A Qualitative Exploration of Young South African Women’s Patterns and Reasons for Using E-Cigarettes

Abstract

Electronic cigarettes have become increasingly popular, especially among young people when compared to other demographic groups. This study explored young South African women’s experiences of using e-cigarettes. Age of initiation, patterns and reasons for using e-cigarettes, the financial impact and the experience of quitting were explored. This qualitative study used an interpretive research paradigm. Data were collected from three focus groups that were guided by a discussion guide. The total sample comprised 11 young women aged between 18 and 25 years who had used or were using e-cigarettes. Data were analysed using thematic analysis with the aid of NVivo version 12. Findings revealed five key themes: (1) age of e-cigarette initiation ranged from pre-adolescence to adolescence, and in adulthood; (2) patterns of use included occasional and daily use, concurrent use with tobacco products (dual use) and use with tobacco products and alcohol. Participants reported using e-cigarettes at social events, with other peers and alone; (3) reasons for use included emotional regulation (easing stress, boredom), peer pressure, experimentation, the appeal of e-cigarettes’ designs and flavours, ease of access and enhanced social media presence; (4) the impact of e-cigarette use weighed on financial and familial issues; (5) concerning quitting, only one participant reported successfully quitting while some participants had tried to quit but had been unsuccessful and advocated for more cessation support. Interventions to address how to better manage peer pressure, boredom and stress as well as policies to regulate the design and flavours of e-cigarettes are needed to help young women not to get initiated into a lifetime of nicotine addiction. Cessation support is also needed to assist young people (especially women) who wish to quit using e-cigarettes.

1. Introduction

Electronic cigarettes (e-cigarettes) are battery-operated devices that deliver an aerosol that is generated when a liquid mixture of nicotine and other chemicals is heated [1]. E-cigarettes do not contain tobacco and are thus generally regarded as nicotine (not tobacco) products. The nicotine in e-cigarettes could either be extracted from the tobacco plant or manufactured synthetically [2]. E-cigarette devices differ in shape, size and design while e-liquids are available in hundreds of different flavours. Some e-liquids do not contain nicotine but do contain other chemicals such as vegetable glycerine and propylene glycol.

Evidence from within South Africa and around the world shows that e-cigarettes are more popular among young people, used more by them and may serve as a gateway to using other addictive products [3]. This signals the importance of this study. The 2021 South African Global Adult Tobacco Survey found that, in South Africa, e-cigarette use was highest among 15- to 24-year-olds at 3.1% compared to 2.5% among the 25- to 44-year-olds and 0.9% among 45- to 64-year-olds [4]. Consistent with these findings, a Nigerian study of in-school adolescents and young adults aged between 15 and 35 years also found that the 18- to-24-year-olds had the highest odds of e-cigarette use at 61.9% compared to ages 24 to 35 years and the 15- to 18-year-olds at 35% and 2.5%, respectively [5]. It has further been reported that women are more likely than men to initiate e-cigarette use due to the influence of their family or friends [6].

There is also emerging evidence that links e-cigarette use to the initiation of smoking combustible cigarettes [7] and other drugs among young people [3]. A systematic review found that teenagers who had used e-cigarettes had four times higher odds of initiating smoking combustible cigarettes [8].

Existing evidence reveals that men are more likely to use e-cigarettes than women, but not much is known about the reasons for this. A 2020 survey conducted in Canada, the USA, England and Australia revealed that most women used e-cigarettes because they perceived it to be ‘less harmful to others’ whereas men mentioned that they perceive it to be ‘less harmful than smoking conventional cigarettes’ [9].

