Electronic nicotine delivery systems remain a public health concern, and the rising popularity of electronic cigarettes (e-cigarettes) has been attributed to youth-oriented design features such as, appealing device aesthetics and flavored products. These devices are often promoted and marketed as a safer alternative to combustible tobacco products, yet they can facilitate tobacco use initiation and nicotine addiction. E-cigarette aerosols contain cancer-causing chemicals, volatile organic compounds, and heavy metals, and nicotine poses specific risks to fetal development and brain development through approximately age 25. Studies conducted largely outside the African continent have documented high and increasing e-cigarette use, with multiple factors been associated with adolescents’ uptake. These include individual tobacco-use trajectories, interpersonal norms and household exposures to tobacco use behavior, community-level influences such as school or neighborhood access to tobacco and nicotine products, and exposure to secondhand smoke, and broader policy and economic environments—including Zambia’s distinctive tobacco-growing political–economic context. This study aimed to quantify e cigarette awareness and current use, examine heterogeneity by residence (rural/urban) and tobacco-growing locality (yes/no), and identify correlates across multiple social ecological levels.

This study analyzed secondary data from the 2021 Global Youth Tobacco Survey (GYTS) - Zambia, a standardized and nationally representative cross-sectional school-based survey designed to systematically monitor youth tobacco use and track key tobacco control indicators. The analyses incorporated complex survey design features for prevalence estimation, addressed substantial item nonresponse using multiple imputation, and evaluated predictor collinearity to inform stable multivariable model specification.

Results indicated high overall awareness with more distinct behavioral and exposure patterning for current use. Descriptive stratification showed higher current e-cigarette use among rural compared to urban students [18.1% (CI 12.6, 23.7) vs. 13.4% (CI 8.6, 18.3)] and among students living in tobacco-growing versus students living in non–tobacco growing localities [21.8% (CI 14.9, 28.7) vs. 15.4% (12.1, 18.7)]. Current e-cigarettes use clustered most strongly with conventional tobacco use behaviors and secondhand smoke exposure (e.g., higher odds among students reporting ever cigarette smoking, frequent cigarette smoking, smokeless tobacco use, smoking dependence, and exposure to secondhand smoke (at home and in public places). In contrast, many other covariates showed limited independent association after accounting for correlated tobacco-use histories and exposure environments.

Findings indicated that adolescent e-cigarette use in Zambia is prevalent and embedded in broader patterns of tobacco-use and exposure. This supports integrated tobacco control and prevention, and regulatory approaches that address poly-use and smoke-free environments—particularly in higher-prevalence geographic contexts. These conclusions must be considered within key limitations including cross-sectional design, self-report measurement, potential awareness misclassification due to local terminology, and the assumptions required for multiple imputation and stratified modeling with sparse data.