Welsh primary schoolchildren’s perceptions of e-cigarettes: a mixed method study

Background: There are concerns that the growing popularity of e-cigarettes promotes experimentation among children. Current research has focused almost exclusively on children over 11 years. Given the possible lifelong health harms caused by behaviours established in early childhood, understanding younger children’s perceptions is essential; to inform tobacco control policies, prevention strategies and the wider debate on further regulation of vaping. In one of the first global studies to provide insights into younger children’s perceptions of e-cigarettes, we explored Welsh primary schoolchildren’s (aged 7-11) awareness of e-cigarettes relative to tobacco smoking, their understanding of the risks and benefits associated with e-cigarettes and their intentions and beliefs about vaping. Methods: Data was collected using a mix of methods in June and July 2017 from 8 purposively selected primary schools across Wales. Four hundred and ninety-five children (52% female), aged 7 years (n=165), 9 years (n=185) and 11 years (n=145) completed a class-administered booklet encompassing a draw and write exercise and questionnaire. Ninety-six children participated in 24 peer cohort-based discussion groups comprised of 2 boys and 2 girls. Data from the three tools were analysed independently and findings triangulated. Questionnaire analyses used frequencies, descriptive statistics and chi-squared tests. Content analysis was undertaken on the draw and write data and peer discussion groups were analysed thematically. Results: Primary schoolchildren have general awareness of e-cigarettes but understanding of any health harms or the role of nicotine in e-cigarettes is poor or misperceived, particularly in the youngest children. Vaping was viewed as healthier than smoking by most and there was some recognition that e-cigarettes were used for smoking cessation. Few children intended to smoke (1.8%) or vape (3.9%) in the future but almost half

. Children were instructed by a researcher to draw a person who smokes and describe why they smoke, how they feel and what they would see and smell if standing nearby. This was repeated for a person using e-cigarettes. Children were then instructed to complete the questionnaire, which collected demographic information, family smoking and vaping behaviours, knowledge and beliefs about electronic and tobacco cigarettes, and their future intentions to smoke or vape. Lastly, small group mixed-sex peer discussions were conducted with a subsample of children (n = 96). Two boys and two girls from each participating class were purposively selected by the teacher on the basis they would be confident and comfortable speaking with researchers outside the classroom (38).
To assess knowledge of and attitudes toward smoking and vaping, perceptions of health risks and social norms, participants were asked to discuss what they knew about electronic and tobacco cigarettes, who they thought vapes and smokes and why, the consequences of vaping and smoking and the influence of flavours on vaping behaviour. A range of photographs depicting tobacco and e-cigarettes, e-liquids and a variety of people vaping and smoking were used as elicitation devices to help prompt discussion with the children (42).

Data Analysis
Data from the three tools were analysed independently and findings triangulated. For D&W, an iterative qualitative coding framework was developed from the responses (27).
The children's written responses were coded by one researcher (LP), refined and then combined into content categories. Simple frequency counts were used and themes in the data were identified. A child's response was only counted once in each category but could be coded to several categories in the event that the answer had multiple responses.
Children's drawings were not coded but used to illustrate typical themes emerging in the data. Another researcher (AG) reviewed the coding system to aid the credibility and trustworthiness of the analysis, any anomalies were discussed and a final decision was jointly made. Questionnaire data were entered, cleaned and analysed in SPSS v23.
Analyses used frequencies, descriptive statistics and chi-squared tests. Peer discussions were recorded using a digital audio device, transcribed verbatim and imported into QSR NVivio 11 (QSR International Pty Ltd. Version 11, 2012) to assist with coding and analysis.
The native Welsh speaking research assistants transcribed the Welsh peer discussions and checked each other's work for accuracy. Thematic analysis (43) carried out by one researcher (KRH) and cross-checked by another (LP) was both theory-driven, informed by existing literature and the topics covered in the peer discussion and data-driven, with themes emerging from the qualitative data. Transcripts were read and open coded line by line. Codes were then grouped into categories and examined for salient themes (43).
Saturation was considered to be reached as no new codes were identified in the final transcripts analysed.

