Introduction
Vaping is thought to be safer than tobacco1 and involves inhaling an aerosol of glycerol and propylene glycol with varying nicotine concentration.Reference Martinelli, Candel, De, Talhout, Knapen and Van Schayck2 Vaping devices include pens, mods, and pod systems, which appeal to younger people and non-smokers.3 Rapid technological progression has outpaced regulation, complicating assessment of its health effects.Reference Giovacchini, Crotty Alexander and Que4 Recent statistics indicate a rise in experimentation among young people from 13.9 per cent in 2020 to 20.5 per cent in 2023,Reference Hellyer5 highlighting the dichotomous nature of vaping, promoted as a smoking cessation tool, while acting as a gateway to tobacco smoking in non-smokers.Reference Hartmann‐Boyce, McRobbie, Bullen, Begh, Stead and Hajek6
Vaping’s role in otolaryngological disease remains unclear, with limited research suggesting a probable association with oral and head and neck pathologies.Reference Hartmann‐Boyce, McRobbie, Bullen, Begh, Stead and Hajek6, Reference Kosmider, Cox, Zaciera, Kurek, Goniewicz and McRobbie7 This study aims to investigate the prevalence of vaping among an ENT patient population, with a focus on the attitudes to, and awareness of, vaping’s potential health risks.
Materials and methods
This was a questionnaire-based study. Adults equal to or older than 18 years attending ENT clinics in three hospitals within the mid and south Essex region of England were recruited. The hospitals serve a catchment population of 1.2 million people. Adults unable to provide informed consent were excluded.
A non-validated questionnaire was used to collect data on demographics, vaping behaviours, perceptions and awareness of risks posed by vaping, and the knowledge of vaping’s role in smoking cessation (Appendix 1). Printed surveys were administered from January to May 2024 to patients in the clinic waiting area prior to attending their appointment. Surveys with less than 50 per cent of questions answered were excluded from analysis.
Statistical analysis
Microsoft Excel (Version 16.9) was used for data organisation and cleaning. Statistical analysis was conducted using SPSS version 25. Descriptive statistics were calculated for categorical variables and chi-squared testing for relationships between demographics and vaping status.
Ethical considerations
The study was approved by the Mid & South Essex NHS Foundation Trust Clinical Effectiveness Unit under reference number GSURG089.
Results
Demographic information
There were 284 participants. Age categories were 18–25, 26–35, 36–45, 46–55, 56–65, 66–75, and 76-plus years (Table 1). Ages 18–25 had the highest number of vapers (n = 18; 26 per cent). No vapers were equal to or older than 76 years. Non-vapers tended to be older (ages 56-65; n = 47; 22 per cent). Around 54 per cent of vapers (n = 37) were female (M:F = 0.8). Three participants identified as non-binary: two were vapers, and one was a non-vaper.
Demographic data of survey respondents
Of the vapers, most had completed high school (n = 38; 58 per cent) and were employed (n = 44; 65 per cent) (Table 1). Of the non-vapers, the majority had also completed high school (n = 106; 50 per cent) and were employed (n = 119; 55 per cent). Unemployment was higher among vapers (13 per cent; n = 9) than non-vapers (6 per cent; n = 12) (Table 1), which reached statistical significance (p = 0.027) (Table 2). No significant difference was found between vaping status and the demographic factors of education or gender. Only one vaper (1 per cent) was a student, whereas five non-vapers (2 per cent) were students.
Chi-squared test of relationships between vaping habits and three demographic variables: gender, education and employment status
Vaping habits
Participants were allowed to select multiple options for specific questions. Out of all 284 participants, 24 per cent (n = 68) used vaping devices and 60 per cent (n = 40) vaped daily. Regarding vaping devices (Table 3 and Figure 1), pens were most popular (n = 51; 59 per cent). The most reported motive for vaping was smoking cessation (n = 41; 49 per cent), then stress alleviation (n = 15; 18 per cent), socialising with friends (n = 12; 14 per cent), flavour enjoyment (n = 8; 10 per cent) and curiosity (n = 6; 7 per cent) (Table 3 and Figure 1). Vaping devices were most sourced from convenience stores (n = 36; 47 per cent) (Table 3).
Graphical representation of selected vaping habits: (a) Types of vaping devices used; (b) Reasons for vaping.