The use of e-cigarettes and their dual use with combustible cigarettes have been increasing in recent years in South Africa [10]. One reason for the increasing prevalence of e-cigarette use is the attractive designs and flavours offered to consumers. Young people are known to be particularly attracted to colourful images and products [11]. Therefore, the invention of attractive e-cigarette devices and the large variety of colourful flavours, such as strawberry, chocolate, cotton candy, bubble gum and apple, have been linked to the initiation of e-cigarette use by young people [12,13,14]. Research also shows that some young people use e-cigarettes as a means to cope with stress, anxiety, boredom, and other emotional states, highlighting that emotion regulation is a key psychosocial motivation for e-cigarette use [15].

Young people are also particularly susceptible to social influence, which creates vulnerability to risk-taking behaviours, particularly at an adolescent age [16]. With the advent of social media, the marketing and promotion of e-cigarettes has taken a different turn, creating regulatory nightmares for governments. The e-cigarette industry is known to use social media influencers [17] who create social media challenges. This increases the visibility of these products both online and offline and encourages young people to experiment with these products.

There is a lack of studies in South Africa exploring why e-cigarettes are popular among young people or why young women use these products and their experiences with buying or trying to quit using e-cigarettes. This study sought to explore the experiences of young South African women who use or have recently used e-cigarettes. Their age of initiation, patterns and reasons for using e-cigarettes, the financial impact and their experience with quitting were also explored.

This study contributes to understanding how and why nicotine addiction is initiated and sustained by young South African women. The study findings contribute to the broader substance use literature and offer a better understanding of psychosocial factors that influence addictive behaviours.

2. Materials and Methods

2.1. Design

A qualitative research design using the interpretive paradigm was used due to its alignment with the intentions of this study. A qualitative research method is suitable for gaining a deeper understanding of a phenomenon and how it is experienced by a specific group of people [18,19].

2.2. Sample and Sampling Technique

Purposive and snowball sampling was used to identify potential participants who met the criteria for the study and who were then invited to participate. Inclusion criteria were, being a female participant aged between 18 and 25 years, currently attending a tertiary institution, currently using or having used e-cigarettes in the past and living in the Gauteng province of South Africa. Participants also had to confirm their willingness to participate in the study. Snowball sampling was used to reach more participants through already volunteered participants. While 18 participants agreed to participate in the study initially (six per focus group), only 11 young women participated due to COVID-19 challenges and ‘no-shows’ during the focus group discussions. However, this number was judged sufficient as the study was meant for a Master’s Dissertation. According to Bekele and Ago [20], qualitative researchers typically recommend 5 to 25 participants for a qualitative study that investigates lived experiences.

2.3. Data Collection Instrument

A semi-structured discussion guide was developed to guide the focus group discussions. Among other questions, participants were asked to share their age of initiation of e-cigarette use, patterns of use and reasons for using these products. A copy of the semi-structured discussion guide used for this study is provided as a Supplementary Materials. This study is part of a larger study that formed the master’s research project of the first author of this article, ZRSM [21].

2.4. Data Collection

Data were collected using three focus groups (FGs) with varying numbers of participants: FG1 = 2, FG2 = 3 and FG3 = 6, with a total of 11 participants. Initially, 18 participants agreed to participate in the study (6 per FG) as reported in the sampling section. All focus group discussions were held at venues suitable to and identified by the participants and all discussions were audio recorded to ensure that data were well captured. Two recording devices were used simultaneously as a risk management strategy. Participants gave permission to record the discussions after the reason for the study and why the recording was important were explained to the participants. Drawing on her facilitation experience, ZRSM, who conducted the focus group discussions, established a supportive environment for all participants by setting clear ground rules at the outset of the discussion. Some of the ground rules included confidentiality of participants’ opinions, respect for diverse viewpoints, equal opportunities for everyone to speak and the encouragement that all opinions, experiences and perceptions were valid. An icebreaker was used to make all participants feel at ease before the main interview questions were asked. The audio recordings were securely stored on two password-protected devices for safekeeping, with the first author having sole access to the audio recordings. Field notes were taken to complement the recorded data and to provide descriptions of non-verbal communications observed, which enriched the qualitative value of the data collected. Participants were each given a R50 airtime voucher. Five of the participants who had to travel to the venue of the focus group discussion were reimbursed with between R20 and R35 for their transportation.

