E-cigarette, cannabis, hookah and tobacco use patterns in fee-paying South African high schools
DOI:
https://doi.org/10.7196/SAMJ.2026.v116i1.3847Keywords:
youth and adolescents, Electronic cigarettes, cannabis, tobacco, Public healthAbstract
Background. Monitoring adolescent substance use is crucial for informing public health strategies. However, in South Africa (SA), recent large-sample data on the use and co-use of tobacco, nicotine and cannabis among youth remain scarce.
Objectives. To describe the use and co-use of cannabis, hookah, tobacco cigarettes and electronic cigarettes (e-cigarettes/vapes) among SA high-school learners, and to examine how these patterns vary by school-based characteristics, including grade, school fee category and school gender composition.
Methods. A cross-sectional survey was administered to 25 149 learners in grades 8 - 12 from 52 fee-paying high schools across eight provinces. Learners reported their past-30-day use of cannabis, hookah, tobacco cigarettes and e-cigarettes/vapes. Key outcomes included current use of each individual product, any one of the four products, as well as dual-usage patterns. Multilevel logistic regressions examined associations between school grade, fee category (lower-, mid-, or high-fee), gender composition (co-educational, all boys, all girls) and the odds of single, any and dual product use.
Results. Among sampled learners, 19.39% (95% confidence interval (CI) 18.91 - 19.88) reported current use of any product. Vape use was most prevalent (16.83%, 95% CI 16.37 - 17.30), followed by cannabis (5.13%, 95% CI 4.86 - 5.41), hookah (3.16%, 95% CI 2.95 - 3.39) and tobacco cigarettes (2.08%, 95% CI 1.91 - 2.27). Dual use was especially common among vape users, with more than one-third (34.31%, 95% CI 32.88 - 35.77) reporting concurrent use of at least one other product: 22.06% (95% CI 20.83 - 23.35) cannabis, 13.50% (95% CI 12.50 - 14.58) hookah and 10.13% (95% CI 9.25 - 11.08) tobacco cigarettes. Usage rates were highest among learners in Grade 12, in co-educational schools and in lower-fee schools. Multivariable regression analyses showed that advanced grade level was significantly associated with increased odds of current use across all product types. Compared with learners in all-boys schools, those in co-educational schools had significantly higher odds of cannabis use (odds ratio (OR) 1.53, p<0.05) and dual use (OR 1.42, p<0.1), while learners in all-girls schools had significantly lower odds of any product use (OR 0.75, p<0.05) and of vape use (OR 0.73, p<0.05). Regression results further revealed significantly elevated odds of hookah use and dual use among learners attending lower- and middle-fee schools compared with learners in high-fee schools.
Conclusion. The widespread use of e-cigarettes, along with dual use among e-cigarette users, in fee-paying high schools signals a significant public health concern, underscoring the need for comprehensive interventions. Elevated hookah and dual use in lower-fee schools, along with increased cannabis and dual use in co-educational settings, underscore the need for targeted interventions to address context-specific vulnerabilities among SA adolescents.
References
1. Goriounova NA, Mansvelder HD. Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function. Cold Spring Harb Perspect Med 2012;2(12):a012120. https://doi.org/10.1101/cshperspect.a012120
2. Steinfeld MR, Torregrossa MM. Consequences of adolescent drug use. Transl Psychiatry 2023;13(1):313. https://doi.org/10.1038/s41398-023-02590-4
3. Gray KM, Squeglia LM. Research review: What have we learned about adolescent substance use? J Child Psychol Psychiatry 2018;59(6):618-627. https://doi.org/10.1111/jcpp.12783
4. Laursen B, Veenstra R. Toward understanding the functions of peer influence: A summary and synthesis of recent empirical research. J Res Adolesc 2021;31(4):889-907. https://doi.org/10.1111/ jora.12606
5. World Health Organization, US Centers for Disease Control. Global Youth Tobacco Survey: South Africa, 2011. Geneva: WHO, 2011. https://extranet.who.int/ncdsmicrodata/index.php/catalog/175 (accessed 9 June 2025).
6. Van Zyl-Smit RN, Filby S, Soin G, et al. Electronic cigarette usage amongst high school students in South Africa: A mixed methods approach. eClinicalMedicine 2024;78:102432. https://doi. org/10.1016/j.eclinm.2024.102432
7. National Department of Health, South Africa, Statistics South Africa, South African Medical Research Council, ICF. South Africa Demographic and Health Survey 2016. Pretoria: NDoH, 2019.
