A qualitative analysis of how underage adolescents access nicotine vaping products in Aotearoa New Zealand.

INTRODUCTION: Despite policies setting a minimum legal sales age, youth continue to access electronic cigarettes (ECs). Evidence of rising youth vaping prevalence in many countries suggests existing measures have serious loopholes and raise important questions about how youth source vaping products. METHODS: We explored how youth source ECs using in-depth interviews with 30 adolescents aged 16-17 who vaped at least once a month and lived in Aotearoa New Zealand. Our semi-structured interview guide probed participants' vaping experiences and how they developed and used social, quasi-commercial, and commercial supply routes to access ECs. We used an inductive reflexive thematic analysis approach to interpret the data. RESULTS: Nearly all participants shared ECs with peers and sharing was the sole access route for some. Many used proxies, often older relatives or people they knew socially, to purchase ECs on their behalf; however, others recruited proxies by approaching previously unknown people they identified on social media. Participants also sourced ECs via quasi-commercial networks that existed within schools and on social media, and some purchased in their own right, usually from smaller retail outlets that did not ask for ID. CONCLUSIONS: Disrupting social supply will be challenging, though reducing ECs' availability, appeal, and affordability could make social supply, including sharing and proxy purchasing, more difficult. Reports that youth purchase ECs from commercial retailers known to waive age verification suggests stronger monitoring and enforcement, along with escalating retailer penalties, is required. IMPLICATIONS: Vaping access routes sit on a continuum from informal, spontaneous sharing to carefully planned commercial purchases.While supply via friends, siblings and other social contacts is an important means of access, nicotine dependence drives some to use riskier access routes, including approaching unknown people to act as proxy purchasers.Evidence young people identify non-compliant retailers suggests policy makers should monitor and enforce existing measures more stringently and consider additional penalties for recidivist under-age suppliers.A more comprehensive response that reduces the appeal, addictiveness, affordability, and availability of vaping products would address factors fostering and maintaining youth vaping.

Trends and the Gender Gap in the Reporting of Sexual Initiation Among 15-Year-Olds: A Comparison of 33 European Countries.

Early sexual intercourse initiation has been associated with immediate and long-term risks, which makes the study of trends in sexual initiation an important topic for policy makers. This study investigated trends over time in reported sexual initiation among 15-year-olds across 33 countries between 2010-2018. In addition, we examined if there were cross-country differences in the gender gap in reported sexual initiation in 2018, and whether these could be attributed to gender inequality and gender role attitudes. To answer these questions, we combined individual-level data from the international Health Behaviour in School-aged Children study collected in 2010 (N = 57,656), 2014 (N = 56,745) and 2018 (N = 55,127) with country-level data on gender inequality and gender role attitudes. We found a decrease over time in early sexual initiation in most countries, but also cross-country differences in these trends. More boys than girls reported sexual initiation in 2018. This gender gap also varied across countries and slightly decreased over time. In countries with less progressive gender role attitudes and more gender inequality, fewer girls reported early sexual initiation, resulting in a larger gender gap in these countries. To conclude, policy makers, healthcare providers and educators should focus on changing stereotypical gender norms.

Addressing Intergenerational Inequity in Tobacco-Harm: What Helps Children of Smokers to Remain Nonsmokers?

INTRODUCTION: Children of people who smoke are more likely to take up smoking themselves. In Aotearoa New Zealand (NZ), adolescent smoking declined dramatically between 2000 and 2016 despite limited change in parental smoking, demonstrating that the cycle can be broken. AIMS AND METHODS: This study aimed to identify modifiable factors associated with never smoking in Year 10 students (14-15 years) who had at least one caregiver who smoked. We used data from the Youth Insights Survey (2016 and 2018, pooled, N = 5,422) and identified students with at least one caregiver (mother, father, grandparent, other caregiver) who smoked (N = 2,205). To investigate modifiable factors potentially associated with nonsmoking we used logistic regression with marginally adjusted prevalence estimates. RESULTS: Overall, 41% of students had at least one caregiver who smoked. In this group, the majority (65%) had never smoked themselves. After adjustment, never-smoking was more prevalent among students attending low-deprivation (more affluent) schools (73% had never smoked) compared to high-deprivation schools (44%); students not exposed to others' smoking inside the home (72%) or in cars (70%) in the past week compared to those exposed (59% and 51%, respectively); and students whose parents would be upset if they were caught smoking (68% vs 49% for those whose parents would not be upset), or who had high self-esteem (69% vs 55% for those with low self-esteem). CONCLUSIONS: Modifiable factors independently associated with non-smoking in adolescents with caregiver(s) who smoked were: nonexposure to smoking inside the home and in cars, parental expectations of nonsmoking, and high self-esteem. IMPLICATIONS: Even in countries like NZ with relatively low adult smoking rates, children's exposure to caregiver smoking may be prevalent, particularly in structurally disadvantaged populations. This study suggests that action to promote smokefree homes and cars, build high self-esteem in young people, and communicate expectations of non-smoking are likely to help children of people who smoke to remain nonsmokers. A comprehensive approach that also addresses "upstream" factors (eg, socioeconomic deprivation) and underlying causes of structural inequity (eg, institutional racism) is needed. Such policy and community action may help to break intergenerational cycles of tobacco use and health inequity.