2.5. Ethical Considerations

Ethical approval was obtained from the University of Johannesburg’s Research Ethics Committee (ref no: REC-01-074-2020). Key ethical principles for research were applied to ensure the dignity, privacy and autonomy of the study participants.

During the recruitment phase, participants were informed about the study and assured that their participation was voluntary and that their identity would be protected throughout the research. Participation was granted once consent forms were signed by participants. To maintain transparency and ensure the accuracy of the data collected, the study participants were invited to verify the data collected after transcribing and before the analysis of the data. Code names were used to maintain the confidentiality and anonymity of the participants.

2.6. Data Analysis

Audio recordings of FG discussions were first transcribed and thematically analysed with the aid of NVivo version 12. The data were analysed using a six-step inductive thematic analytical process developed by Braun and Clark [22]. The steps include familiarisation, systematically coding the data, identifying concepts and defining relations between them, generating themes, reviewing these themes in relation to codes, and defining and naming the themes [22].

3. Results

3.1. Sociodemographic Profile of Participants

Participants comprised 11 young women with ages ranging from 18 to 23 years. Only one participant reported quitting e-cigarette use recently and one reported using e-cigarettes occasionally. The remaining participants reported using e-cigarettes regularly. Although all race groups were considered, all participants were Black Africans. Table 1 shows the profile of all participants.

Table 1. Demographic and e-cigarette/tobacco use profile of study participants.

Participant Code No.	Age	Current E-Cigarette Use	Former E-Cigarette Use	Daily E-Cigarette Use	Occasional E-Cigarette Use	Dual Use of E-Cigarettes & Combustible Cigarettes	Quit
FG1P1	22	Yes	No	Yes	No	Yes	No
FG1P2	21	No	Yes	Yes	No	Yes	Yes
FG2P1	23	Yes	No	No	Yes	No	No
FG2P2	20	Yes	No	Yes	No	Yes	No
FG2P3	22	Yes	No	Yes	No	Yes	No
FG3P1	22	Yes	No	Yes	No	No	No
FG3P2	21	Yes	No	Yes	No	No	No
FG3P3	19	Yes	No	Yes	No	Yes	No
FG3P4	18	Yes	No	Yes	No	Yes	No
FG3P5	23	Yes	No	Yes	No	No	No
FG3P6	21	Yes	No	Yes	No	No	No

Table 2 presents a summary of the themes and subthemes. Results are categorised under five major themes: age of initiation, patterns of e-cigarette use, reasons for using e-cigarettes, the impact of e-cigarette use and attempts to quit using e-cigarettes.

Table 2. Summary of themes and subthemes.

No.	Theme	Sub-Theme
1.	Age of initiation	Initiation at pre-adolescence Initiation at adolescence Initiation at young adulthood
2.	Patterns of e-cigarette use	Frequency and dual use ○ Daily use ○ Occasional use ○ Dual use of e-cigarettes and hookah/alcohol Individual and social use of e-cigs ○ When alone ○ When with friends ○ At social events
3.	Reasons for using e-cigarettes	Internal reasons for using e-cigarettes: ○ Emotional regulation: ○ To ease stress ▪ Stress due to academic pressure ▪ Stress due to social relations ○ Ease boredom ○ Experimentation ○ Enjoying youthfulness ▪ Using e-cigs for fun ▪ Risk-taking: Using e-cigs due to the perception that you only live once (YOLO) External reasons for using e-cigarettes: ○ Pressure ▪ Pressure to belong/fit in ▪ Peer pressure from friends and peers ▪ Pressure from society ▪ Peer influence ○ Appeal of e-cigs ▪ Appealing flavours ▪ Appealing designs ▪ Portability and ability to use e-cigs anywhere ▪ Ability to be creative when using e-cigarettes ○ Social media influence ▪ Gaining popularity on social media ▪ Attraction to e-cig use on social media (Seeing Influencers on social media using e-cigs) ▪ The use of e-cigs to gain social media followers ○ Easy accessibility and proliferation of e-cigarettes
4.	The impact of e-cigarette use	Financial impact of e-cigarettes ○ Costs of e-cigarettes ○ E-cigs are more expensive ○ E-cigs are less expensive Impact on family members ○ Parents buying e-cigarettes for children
5.	Attempts to quit using e-cigarettes	Successful in quitting e-cig use Failed attempts to quit e-cigarette use Lack of cessation support

