Government of Ireland . Online safety and media regulation act 2022. 2022. https://www.oireachtas.ie/en/bills/bill/2022/6/

59.

Coleman

Johnson

Tessman

, et al. It’s not smoke. It’s not tar. It’s not 4000 chemicals. Case closed: Expeoring attitudes, beliefs, and perceived social norms of e-cigarette use among adult users. Drug Alcohol Depend. 2016;159:80-85. doi:10.1016/j.drugalcdep.2015.11.028

60.

Amrock

Lee

Weitzman

. Perceptions of e-cigarettes and noncigarette tobacco products among US youth. Pediatrics. 2016;138(5):e20154306. doi:10.1542/peds.2015-4306

61.

Gorukanti

Delucchi

Ling

Fisher-Travis

Halpern-Felsher

. Adolescents’ attitudes towards e-cigarette ingredients, safety, addictive properties, social norms, and regulation. Prev Med. 2017;94:65-71. doi:10.1016/j.ypmed.2016.10.019

62.

Hung

Spencer

Goh

, et al. The association of adolescent e-cigarette harm perception to advertising exposure and marketing type. Arch Public Health. 2022;80(1):114. doi:10.1186/s13690-022-00867-6

63.

Simons-Morton

. The protective effect of parental expectations against early adolescent smoking initiation. Health Educ Res. 2004;19(5):561-569. doi:10.1093/her/cyg071

64.

Centers for Disease Control and Prevention . Health communications in tobacco prevention and control. 2018. https://www.cdc.gov/tobacco/stateandcommunity/bp-health-communications/pdfs/health-communications-508.pdf

65.

Fite

Cushing

Poquiz

Frazer

. Family influences on the use of e-cigarettes. J Subst Use. 2018;23(4):396-401.

66.

Strongin

. E-Cigarette chemistry and analytical detection. Annu Rev Anal Chem. 2019;12(1):23-39. doi:10.1146/annurev-anchem-061318-115329

67.

Jenssen

Boykan

. Electronic cigarettes and youth in the United States: a call to action (at the local, national and global levels). Children. 2019;6(2):30. doi:10.3390/children6020030

68.

European Union Drugs Agency . Synthetic cannabinoids in Europe (perspectives on drugs). 2017. https://www.euda.europa.eu/publications/pods/synthetic-cannabinoids_en

69.

O’Mahony

O’Malley

Kerrigan

McDonald

. HHC-Induced psychosis: a case series of psychotic illness triggered by a widely available semisynthetic cannabinoid. Ir J Psychol Med. 2024;41(3):405-408. doi:10.1017/ipm.2024.3

70.

Department of Health . HHC Is now Illegal. Department of Health; 2025. https://www.gov.ie/en/department-of-health/campaigns/hhc-hexahydrovannabinol/ Accessed 8th Sept 2025.

71.

Centers for Disease Control and Prevention . Best practices user guide: youth engagement in tobacco prevention and control. 2019.

72.

Health Service Executive DoE . Making healthy choices 1, activities to support the teaching of the updated junior cycle SPHE specification 2023. 2023. https://www.hse.ie/eng/about/who/healthwellbeing/hse-education-programme/junior-cycle-sphe-training-resources/healthy-choices/

73.

Sontag

Wackowski

Hammond

. Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall. Prev Med Rep. 2019;16:100966. doi:10.1016/j.pmedr.2019.100966

74.

Coady

Chan

Auer

Farley

Kilgore

Kansagra

. Awareness and impact of New York City's graphic point-of-sale tobacco health warning signs. Tob Control. 2013;22(e1):e51-e56. doi:10.1136/tobaccocontrol-2011-050261

75.

Borland

Yong

, et al. The association between exposure to point of sale anti smoking warnings and smokers' interest in quitting and quit attempts: findings from the international tobacco control four country survey. Addiction. 2012;107(2):425-433. doi:10.1111/j.1360-0443.2011.03668.x

76.

U.S. Food and Drug Administration . Youth E-Cigarette Prevention 1. U.S. Food and Drug Administration. Accessed 01/07/25, 2025.https://digitalmedia.hhs.gov/tobacco/print_materials/CTP-120

77.

Berry

Fetterman

Benjamin

, et al. Association of electronic cigarette use with subsequent initiation of tobacco cigarettes in US youths. JAMA Netw Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794

78.

Hughes

Bellis

Hardcastle

, et al. Associations between e-cigarette access and smoking and drinking behaviours in teenagers. BMC Public Health. 2015;15(1):244. doi:10.1186/s12889-015-1618-4

79.

Sunday

Hanafin

Clancy

. ESPAD 2019 Ireland: results from the european schools project on alcohol and other drugs in Ireland. 2020. https://www.tri.ie/uploads/5/2/7/3/52736649/espad_2019_ireland.pdf

80.

Jamal

Park-Lee

Birdsey

, et al. Tobacco product use among middle and high school students—national youth tobacco survey, United States, 2024. MMWR Morb Mortal Wkly Rep. 2024;73(41):917-924. doi:10.15585/mmwr.mm7341a2

81.

East

Reid

Burkhalter

, et al. Exposure to negative news stories about vaping, and harm perceptions of vaping, among youth in England, Canada, and the United States before and after the outbreak of E-cigarette or vaping-associated lung injury (‘EVALI’). Nicotine Tob Res. 2022;24(9):1386-1395. doi:10.1093/ntr/ntac088

82.

Department of Health . Public Consultation on Further Regulation of Tobacco and Nicotine Inhaling Products. Government of Ireland. https://www.gov.ie/en/department-of-health/consultations/public-consultation-on-further-regulation-of-tobacco-and-nicotine-inhaling-products/ Accessed 10th July 2025.

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