Understanding youth drinking decline: Similarity and change in the function and social meaning of alcohol use (and non-use) in adolescent cohorts 20 years apart.

INTRODUCTION: Qualitative research aimed at understanding the decline in youth drinking has so far been hampered by a lack of baseline data for comparison. This New Zealand study overcomes this limitation by comparing archival qualitative data collected at the height of youth drinking (1999-2001) with contemporary data collected for this study (June-October 2022). The aim is to explore changes in the function and social meaning of alcohol use (and non-use) for two cohorts about 20 years apart. METHODS: Both archival and contemporary data were collected from 14 to 17 year old secondary school students (years 10-12) through individual and small-group/pair interviews in matched suburban co-ed schools. Interviews explored friendships, lifestyles, romantic relationships and experiences and perceptions of substance use and non-use. RESULTS AND DISCUSSION: Comparative analysis highlighted changes that may help to explain the decline in youth drinking, including an increased value placed on personal choice and acceptance of diversity; decreased face-to-face socialising and the emergence of social media as a central feature of adolescent social life, perhaps displacing key functions of drinking and partying; increased pervasiveness of risk discourses and increased awareness of health and social risks of alcohol; and increased framing of alcohol use as a coping mechanism by both drinkers and non-drinkers. CONCLUSIONS: Collectively, these changes appear to have shifted the social position of drinking from an almost compulsory component of adolescent social life in 1999-2001, to an optional activity that many contemporary adolescents perceive to have high risks and few benefits.

Defining and measuring 'inhalant' use in population-based surveys.

BACKGROUND: The term 'inhalants' is commonly used to describe a group of drugs that are characterised by the route of administration. There are three main sub-groups of inhalants; volatile solvents, alkyl nitrites, and nitrous oxide. These drugs all have different pharmacological properties, use patterns, and potential harms; yet they are sometimes grouped together in survey instruments. This critical review aimed to present a comparative analysis of how these inhalant drugs are defined, and use measured, across a range of population-level drug use surveys. METHODS: Population-level drug use surveys of youth (n=5) and general population (n=6), which measured use of at least once type of inhalant drug, were analysed as case studies. The types of inhalants surveyed were extracted, as well as definitions of these drugs, from code books or survey methods. RESULTS: Differing definitions were used between surveys, and included differences between countries, and between surveys intended to measure youth and general population drug use. Of the six general population surveys; five reported nitrous oxide use, five reported volatile solvent use, and four reported alkyl nitrite use. Of the five youth-specific surveys; three reported volatile solvent use, whereas only one reported on alkyl nitrite use, and one reported nitrous oxide use. CONCLUSIONS: There is no consistent approach used to define or measure the use of inhalant drugs, which has implications for global comparisons and understanding drug use in different populations. We conclude that the term 'inhalants' should be discontinued, due to the limited value in continuing to group very different types of drugs solely on the basis of their route of administration. Improving the epidemiology of volatile solvents, alkyl nitrites, and nitrous oxide as distinct drug types will be of benefit to harm reduction, treatment, and prevention efforts, and ensure these are targeted appropriately to population groups and context of use.

Early-onset smoking and vaping of cannabis: Prevalence, correlates and trends in New Zealand 14-15-year-olds.