3.1.1. Age of Initiation

The majority of the participants in this study started using e-cigarettes between the ages of 13 and 18 years while in high school. One participant mentioned starting e-cigarette use in her early 20s in her first year at university. She attributed this to the independence experienced at university, freedom and a greater degree of autonomy from parental control. Other participants responded as follows:

‘I think I was 15 years old when I started using e-cigarettes’

(FG1 P2)

‘We are away from parents and stuff; we get to do things without our parents seeing them and stuff yeah. The majority of us are from high school irrespective of whether it was last year or two years back but then now we are finding our own independence; we are learning to be on our own.’

(FG3 P3)

3.1.2. Patterns of E-Cigarette Use

The frequency of e-cigarette use differed across participants with the majority of the participants reporting daily use while a few reported occasional use. E-cigarette use was seen as a collective social practice rather than an individual practice. The use of e-cigarettes only when with friends and at social events such as parties was commonly cited by participants. Only one participant mentioned their preference for using e-cigarettes when alone because e-cigarettes had one mouthpiece, and e-liquid would finish quickly when shared with others. This participant reported that sharing e-cigarettes was less enjoyable than sharing hookah.

‘Yeah also that you know with friends—I think when you are with friends, you don’t get much of it [Participant 1 laughs] by the time it gets to you—the flavour [e-liquid] is already finished so you are not enjoying it.’

(FG1 P2)

Some of the participants also mentioned using e-cigarettes only when drinking alcohol or smoking hookah. Participants mentioned using e-cigarettes daily, especially during a stressful period (such as an exam season).

‘I do it, I do vape when I drink, most of the time … I normally do it with alcohol, where there is alcohol there is vaping.’

(FG3 P3)

3.1.3. Reasons for Using E-Cigarettes

The reasons for initiating or continuing the use of e-cigarettes were categorised into internal and external reasons. The internal reasons included relieving stress, relieving boredom, experimentation and enjoying youthfulness. The external reasons for using e-cigarettes included peer pressure and influence from peers and family, the appeal and accessibility of the products and social media influence.

Internal reasons for using e-cigarettes (Emotional regulation): Easing stress was frequently cited as the reason for using e-cigarettes. In particular, stressful situations such as dating, pressure from parents and academic pressure were mentioned as common causes of increased e-cigarette use among the participants. Participants also described university life as overwhelming and therefore used e-cigarettes as a form of stress management or as a coping mechanism. Participants associated the use of e-cigarettes with coping with ‘bad days’.

‘… The same applies to hubbly or vaping—the moment you start smoking and you release that smoke you feel much better. So, it’s sort of a stress reliever …’

(FG1 P2)

Another factor cited as a reason for e-cigarette use was boredom. E-cigarette use was viewed as a way of passing time and mitigating the feeling of boredom. The versatile nature of e-cigarettes once the vapour is released was also mentioned as another reason for use, such as releasing vapour creatively and forming different shapes through the mouth and nostrils, which was referred to as ‘fun’. The ability to create fun moments when using e-cigarettes was also described as enjoying youthfulness. ‘Sidla ubusha bethu’ or ‘re thabela bocha ba rona’ (respective meaning in isiZulu and Sesotho languages of South Africa: we are enjoying being young) were common phrases used by participants. This phrase relates to indulging in pleasurable pursuits, including risky behaviours, in the belief that ‘life is too short’ and ‘you only live once’ (termed ‘YOLO’ by the participants), hence the need to enjoy one’s self while young.