Vaping habits of survey respondents
Perceptions and awareness of vaping
Less vapers (n = 16; 24 per cent) than non-vapers (n = 127; 60 per cent) viewed it as “very harmful” despite 28 per cent (n = 19) of vapers stating that they were “extremely aware” of the health risks, compared to 34 per cent (n = 73) of non-vapers (Table 4). A smaller proportion of vapers (n = 7; 10 per cent) and non-vapers (n = 28; 13 per cent) reported that they were “not aware at all” of the health concerns linked to vaping (Table 4). Most patients thought vaping was addictive: 84 per cent of vapers (n = 57), and 88 per cent of non-vapers (n = 189). Over 76 per cent (n = 52) of vapers and 85 per cent (n = 183) of non-vapers reported receiving no information on vaping’s known health hazards. For those who did receive information, the media was the most popular source, with 29 per cent (n = 26) of vapers and 31 per cent (n = 77) of non-vapers citing it. Social media, specifically, accounted for 17 per cent (n = 15) of vapers’ and 14 per cent (n = 35) of non-vapers’ information source (Table 4).
Perceptions and awareness of vaping
Vaping as a cessation tool and attitudes towards regulation
Among vapers, 91 per cent (n = 62) had previously smoked, whereas only 9 per cent (n = 6) had never smoked (Table 4). In contrast, over half of non-vapers (55 per cent, n = 118) had never smoked. Among vapers who had previously smoked, 72 per cent (n = 49) began vaping as an alternative to smoking; 18 per cent (n = 12) started vaping in addition to smoking (Table 4).
There was disparity in opinion between vapers and non-vapers when it came to vaping product regulations: 60 per cent (n = 41) of vapers supported stricter regulation, 12 per cent (n = 8) were against it, and 28 per cent (n = 19) were unsure (Table 4). Conversely, 84 per cent (n = 182) of non-vapers backed stricter regulation, while only 3 per cent (n = 7) were opposed and 8 per cent (n = 18) were unsure.
Suggestions for educational campaigns or support programmes
Graphical representation of selected vaping perceptions and awareness: (a) Perception of potential harm; (b) Awareness of health risks.
The most common proposal was to develop education in schools, which many respondents suggested in various ways (e.g., “education in school and university,” “school educational campaigns,” “school visits to educate”) (Table 5). Another frequently stated option was more regulation of vaping products, with participants urging measures such as “ban vapes,” “regulate to the same level as cigarettes” and “limit sales to minors.”
Condensed suggestions for educational campaigns and support programmes
Several participants also suggested more targeted awareness campaigns, including the use of media and social media to “push dangers of vaping” and increasing “warnings on the addictive effects of nicotine” (Table 5). A few respondents recommended increasing the legal purchasing age and making vaping products less accessible by measures like “locking them behind cabinets” or “reducing vape shops.”
Discussion
Synopsis of key findings
Our study found that patients aged 18–25 were most likely to vape, with higher unemployment among non-vapers. Pens were the vaping delivery device of choice and smoking cessation and stress relief the primary motivators to vaping. Both vapers and non-vapers considered vaping addictive, but vapers perceived it as less harmful that non-vapers, who supported stricter regulations. Suggested interventions included educational programmes in schools, stricter sales regulations and increased public awareness through media campaigns.
Comparison with other studies
Much of vaping research focuses on its rapid adoption, the growing understanding of its health and societal impacts. There was an age and educational difference between vapers and non-vapers, with an inverse correlation between vaping prevalence and the age of vapers, and a trend of fewer vapers with increasing age. This was evidenced by no vapers in the 76-plus age category, most vapers being within the 18–25 age category. This finding is consistent with previous research, indicating that younger age groups perceive vaping as a safer alternative to smoking or as a trend, making them more inclined to adopt it.Reference Szukalska, Szyfter, Florek, Rodrigo, Rinaldo and Mäkitie8 The gender distribution of vapers in this research was balanced, with a slight majority of females, contrasting with previous research that found vaping to be more prevalent among males.Reference Yimsaard, McNeill, Yong, Cummings, Chung-Hall and Hawkins9 Educational attainment was not found to be significant as both vapers and non-vapers exhibited similar levels of attainment.
Unemployed participants were more likely to vape, mirroring the trend in tobacco users, who, if unemployed, were twice as likely to smoke.10 Most vapers reported daily use, suggesting nicotine dependence. Vape pens were the most used devices, likely due to their low cost, prevalent marketing and disposable nature.1 The primary motivation for vaping was smoking cessation, yet a notable proportion of vapers cited other reasons, such as stress relief, flavour enjoyment and socialising. The diverse motivations indicate that, while some vapers may be using e-cigarettes as a harm reduction tool, others may be engaging in vaping for recreational and stress-coping purposes, potentially increasing their risk of long-term dependency.