INTRODUCTION: Initiating cannabis use at an early age elevates risk of harm. Cannabis vaping is an emerging issue, and it is unknown whether the patterning and correlates of early-onset cannabis vaping differ from those of cannabis smoking. METHODS: We used repeat cross-sectional data from a nationally representative biennial survey (2012-2018) of students aged 14-15 years in New Zealand (N = 11,405), response rate 65% (2012), 64% (2014-2016) and 59% (2018). RESULTS: Between 2012 and 2018 lifetime cannabis use decreased, but regular use (past month, weekly, daily) was stable. Prevalence of past month, weekly and daily use in 2016-2018 (pooled) was 8.6%, 3.4% and 1.5%, respectively. Cannabis vaping was reported by 24% of past month cannabis users. The demographic profile of early-onset cannabis smokers and vapers was similar, with elevated use of both modes among Maori (Indigenous), same- or both-sex attracted students and those in low decile (high-deprivation) schools. Correlates were similar for both modes. Cannabis use was strongly associated with tobacco and alcohol use. The next strongest associations (after adjustment) were exposure to second-hand smoke at home, student income >$50/week and low parental monitoring of whereabouts. Past week social media use, psychological distress and low parental monitoring of spending were also associated with both modes. DISCUSSION AND CONCLUSIONS: Early-onset cannabis use is much higher in structurally disadvantaged groups, and among those who use tobacco and alcohol. Comprehensive multisubstance approaches to prevention are indicated in this age group. Efforts to reduce socio-economic inequity and exposure to other risk factors may reduce cannabis-related harm.

Rapid and unequal decline in adolescent mental health and well-being 2012-2019: Findings from New Zealand cross-sectional surveys.

OBJECTIVE: To investigate prevalence and trends in key mental health and well-being indicators among New Zealand secondary school students. METHODS: Representative cross-sectional youth health surveys with 2-4% of the New Zealand secondary school population were conducted in 2001, 2007, 2012 and 2019 (total n = 34,548). RESULTS: In 2019, 69.1% reported good well-being (95% confidence interval = [67.6, 70.6]; World Health Organization 5-item), 22.8% reported clinically significant depression symptoms (95% confidence interval = [21.4, 24.1]; Reynolds Adolescent Depression Scale-Short Form) and 41.8% reported possible anxiety symptoms (95% confidence interval = [40.5, 43.2]; Generalized Anxiety Disorder 2, adapted). Past-year prevalence of periods of low mood (38.3%, 95% confidence interval = [36.6, 40.1]), deliberate self-harm (24.1%, 95% confidence interval = [22.8, 25.4]), suicide thoughts (20.8%, 95% confidence interval = [19.2, 22.4]) and suicide attempts (6.3%, 95% confidence interval = [5.5, 7.0]) were observed. After relative stability from 2001 to 2012, there were large declines in mental health to 2019. The proportion reporting good well-being decreased (odds ratio 0.71, 95% confidence interval = [0.65, 0.78], p < 0.001), depression symptoms increased (odds ratio 1.96, 95% confidence interval = [1.75, 2.20], p < 0.001) and past-year suicide thoughts and suicide attempts increased (odds ratio 1.41, 95% confidence interval = [1.25, 1.59], p < 0.001; odds ratio 1.60, 95% confidence interval = [1.32, 1.92], p < 0.001). Past-year deliberate self-harm was largely stable. Declines in mental health were unevenly spread and were generally greater among those with higher need in 2012 (females, Maori and Pacific students and those from higher deprivation neighbourhoods), increasing inequity, and among Asian students. CONCLUSION: Adolescent mental health needs are high in New Zealand and have increased sharply from 2012 among all demographic groups, especially females, Maori, Pacific and Asian students and those from high-deprivation neighbourhoods. Ethnic and socioeconomic disparities have widened.

The great decline in adolescent risk behaviours: Unitary trend, separate trends, or cascade?

In many high-income countries, the proportion of adolescents who smoke, drink, or engage in other risk behaviours has declined markedly over the past 25 years. We illustrate this behavioural shift by collating and presenting previously published data (1990-2019) on smoking, alcohol use, cannabis use, early sexual initiation and juvenile crime in Australia, England, the Netherlands, New Zealand, and the USA, also providing European averages where comparable data are available. Then we explore empirical evidence for and against hypothesised causes of these declines. Specifically, we explore whether the declines across risk behaviours can be considered 1) a 'unitary trend' caused by common underlying drivers; 2) separate trends with behaviour-specific causes; or 3) the result of a 'cascade' effect, with declines in one risk behaviour causing declines in others. We find the unitary trend hypothesis has theoretical and empirical support, and there is international evidence that decreasing unstructured face-to-face time with friends is a common underlying driver. Additionally, evidence suggests that behaviour-specific factors have played a role in the decline of tobacco smoking (e.g. decreasing adolescent approval of smoking, increasing strength of tobacco control policies) and drinking (e.g. more restrictive parental rules and attitudes toward adolescent drinking, decreasing ease of access to alcohol). Finally, declining tobacco and alcohol use may have suppressed adolescent cannabis use (and perhaps other risk behaviours), but evidence for such a cascade is equivocal. We conclude that the causal factors behind the great decline in adolescent risk behaviours are multiple. While broad contextual changes appear to have reduced the opportunities for risk behaviours in general, behaviour-specific factors have also played an important role in smoking and drinking declines, and 'knock-on' effect from these behavioural domains to others are possible. Many hypothesised explanations remain to be tested empirically.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis.