‘Ewe sidla ubusha bethu [meaning in isiXhosa and isiZulu: ‘yes—we are enjoying our youthfulness’].

(FG2 P3)

External reasons for using e-cigarettes: While stress was identified as a reason for continued use, peer pressure and peer influence were identified as reasons for initiating e-cigarette use. Using e-cigarettes because it was a common practice among peers (peer influence), wanting to fit into popular groups and friends’ testimonies about the pleasant feeling after e-cigarette use were recurrent themes among the participants.

‘Yes, so when I got to res (student’s residence), I met friends, then they started to introduce me to these things. I joined them, it was fun and that’s how I learned vaping.’

(FG1 P1)

Participants reported feelings of curiosity due to the appeal and smell (flavours) of e-cigarettes, which led to experimentation.

‘We have a blue mix, uhm we have there is uh cherry, frozen cherry. The frozen cherry it’s like you are eating something like … it’s nice I can’t, I don’t know how to explain it, but it is nice, it’s like it’s frozen inside of your mouth when you … yeah it’s nice …’

(FG1 P1)

In addition, curiosity was aroused due to the popularity of these products on social media, especially when witnessing influencers using these products. Participants viewed e-cigarette use on social media as a fun and harmless activity and as a means of gaining popularity and increasing followership and ‘likes’.

‘It’s exposed completely like our celebrities are vaping, they are smoking hookahs. We see it daily in almost every music video; you will see it and in movies …’

(FG2 P2)

There were dissimilarities in perceptions of the accessibility of these products. Some participants believed that e-cigarettes were inaccessible, especially if far from urban areas, while some believed these products were easily accessible anywhere.

‘It’s out there now, it’s out there … you go out to clubs, you get to a shop, when you walk to town, you pass about five stores selling vapes and hookahs.’

(FG2 P2)

One participant blamed the government for the accessibility and proliferation of these products.

‘The person who did that, who bring it here in South Africa, they have to put them behind the bars because it’s like they use, they mix poisons to do those drug; so for me it’s those people who are wrong, it’s our government who is wrong to allow those things to be out here, knowing that this thing is … dangerous for us, will make us not feel well, not thinking straight.’

(FG2 P1)

3.1.4. The Financial Impact of E-Cigarette Use

The financial impact of using e-cigarettes mentioned by participants was related to the cost of the product. Participants also reported parents sometimes buying these products for their children. They mentioned that the minimum price for e-cigarettes was R100.

‘… Vapes start from R100 upwards.’

(FG3 P4)

In comparison to combustible cigarette costs, participants expressed mixed views with some perceiving e-cigarettes to be more expensive and others perceiving them to be cheaper.

‘… cigarettes are more like cheaper than vapes.’

(FG3 P4)

The number of puffs per device and the constant replenishment of flavours were cited as reasons for e-cigarettes being expensive.

‘The pens don’t last for long. One pen can last for maybe two weeks depending on how many times you smoke so it’s a lot.’

(FG3 P2)

Some participants viewed cigarettes as more expensive because of the need to repeatedly buy them.

‘I think cigarettes is expensive because you gonna like smoke maybe 10, every time, money for 10, where are you going to get that money?’

(FG2 P1)

To avoid losing their children to the streets, two participants stated that their families bought them e-cigarettes and some stated that they added money for e-cigarettes into their budget.

‘… back home, they have accepted it to the point that I can say “can you borrow me” and they just say “hey—you are exhausting,” and they just give me the money.’

(FG1 P1)

‘… eventually, they got me hubbly as well as a vape, so they bought them for me.’

