{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T02:52:31Z","timestamp":1770346351172,"version":"3.49.0"},"reference-count":0,"publisher":"South African Medical Association NPC","license":[{"start":{"date-parts":[[2026,2,4]],"date-time":"2026-02-04T00:00:00Z","timestamp":1770163200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["S Afr Med J"],"abstract":"<jats:p>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.\nObjectives. 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.\nMethods. 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.\nResults. 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&lt;0.05) and dual use (OR 1.42, p&lt;0.1), while learners in all-girls schools had significantly lower odds of any product use (OR 0.75, p&lt;0.05) and of vape use (OR 0.73, p&lt;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.\nConclusion. 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.<\/jats:p>","DOI":"10.7196\/samj.2026.v116i1.3847","type":"journal-article","created":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T13:19:03Z","timestamp":1770297543000},"page":"e3847","source":"Crossref","is-referenced-by-count":0,"title":["E-cigarette, cannabis, hookah and tobacco use patterns in fee-paying South African high schools"],"prefix":"10.7196","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6371-6522","authenticated-orcid":false,"given":"S","family":"Filby","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4115-5362","authenticated-orcid":false,"given":"R","family":"Van Zyl-Smit","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"G","family":"Soin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"S","family":"Kurten","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"4425","published-online":{"date-parts":[[2026,2,4]]},"container-title":["South African Medical Journal"],"original-title":[],"link":[{"URL":"https:\/\/samajournals.co.za\/index.php\/samj\/article\/download\/3847\/1711","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/samajournals.co.za\/index.php\/samj\/article\/download\/3847\/1711","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T13:19:05Z","timestamp":1770297545000},"score":1,"resource":{"primary":{"URL":"https:\/\/samajournals.co.za\/index.php\/samj\/article\/view\/3847"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,4]]},"references-count":0,"URL":"https:\/\/doi.org\/10.7196\/samj.2026.v116i1.3847","relation":{},"ISSN":["2078-5135","0256-9574"],"issn-type":[{"value":"2078-5135","type":"electronic"},{"value":"0256-9574","type":"print"}],"subject":[],"published":{"date-parts":[[2026,2,4]]}}}