Participant Characteristics
Similar numbers of children were recruited from each year group: aged 6-7 years (33.3%); 8-9 (37.4%) and 10-11 (29.3%) and 27.8% reported that they spoke the Welsh language at home. Two schools were in urban areas, 5 were rural and 1 semi-rural. Two schools were in the most deprived and 2 schools in least deprived deprivation category (44) ( Table 1). Table 1 here

Awareness of e-cigarettes
Children across the 3 year groups demonstrated a general awareness of e-cigarettes. The vast majority (94.9%) could distinguish pictures of e-cigarettes from tobacco cigarettes in the questionnaire (year 2, 89%; year 4, 96.7%; year 6, 100%: p<0.001). Most thought electronic and tobacco cigarettes looked different from each other (93.3%) and that the internal components were different (82.5%). Around half reported they smell different (51.1%) and the smoke was different (48.0%) ( Table 2). Table 2 here Awareness of e-cigarettes was evident in the peer discussions as well. Children across all 3 year groups were able to discern the difference between tobacco and e-cigarettes from a series of photograph, discussed them using appropriate terminology such as 'ecigarettes', 'e-cigs', 'electric fags' and 'vapes' and recognised they were different from tobacco cigarettes. The youngest children were of the opinion that e-cigarettes were comprised of 'metal and oil' or 'plastic' and 'glass'. Some said they contained 'chemicals', were reusable and more durable: "They might be stronger longer and you don't throw it away.'" (Female, Age 7, School 1) "I think they're better for you, you can charge them back up, you don't have to throw them out and that could start a fire." (Male, age 7, School 6) The older children, particularly those exposed to people who vape had a more nuanced understanding of e-cigarettes and were better able to discuss their composition, how they are used and the differing nicotine levels: In the questionnaire, a higher proportion of children thought tobacco cigarettes were used more (59.9%) and were easier to purchase (57.8%), than e-cigarettes. 73.7% reported seeing tobacco cigarettes more often than e-cigarettes (14.5%). Over six in ten (61.8%) also reported that e-cigarettes were safer to use than tobacco cigarettes ( Table 2). This was evidenced in the qualitative findings with some of the younger children in particular highlighting that ecigarettes did not need to be lit and therefore would not be a fire hazard: n=23; year 4, n=24, year 6, n=47) ( Table 3). Table 3 here In the peer discussions, awareness that e-cigarettes 'got fruit flavours inside of it' was commonplace and there was a general consensus across all age groups that sweet and fruit flavoured e-liquids were more likely to appeal to young people and could 'entice' and 'encourage' them to vape: "The young ones might be encouraged to use it, the electronic one, because they love fruit and they might not know that it is really unhealthy" (Female, Age 7, School 3) "I think that the younger people will want to do it because with all the different flavours, they just want to try them" (Female, Age 9, School 1) In peer discussions, many children were aware of a legal age of purchase for tobacco and e-cigarettes, although the majority were unsure of the exact age. Some thought that "anyone over the age of 16 There was some misunderstanding of the legal consequences of purchasing tobacco and ecigarette underage, with some of the younger children believing that children or their parents could go to prison if they were found to be smoking or vaping.
In the D&W exercise, the word addicted was mentioned 103 times, almost exclusively with regard to how tobacco smokers feel and why they smoke tobacco cigarettes. Addiction in relation to tobacco smoking was mentioned in all year 6 peer discussions but rarely with reference to e-cigarettes. Nicotine was also referred to less frequently by the older children when discussing either electronic or tobacco cigarettes. Few of the younger children actually used the terms addiction or nicotine when discussing smoking or vaping but discussions did convey some recognition of the concepts: Only a couple of the older children made the connection between nicotine and addiction: " They can also be really bad as well because say they had a flavour in them and they had nicotine then because the flavour could be addictive and then there is nicotine in it so could be then it could be the same as a normal cigarette" (Male, age 11, School 5) Notably a few of the children across the discussion groups knew the amount of nicotine in e-cigarettes was variable and could be altered to aid smoking cessation. Generally these were children exposed to someone who vaped: "And with them [e-cigarettes]…You can cut down….you can get ones with no nicotine at all" (Male, Age 9, School 2) "My father stopped smoking about 3 years ago now, he's been on vapes since then. He has been lowering the nicotine and he is down to zero now" (Male, Age 11, School 5)

Health harms of e-cigarettes
In general, children in the study had poor understanding of any health harms related to ecigarettes, often associating vaping and smoking with similar levels and types of harms.
Similar misperceptions emerged in the peer discussion groups. Younger children in particular thought e-cigarettes were healthier and less harmful than tobacco cigarettes because they contained fruit flavours: "It's strawberry flavoured and strawberries are healthy" (Female, Aged 7, School 1)