(FG1 P2)

3.1.5. Quitting E-Cigarettes

Among the participants, only one had successfully quit e-cigarette use because of the health effects she had experienced.

‘Yeah, heart palpitations, I have headaches and what not and what not. So jah (yeah) I was so scared because heart palpitations are very scary, yes, so I stopped. I no longer smoke … it was not easy though cause when you see friends smoking vapes, you also want to vape, you also want to go there but from my experience, I don’t think I will ever go back there again.’

(FG1 P1)

Some participants indicated that they wanted to quit but the challenge was in making the decision while others had attempted without success.

‘Well, I think we all have a story of wanting to quit [laughs], but we don’t … I also tried but mina (me) I also said ey I tried but eish—I actually am not seeing myself stopping actually.’

(FG1 P2)

Some participants had not attempted to quit because they believed they were already addicted:

‘… even this morning before I got here—I was doing the things. For me, me—I am addicted to it.’

(FG1 P2)

While having not tried to quit, one participant noted that it may be difficult to quit due to the lack of cessation support. She further expressed that some people may want to quit but it is hard for them as they do not have a replacement for e-cigarettes. Another participant mentioned that the best approach to quitting was to adopt a gradual approach until one succeeded.

‘… I think they have tried. Firstly, I think it’s hard for them to quit, not having anything to replace with, if you are quitting cigarettes, what am I going to do, you need a substitute you know.’

(FG2 P1)

The inability to quit the use of e-cigarettes was also attributed to its perceived benefit of easing stress.

‘… so, it’s sort of a stress reliever hence it’s so difficult to actually quit vape.’

(FG1P2)

4. Discussion

This article reports on young women’s experiences of using e-cigarettes, including their patterns and reasons for use, age of initiation, financial impact and attempts to quit.

In this study, young women reported varied patterns of using e-cigarettes, including daily and occasional use as well as dual use with other tobacco products or alcohol. A 2017 systematic review and meta-analysis of longitudinal studies showed that e-cigarettes were associated with an increased risk of future cigarette smoking initiation and current cigarette smoking [14].

This study found that the majority of the participants initiated using e-cigarettes between the ages of 13 and 18 years while they were in high school. This is in line with existing research showing that the typical age of e-cigarette initiation ranges from 12 to 18 years [23,24,25,26]. For example, a study conducted among 4537 United States (US) high school students showed that the majority initiated e-cigarette use between the ages of 17 and 18 years [27]. However, it also found that early onset users—those who started at the age of 12 years—were more likely to report current use and frequent use compared to those who initiated e-cigarette use at the age of 14 or older [27].

Similarly, a study by Perez et al. noted that the greatest increases in initiation of e-cigarette use occurred between ages 18 and 19 for men and women, respectively [23]. Consistent with the findings of this study, they found that early initiation is often driven by peer pressure, curiosity, coping with stress and attempting to fit in or belong to a group [28,29].

Participants in this study identified a range of internal and external reasons for using e-cigarettes, with stress relief emerging as a prominent internal motivation. Although it is common to hear those who smoke cigarettes citing cessation as a reason for using e-cigarettes, evidence shows that most e-cigarette users end up not quitting smoking cigarettes but become dual users [30]. While not specific to determining dual use, a 2018 South African study on the association between e-cigarette use and quitting behaviour revealed that 36.2% of women and 36.1% of men who used e-cigarettes used both combustible and e-cigarettes [31]. This is further corroborated by a study conducted in Poland among 15–19-year-olds, which monitored e-cigarette use between 2010 and 2011, and 2013 and 2014. This study revealed a simultaneous increase in the use of conventional cigarettes from 23.9% to 39% (2010 to 2011, and 2013 to 2014) and for e-cigarettes from 21.8% to 36% during the same period [32]. The simultaneous increase in e-cigarette and combustible cigarette use among the youth population in Poland confirms dual use and is consistent with studies conducted in the US [33].