Convenience stores emerged as the most common source for obtaining vaping products. The popularity of convenience stores can be attributed to the surge in new disposable e-cigarettes, with studies showing that, despite current restriction on purchases for under 18-year-olds, young people are still able to bypass current restrictions on their sale.Reference Debbaneh, Dhir, Anderson and Rivero11 This reflects the literature which has also reported a more recent shift of e-cigarette purchases to convenience stores and supermarkets.Reference Foulds, Veldheer and Berg12
Our study found that non-vapers perceived vaping as very dangerous and were more aware of potential health risks than vapers, who frequently viewed vaping as either slightly harmful or of neutral risk. Most participants thought vaping was addictive. Additionally, 83 per cent of participants had not received information on vaping-associated health risks. Those who did, mainly relied on general media and social media, with few crediting education establishments and healthcare professionals, suggesting a failure in public health communications to raise awareness on vaping’s impacts, which itself may be due to a paucity of concrete data. A considerable number of vapers had smoked before; however, 9 per cent had never previously smoked,Reference Kumral, Saltürk, Yildirim, Uyar, Berkiten and Atar13 raising concerns that it could become a gateway to nicotine addiction. Regarding vaping and tobacco users, one meta-analysis of 107 studies showed dual use to deliver a wider range of toxins than vaping or smoking alone and was associated with a 20–40 per cent increased risk of smoking related diseases than smoking alone.14
Non-vapers were more likely to support stricter regulation, indicating a need for a carefully balanced approach, considering both the public health imperative and the role played in smoking cessation. Compared to a placebo, e-cigarettes help smokers cut back or quit traditional cigarettes.Reference Jackson, Tattan-Birch and Brown15 However, this benefit is offset by dual use of both e-cigarettes and traditional cigarettes by smokers and by non-smoker usage.Reference Hartmann‐Boyce, McRobbie, Bullen, Begh, Stead and Hajek6 Understanding how motivations such as smoking cessation, stress relief and social influence drive vaping behaviour, and whether this contributes to the risk of transitioning to traditional smoking, is crucial for public health measures.
The study found a broad agreement on the need for more robust public health interventions, with both vapers and non-vapers proposing better teaching in schools and stricter regulations as significant measures, reflecting the desire for proactive measures to prevent vaping initiation among youth. Vaping regulation varies globally. Despite the UK’s Tobacco and Related Products Regulations on the marketing, chemical composition and sale of e-cigarettes,16 vaping device access by vulnerable populations remains problematic. Recent studies indicate that, while these regulations have curbed some harmful practices, they have not adequately addressed the issues posed by new sleeker product designs and modern marketing strategies.Reference Soule, Bansal-Travers, Grana, McIntosh, Price and Unger17
Vaping and ENT health
Vaping’s role in ENT diseases, particularly in contributing to inflammation, impaired mucociliary function and oral health complications, cannot be overlooked, despite studies showing that e-cigarettes contain fewer harmful chemicals than traditional cigarettes. Aerosolised e-liquid contains traces of toxicants and known carcinogens such as formaldehyde, acetaldehyde and acrolein, as well as particulate matter that may lead to respiratory and cardiovascular complications.Reference Berry, Fetterman, Benjamin, Bhatnagar, Barrington-Trimis and Leventhal18–Reference Golan, Muthigi, Ghomeshi, White, Saltzman and Diaz20 There is also evidence that vaping may play a role in the development of head and neck squamous cell carcinoma, but more long-term studies are required to validate this link given the relatively short history of e-cigarette usage and limited data,Reference Fadus, Smith and Squeglia21 but a systematic review by Wilson et al. (2023) found that e-cigarette exposure can promote oxidative stress, cytotoxicity and inflammation in head, neck and oral cells.Reference Golan, Muthigi, Ghomeshi, White, Saltzman and Diaz20 In vitro and animal studies have further demonstrated that e-cigarette-related inflammatory cytokines interfere with mucociliary function through reduced ciliary beat frequency and growth,Reference JC, Vrinten, Cheeseman, Bunce, Hopkinson and Filippidis22, Reference Wilson, Tellez Freitas, Awan, Ajdaharian, Geiler and Thirucenthilvelan23 increasing users’ susceptibility to chronic rhinosinusitis and otitis media.Reference Amanian, Phulka and Hu24 One study found that 48.9 per cent of vapers experienced at least one inflammatory condition, with the most common being chronic otitis media and allergic rhinitis.Reference JC, Vrinten, Cheeseman, Bunce, Hopkinson and Filippidis22
Clinical applicability
Educational material emphasising the potential health risks of vaping, including possible otolaryngological and respiratory complications, as well as the addictive nature of vaping should be considered in all ENT clinics. Further research is also needed to explore the long-term ENT-related health impacts of vaping.