8. Mohale D, Mokwena KE. Substance use amongst high school learners in the south of Johannesburg: Is this the new norm? S Afr Fam Pract 2020;62(1):e1-e6. https://doi.org/10.4102/safp.v62i1.5122
9. Naicker N, Teare J, Albers P, Mathee A. Prevalence of hookah pipe smoking in high-school learners in Johannesburg, South Africa. S Afr Med J 2020;110(6):546-551. https://doi.org/10.7196/SAMJ.2020. v110i6.14333
10. Parry C, Myers B, Caulkins J. Decriminalisation of recreational cannabis in South Africa. Lancet 2019;393(10183):1804-1805. https://doi.org/10.1016/S0140-6736(19)30011-X
11. Swartz MC, Dannatt L, Lachman A. Cannabis use among hospitalised adolescents before and after decriminalisation in South Africa. S Afr J Psychiatr 2024;30:2244. https://doi.org/10.4102/ sajpsychiatry.v30i0.2244
12. Mmethi TG, Modjadji P, Mathibe M, et al. Substance use among school-going adolescents and young adults in rural Mpumalanga Province, South Africa. Behav Sci 2024;14(7):543. https://doi.org/10.3390/ bs14070543
13. Ramlagan S, Peltzer K, Matseke G. Epidemiology of drug abuse treatment in South Africa. S Afr J Psychiatr 2010;16(2):40-49. https://doi.org/10.4102/sajpsychiatry.v16i2.172
14. Buckner JD, Morris PE, Zvolensky MJ. Cannabis use and electronic cigarette use: The role of dual use on use frequency and related problems. Psychiatry Res 2021;304:114126. https://doi.org/10.1016/j. psychres.2021.114126
15. Osei AD, Mirbolouk M, Orimoloye OA, et al. Association between e-cigarette use and cardiovascular disease among never and current combustible-cigarette smokers. Am J Med 2019;132(8):949-954. https://doi.org/10.1016/j.amjmed.2019.02.016
16. Reddy KP, Schwamm E, Kalkhoran S, et al. Respiratory symptom incidence among people using electronic cigarettes, combustible tobacco, or both. Am J Respir Crit Care Med 2021;204(2):231-234. https://doi.org/10.1164/rccm.202012-4441LE
17. Davids H, Roman N, Rich E. Peer pressure and social acceptability between hookah pipe users and non-users among a sample of South African adolescents. S Afr J Child Health 2022;16(3):139-145. https://doi.org/10.7196/SAJCH.2022.v16i3.1709
18. Park-Lee E, Jamal A, Cowan H, et al. Notes from the field: E-cigarette and nicotine pouch use among middle and high school students - United States, 2024. Morb Mortal Weekly Rep 2024;73(35):774-778. https://doi.org/10.15585/mmwr.mm7335a3
19. Jamal A, Park-Lee E, Birdsey J, et al. Tobacco product use among middle and high school students - National Youth Tobacco Survey, United States, 2024. Morb Mortal Weekly Rep 2024;73(41):917-924. https://doi.org/10.15585/mmwr.mm7341a2
20. World Health Organization. Technical note on call to action on electronic cigarettes. Geneva: WHO, 2023. https://cdn.who.int/media/docs/default-source/tobacco-hq/regulating-tobacco-products/ends- call-to-action-background.pdf (accessed 28 April 2025).
21. Ayo-Yusuf O, Nkosi L, Agaku I. E-cigarette use and regulation in South Africa: A synthesis of evidence in response to industry efforts to undermine product regulation. Curr Addict Rep 2022;9(4):363-372. https://doi.org/10.1007/s40429-022-00437-3
22. Agaku IT, Egbe CO, Ayo-Yusuf OA. E-cigarette advertising exposure among South African adults in 2017: Findings from a nationally representative cross-sectional survey. BMJ Open 2021;11(8):e048462. https://doi.org/10.1136/bmjopen-2020-048462
23. Pettigrew S, Santos JA, Pinho-Gomes AC, et al. Exposure to e-cigarette advertising and young people’s use of e-cigarettes: A four-country study. Tob Induc Dis 2023;21:141. https://doi.org/10.18332/ tid/172414
24. Camenga D, Gutierrez KM, Kong G, et al. E-cigarette advertising exposure in e-cigarette naïve adolescents and subsequent e-cigarette use: A longitudinal cohort study. Addict Behav 2018;81:78-83. https://doi.org/10.1016/j.addbeh.2018.02.005
25. Hansen J, Hanewinkel R, Morgenstern M. Electronic cigarette advertising and teen smoking initiation. Addict Behav 2020;103:106243. https://doi.org/10.1016/j.addbeh.2019.106243
26. Wang Y, Duan Z, Weaver SR, et al. Association of e-cigarette advertising, parental influence, and peer influence with US adolescent e-cigarette use. JAMA Netw Open 2022;5(9):e2233938. https://doi. org/10.1001/jamanetworkopen.2022.33938
27. Struik LL, Dow-Fleisner S, Belliveau M, et al. Tactics for drawing youth to vaping: Content analysis of electronic cigarette advertisements. J Med Internet Res 2020;22(8):e18943. https://doi. org/10.2196/18943
28. Egga DK, Oduyoye O, Jacob IA, et al. Characterisation of substance use pattern among secondary school students in Nasarawa State, Nigeria. Discov Public Health 2024;21(1):238. https://doi. org/10.1186/s12982-024-00133-8
29. Steinberg L. A social neuroscience perspective on adolescent risk-taking. Dev Rev 2008;28(1):78-106.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 S Filby, R van Zyl-Smit, G Soin, S Kurten
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Licensing Information
The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Publishing Rights
Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.