The academic pressure and social dynamics faced by these young women illustrate the complex interplay between mental health and substance use, suggesting that e-cigarettes are often perceived as a coping mechanism [34,35]. Furthermore, the study found that young women engaged in e-cigarette use not only for stress relief but also for entertainment and social acceptance.

These patterns are supported by theoretical literature, such as the Health Belief Model, which explains that individuals’ perceptions and decisions about health risk behaviours are shaped by factors such as social influences, perceived susceptibility, perceived benefits and social norms [36,37]. For example, while most participants in this study were aware of the health risks associated with e-cigarette use, they continued to use e-cigarettes due to the perceived social benefits—the desire to fit in and feel a sense of belonging. This may have influenced their quitting behaviour with several participants reporting attempting to quit and wanting to quit yet continuing to use e-cigarettes to avoid social exclusion and bullying. Also, the use of e-cigarette for emotional regulation (like stress relief, and cope with boredom) was highlighted by the participants, which is aligned with findings from a previous study among young Australians [15].

The customisability and aesthetic appeal of e-cigarettes contribute to their attractiveness, reinforcing self-identity and social status among peers [11].

Previous research studies corroborate this study’s findings that young adults use e-cigarettes to regulate their emotions, that is for relaxing or relieving stress, and to feel good [32,33,38]. This study revealed that e-cigarettes were viewed as a way of passing time and mitigating a sense of boredom. The use of e-cigarette for emotional regulation (like stress relief and coping with boredom), as highlighted by the participants, aligns with findings from a previous study among young Australians [15].

Young women perceived these products as intriguing due to the variety of designs and colours. Previous studies have linked the customisability of e-cigarettes to the promotion of self-identity, reflecting a sense of fashion and lifestyle preference as well as the enjoyment of blowing out large clouds of the aerosol for entertainment [38].

Pressure and influence from peers, friends and family, social media and the appeal and ease of access to these products were identified as external reasons for e-cigarette use. This corroborates the findings from studies conducted in the US, which found that having social networks who used e-cigarettes and peer influence were positively associated with the initiation of e-cigarettes use [35].

External pressures, such as peer influence and social media trends, were also significant factors influencing the initiation and continuation of e-cigarette use. The normalisation of e-cigarettes in social contexts can create positive attitudes towards their use, further entrenching their appeal among young women [39]. Existing research on gender further highlights differences in the motivations behind e-cigarette initiation [9]. A study by Piñeiro found that boys and men were more likely to start using e-cigarettes due to peer pressure and for enjoyment, whereas girls and women reported using them primarily to cope with stress [6]. However, in this study, participants mentioned both peer pressure and stress management as reasons for using e-cigarettes.

These findings are consistent with the findings of previous literature [11,12,38] that young people are attracted to using e-cigarettes because of their availability, range of exotic flavours and sleek design. The attractiveness of these products gives young people the impression that the products are less harmful than combustible cigarettes [40]. Previous studies conducted among university students have also implicated peer pressure as a contributory factor to initiating e-cigarette use [41].

In this study, young women also mentioned that their use of e-cigarettes enabled them to gain social media popularity as it earned them followers and financial incentives. This aligns with findings from other studies that highlight how peer influence and social media visibility play significant roles in promoting e-cigarette use, particularly among young women [42]. Social media normalises e-cigarettes and encourages the formation of positive attitudes towards e-cigarettes by other young people, which could then lead to their experimenting with these products [42]. Furthermore, evidence shows that gender differences in e-cigarette use were also mediated by influencers and social networks. A 2016 qualitative study conducted in the US among e-cigarette users revealed that male users were more likely to report initiation of e-cigarettes as a tool to quit smoking conventional cigarettes for health reasons, whereas female users reported initiation of e-cigarettes due to social influence [6]. In addition to addiction, male users attributed continued use of e-cigarettes to enjoyment and taste, whereas female users’ continued use was linked to stress reduction and mood management. The study also concluded that female users were more responsive to social influence surrounding e-cigarette use [6].