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One older child (age 11) felt 'safer' breathing in flavoured smoke rather than cigarette smoke, stating that: "I know someone that had one once and it was cherry flavour and every time they puffed it out it smelled really nice so it made me feel a bit better and safer that I'm not breathing in all the bad things" (Girl, Age 11, School 6).
Unsurprisingly, older children had a better grasp of the health consequences of tobacco smoking and whilst many were unsure how e-cigarettes impacted on health, many surmised that they would be better than or different to tobacco cigarettes, mainly because they of their composition: "There is not tobacco in them so they can't harm you as much" (Male, Age 11, School 7) "They are ever so slightly better because they have no tar and stuff" (Male, Age 11, There was also some appreciation by older children that potential health harms of ecigarettes are still unknown and therefore caution is warranted:

"I think people get a bit like 'Oh I want to try that' but they don't actually know the harms they [e-cigarettes] can do to you" (Female, Age 11, School 6)
In about 2 years' time we could find out that they're [e-cigarettes] even worse than the other ones but we don't know yet" (Male, Age 11, School 1) The notion that e-cigarettes were healthier than tobacco cigarettes prevailed throughout the study although e-cigarettes were still considered to be more harmful than not smoking or vaping at all. Questionnaire results showed that more than half believed that tobacco cigarettes were worse for smoker's lungs (59.6%) and worse for other people's lungs (55.4%) compared to e-cigarettes. This increased with age from 46% of children aged 7 years to 72.7% aged 11. More children (74.6%) thought smoking was never a good thing to do as compared to those who thought using an e-cigarette was never a good thing to do (57.5%). Children were less likely to feel that using an e-cigarette was never a good thing to do if they lived with somebody who used them (30.9%) compared to not living with more likely if the child lived with someone who smoked (p=0.02), and intention to vape was significantly more likely if they lived with an e-cigarette user (p<0.001) ( Table 2). ).
Almost all peer discussion participants were adamant that they would not smoke tobacco or use e-cigarettes in the future, primarily over concerns about the health consequences:

Acceptability of vaping and smoking
In the questionnaire, almost half of the children reported it was okay for grown-ups to use e-cigarettes (49.6%) or tobacco cigarettes (46.2%). Results were age related, with acceptability decreasing with age for both tobacco smoking in adults (p<0.001) and vaping in adults (p=0.024). Acceptability in adults was influenced by exposure to e-cigarettes in the home. Over a fifth (22.4%) indicated that somebody who lives in their household uses e-cigarettes and 32.3% had somebody in their household who smoked tobacco (Table 2). Children who lived with an e-cigarette user were more likely to report that it was ok for grown-ups to use e-cigarettes (63.0%), compared with of those who did not live with someone who used e-cigarettes (45.5%) (p=0.03) ( Table 2).
Subtle familial influences were noted in peer discussion data. Findings suggest that children who had family members that were e-cigarette users or smokers were much more knowledgeable about the products and could discuss how they were used and where they could be purchased. These children were also able to comment more broadly on the variety of fruit flavoured liquids available and the use of e-cigarettes to stop smoking.
Some understanding of role modelling was evident as well: "Also because sometimes if your mum or dad smokes they influence you because you're trying to be like your mum or dad or grownups-so if you see somebody who inspires you smoking you kind of want to do that (Male, Age 9, School 8) Acceptability of e-cigarette use in children was very low. Six (1.2%) participants thought it was okay for children their age to use e-cigarettes and only 1 (0.2%) to smoke tobacco cigarettes. There were no significant differences in acceptability of e-cigarette use by gender or age. It was also low for children who lived with e-cigarette users (1.8%) and those not living with e-cigarette users (1.0%) but this difference was statistically significant (p=0.005) ( Table 2).
Many of the children in peer discussions thought it was more acceptable for adults to use electronic and tobacco cigarettes than children because of the legal age restriction.
Furthermore, there was a perception that adults were better able to make decisions about behaviours that had potential risk. Some children suggested that the smoke from tobacco cigarettes was more harmful to children's bodies because they were still developing:

Study Limitations
Our study was based a small sample of 8 Welsh schools, purposively selected for maximum variation, and therefore findings cannot be generalised to all children in Wales.
As a school based mixed method study conducted in a classroom setting,