INTRODUCTION: Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG. METHODS: We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach. RESULTS: We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice. CONCLUSIONS: Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Indigenous adolescent health in Aotearoa New Zealand: Trends, policy and advancing equity for rangatahi Maori, 2001-2019.

Background: Rangatahi Maori, the Indigenous adolescents of Aotearoa New Zealand (NZ), have poorer health outcomes than Pakeha (NZ European /other European/"White") adolescents. We explored the influence of policies for Indigenous youth by presenting health trends, inequities and contrasting policy case examples: tobacco control and healthcare access. Methods: Cross-sectional representative surveys of NZ secondary school students were undertaken in 2001, 2007, 2012 and 2019. Health indicators are presented for Maori and Pakeha adolescents (relative risks with 95% CI, calculated using modified Poisson regression) between 2001-2019 and 2012-2019. Policy examples were examined utilising Critical Te Tiriti Analysis (CTA). Findings: Rangatahi Maori reported significant health gains between 2001 and 2019, but an increase in depressive symptoms (13.8% in 2012 to 27.9% in 2019, RR 2.01 [1.65-2.46]). Compared to Pakeha youth there was a pattern of persistent Maori disadvantage, particularly for racism (RR 2.27 [2.08-2.47]), depressive symptoms (RR 1.42 [1.27-1.59]) and forgone healthcare (RR 1.63 [1.45-1.84]). Tobacco use inequities narrowed (RR 2.53 [2.12-3.02] in 2007 to RR 1.55 [1.25-1.93] in 2019). CTA reveals rangatahi Maori-specific policies, Maori leadership, and political support aligned with improved outcomes and narrowing inequities. Interpretation: Age-appropriate Indigenous strategies are required to improve health outcomes and reduce inequities for rangatahi Maori. Characteristics of effective strategies include: (1) evidence-based, sustained, and comprehensive approaches including both universal levers and Indigenous youth-specific policies; (2) Indigenous and rangatahi leadership; (3) the political will to address Indigenous youth rights, preferences, priorities; and (4) a commitment to an anti-racist praxis and healthcare Indigenisation. Funding: Two Health Research Council of New Zealand Project Grants: (a) Fleming T, Peiris-John R, Crengle S, Parry D. (2018). Integrating survey and intervention research for youth health gains. (HRC ref: 18/473); and (b) Clark TC, Le Grice J, Groot S, Shepherd M, Lewycka S. (2017) Harnessing the spark of life: Maximising whanau contributors to rangatahi wellbeing (HRC ref: 17/315).

Has increasing internet use due to smartphone uptake contributed to the decline in adolescent smoking?

INTRODUCTION: The emergence of low-cost smartphone technology has coincided with major declines in adolescent smoking and other risk behaviours. This study explores the relationship between internet use and smoking in adolescents and investigates whether rising internet use contributed to the decline in smoking between 2012 and 2018. METHODS: Data were drawn from a nationally representative New Zealand survey of students aged 14-15 (N = 11 299), conducted biennially between 2012 and 2018. We used logistic regression to explore the association between internet use and smoking and test whether increasing time on the internet was associated with declining adolescent smoking over the study period. RESULTS: The proportion of students spending 5+ hours per day online increased from 15% to 35%. Heavy internet use was not a protective factor for smoking at the individual level. In 2016/2018, some types of past week internet use were associated with decreased risk of smoking (e.g. doing schoolwork, finding out about news), some were associated with increased risk (e.g. social media use) and others appeared to have no association with smoking (e.g. gaming, online shopping). The relative risk of smoking was lower in 2018 relative to 2012 (relative risk 0.68, 95% confidence interval 0.51, 0.90, after adjustment for demographic factors). Adding internet use to the model did not help to account for smoking decline. DISCUSSION AND CONCLUSIONS: We found no evidence that increasing time spent on the internet during the 2012-2018 period (during which smartphones became ubiquitous) contributed to the decline in adolescent smoking.