This study found that while some young women reported that they spent more money on e-cigarettes, others believed that the initial bulk cost lay with buying the first product, after which it became cheaper to continue buying the e-liquid. The financial burden associated with e-cigarette use cannot be overlooked. While some participants indicated that the initial investment was high, they believed ongoing costs were manageable, leading to a false sense of affordability. A 2021 South African study comparing the cost implications of using e-cigarettes to conventional cigarettes found that those who used e-cigarettes spent more on maintaining their use annually, between R8575 and R19,781 for daily users, compared to R6693 for those who used combustible cigarettes [43]. A South African study found that some university students used their government bursary—the National Student Financial Aid Scheme (NSFAS)—to buy e-cigarettes when they were paid [32].

Regarding quitting, the results of this study indicate that quitting e-cigarette use was not easy for many of the participants because of their addiction to nicotine and the easy accessibility of these products. Barriers to quitting were identified as perceived stress reduction and behavioural gratification derived from using the product. Other barriers to quitting included nicotine withdrawal symptoms, close proximity to other e-cigarette users and mental health challenges [44,45].

In addition, similar to this study’s findings, existing studies have shown mixed perceptions among young people regarding the health risks of e-cigarettes, especially when compared to traditional cigarettes. For example, a mixed-methods study among university students in South Africa revealed that while many participants believed e-cigarettes contained nicotine and were harmful, they still perceived them as a safer alternative [32]. Specifically, 17.0% believed e-cigarettes were less harmful than traditional cigarettes, 30.8% believed they were equally harmful and 44.9% believed they were more harmful [32].

4.1. Theoretical Underpinnings

The findings of this study align with the theoretical underpinnings of the ecological systems theory by Bronfenbrenner [46]. The ecological systems theory is a model showing how behaviour is shaped by multiple layers and nested systems—micro, exo and macro-systems (microsystems such as peers and family; exosystems such as social media and school; macrosystems such as policy and culture) [47]. Findings of this study indicate that peer pressure, social media, family and societal influences, including pressure from school, influence young women’s reasons for using e-cigarettes. Future studies should quantitatively investigate the extent to which each of these influences weighs on young women’s decisions to initiate and continue to use e-cigarettes and what policy and individual level interventions would work best to address them.

4.2. Limitations

The qualitative design used for this study enabled the inclusion of only a small number of participants (11 young women). All participants who agreed to participate in the study were Black Africans, despite the non-racial recruitment criteria. The results of this study might not apply to all young women in South African tertiary institutions or to other racial groups, even though Black Africans make up about 76% of the South African population. We recommend that future studies include all race groups in South Africa and investigate these findings using quantitative methods involving a larger sample size. Furthermore, participants’ responses were self-reported and may be subject to recall bias or social desirability, especially as a result of participants being among their peers. Despite these limitations, the findings of this study reveal significant insights for public policy. The internal and external motivations for e-cigarette use—ranging from emotional regulation (e.g., stress relief), and experimentation to peer influence and social media dynamics—underscore the necessity for targeted public health interventions for this population.

5. Conclusions

This study highlighted the concern that some young women initiated the use of e-cigarettes when they were below the legal age to buy tobacco products in South Africa. Also, the social norms developed around the use of e-cigarettes, including trends on social media, sleek designs and exotic flavours of e-liquids, attract young women to using these products. Interventions to reduce the uptake of e-cigarettes should include putting in place effective policies to regulate the marketing and promotion of these products, including on the internet, to protect young people from lifetime nicotine addiction. The findings from this study not only show some of the motivations behind e-cigarette use among young South African women but also emphasise the need for tailored public health interventions. Addressing the underlying issues of stress and social influence is crucial to crafting effective cessation programmes, gender-sensitive prevention interventions and policies aimed at reducing e-cigarette use prevalence in this vulnerable population.