Limitations of this study
The cross-sectional design restricted the capacity to demonstrate causal correlations between demographic characteristics, vaping habits, and attitudes. Self-reported statistics may also be influenced by response bias, especially on sensitive issues like smoking and vaping behaviours. Furthermore, the sample size and geographic concentration in the East of England may not represent the larger population, reducing the generalisability of the results.
• Almost a quarter of patients attending our ENT clinics reported vaping, with the highest rates seen in those aged 18–25 years and the unemployed.
• The primary reason for vaping was smoking cessation, followed by stress relief and social factors.
• Vapers viewed vaping as less harmful compared to non-vapers, over half of whom rated it as very harmful.
• Over three-quarters of respondents lacked information about the risks associated with vaping.
• There is a need for targeted educational campaigns and stricter regulations to address vaping’s potential impacts on ENT health.
Conclusion
These findings highlight the need for targeted educational campaigns and stricter regulations to address vaping’s potential health impacts, particularly in ENT. Further research is needed into the health risks vaping poses on ENT health so that patients can be better informed.
Source of financial support and funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethical considerations
The authors assert that all procedures contributing to this work comply with the ethical standards of the Mid & South Essex NHS Foundation Trust Clinical Effectiveness Unit under reference number GSURG089, and with the Helsinki Declaration of 1975, as revised in 2008.
Data sharing and availability
All data generated or analysed during this study are included in this published article and its supplementary information files.
Acknowledgements
None.
Appendix 1
Thank you for participating in our survey on vaping habits and perceptions among young adults. Your responses will contribute valuable insights to our research. Please answer the following questions honestly and to the best of your knowledge.
Demographics
1. What is your age? ______
2. What is your gender?
Male
Female
Non-binary
Prefer not to say
3. What is your level of education?
High school
University
Vocational/Technical school
Other (please specify): _______________
4. What is your current employment status?
Employed
Unemployed
Student
Other (please specify): _________________
Vaping Habits
5. Have you ever used vaping products or e-cigarettes?
Yes
No (If “No,” proceed to question 10)
6. How often would you vape?
Daily
Weekly
Monthly
Occasionally
Rarely
7. What types of vaping products have you used? (Select all that apply):
E-cigarettes
Vape pens
Mods
Pod systems
Other (please specify): _____________________
8. What are your reasons for vaping? (Select all that apply):
Smoking cessation
Socializing with friends
Flavour enjoyment
Stress relief
Curiosity
Other (please specify): _____________________
9. Where do you typically obtain vaping products?
Specialty vape shops
Convenience stores
Online
Social sources (friends, family)
Other (please specify): _______________________
Perceptions and Awareness
10. What is your perception of the harms of vaping?
Very harmful
Somewhat harmful
Neither harmful nor safe
Somewhat safe
Very safe
11. Are you aware of any health risks associated with vaping?
Extremely aware
Moderately aware
Slightly aware
Not aware at all
12. Do you believe that vaping is addictive?
Yes
No
Not sure
13. Have you ever received information on the health risks of vaping?
Yes
No
14. Where did you receive information on vaping health risks from? (Select all that apply):
Health professionals
Media (news articles, documentaries)
Educational institutions
Social media
Friends and family
Other (please specify): ____________________
N/A (I have never received information on this)
Additional Information
15. Have you ever smoked traditional cigarettes?
Yes
No
16. If you have smoked traditional cigarettes, did you start vaping as an alternative or in addition to smoking?
As an alternative
As an addition to smoking
N/A (I have not smoked traditional cigarettes)
17. Do you think vaping should be regulated more strictly?
Yes
No
Not sure
18. Do you have any suggestions for educational campaigns or support programs?
___________________________________________________________
___________________________________________________________
___________________________________________________________
Thank you for completing our survey. Your input is invaluable in understanding vaping habits among young adults. If you have any additional comments or suggestions, please feel free to share them below.