New Zealand Youth19 survey: vaping has wider appeal than smoking in secondary school students, and most use nicotine-containing e-cigarettes.

OBJECTIVE: To investigate smoking and vaping in secondary school students (aged 13-18 years) in New Zealand (NZ) following the introduction of 'pod' e-cigarettes, which have been associated with the rapid escalation of youth vaping elsewhere. METHODS: Data on smoking and vaping were collected in 2019 as part of a comprehensive youth health survey (N=7,721). RESULTS: Vaping was 2-3 times more prevalent than smoking, with 10% of students vaping regularly (monthly or more often), and 6% weekly or more often, compared with 4% and 2%, respectively, for tobacco smoking. Nicotine-containing e-cigarettes were sometimes or always used by 80% of regular and 90% of weekly vapers. Regular and weekly smoking was rare in low deprivation (affluent) areas, whereas regular and weekly vaping prevalence was similar across the socioeconomic spectrum. More than 80% of ever-vapers (N=2732) reported they were non-smokers when they first vaped, and 49% of regular vapers (N=718) had never smoked. CONCLUSIONS: A significant proportion of New Zealand adolescents, many of whom have never smoked, use nicotine-containing e-cigarettes regularly. Implications for public health: Vaping is less harmful than smoking, but it is not harmless. Public health action is needed to support young non-smokers to remain smokefree and vape-free.

New Zealand's Climate Change Commission report: the critical need to address the missing health co-benefits of reducing emissions.

The Climate Change Commission's draft report and recommendations provide a pathway towards achieving the New Zealand Government's commitment to net zero emissions by 2050. However, the Commission has not adequately considered the health co-benefits of climate change mitigation. In this viewpoint, we assess how the Commission has considered health co-benefits in the key response domains. Extrapolating UK evidence to the New Zealand context suggests climate change mitigation strategies that reduce air pollution, transition the population towards plant-based diets and increase physical activity via active transport could prevent thousands of deaths per year in coming decades. Substantial health co-benefits would also arise from improved housing, cleaner water, noise reductions, afforestation and more compact cities. The Commission's draft report only briefly mentions many of these health co-benefits, and some are completely absent. We recommend the Commission's final report: (i) use health co-benefits as an explicit frame; (ii) ensure the government's Treaty of Waitangi obligations are met in all the domains covered to maximise benefits for Maori health and wellbeing; (iii) build on the successful COVID-19 response that demonstrated rapid, science-informed and vigorous government action can address major global health threats; (iv) include both public health expertise and Maori health expertise among its commissioners; (v) explain how health co-benefits are likely to generate major cost-savings to the health system.

What explains the decline in adolescent binge-drinking in New Zealand?

BACKGROUND: Binge-drinking prevalence among New Zealand adolescents has declined sharply since 2001, as it has in many other high-income countries. Other adolescent risk behaviours (e.g. smoking, cannabis use and precocious sexual activity) have also declined, raising the possibility of common underlying drivers. This study investigates potential contributing factors - both factors that predict risk behaviours in general, and alcohol-specific factors - and the extent to which they account for the decline in binge drinking. METHODS: The study used nationally representative survey data collected in 2001 (N = 6513), 2007 (N = 5934) and 2012 (N = 5489). The outcome measure was prevalence of past month binge drinking (5+ drinks/session). Predictor variables included factors that predict risk behaviours in general (parental monitoring, family attachment, school attachment, having a part-time job, time spent hanging out with friends); alcohol-specific factors (parental alcohol use, adolescent attitude toward alcohol use); and attitude toward and current use of tobacco and cannabis. Likelihood of binge drinking was modelled for each survey year (ref=2001), adjusting for demographic factors. Predictors were added to this base model, with the degree of attenuation of the odds ratio for year indicating the extent to which the included predictor(s) accounted for the trend. RESULTS: Compared with 2001 the odds of binge-drinking in 2012 were 0.33. The strongest independent contributor to the decline was adolescent attitude toward alcohol use, followed by current cannabis use, then current tobacco use. Collectively, general factors in home, school and leisure settings did not significantly contribute to the downward trend in binge drinking. CONCLUSION: Decreasing acceptability of alcohol use among adolescents was the most important identified contributor to adolescent binge-drinking decline. Drinking, smoking and cannabis use trends were empirically linked, yet the decline in binge drinking was not significantly explained by the included predictors common to risk behaviours in general.