Abstract
Background An increasing number of adolescents and young adults who have never smoked now use e-cigarettes. GPs must screen and counsel effectively as vaping is linked to an increased chance of progression to conventional smoking in those who have never smoked. Limited long-term data compounds risk and uncertainty for chronic users. Evidence to guide GP counselling of adolescents and young adults who vape remains scarce in routine clinical practice.
Aim To investigate GPs’ perspectives on tackling the vaping epidemic, their preparedness, current management approaches, challenges, and potential improvements at personal and national levels.
Design & setting Qualitative study using semi-structured interviews (SSIs) with UK GPs.
Method Invitations for SSIs were sent to Primary Care Networks nationwide. Participants were purposively sampled to reflect the national GP demographic. Interviews were conducted in April and May 2024, reaching data saturation at n = 11. Interviews were transcribed verbatim, imported to NVivo (version 10) and thematically analysed using the Gioia method.
Results Four aggregate dimensions, 11 second-order themes and 29 first-order concepts emerged. Current practice was marked by limited knowledge and variable counselling; drivers for change centred on rising concern about youth vaping; barriers included lack of guidance, services, and time; recommendations emphasised improved education, digital tools and stakeholder engagement.
Conclusion Our findings highlight the urgent need for interventions to address rising e-cigarette use among adolescents and young adults who have never previously smoked. While some GPs are motivated to improve practice, others are uncertain given the limited and mixed evidence currently available. Effective solutions must extend beyond primary care to involve other healthcare professionals and key stakeholders.
How this fits in
GPs increasingly encounter adolescents who vape, yet there is limited evidence to guide how these consultations should be managed. Existing literature has focused largely on adult smoking cessation, offering little practical support for clinicians facing youth vaping in routine practice. This study provides qualitative insights to how GPs currently perceive and address adolescent vaping, identifying uncertainty, inconsistent documentation, and barriers to open discussion. Clinicians can use these findings to reflect on their own practice and advocate for clearer guidance, education, and structured approaches to support young patients more effectively.
Introduction
Vaping prevalence is disproportionately higher among adolescents and young adults compared to the general population, as reported by Action on Smoking and Health (ASH).1 Over the past decade, experimentation with e-cigarettes among adolescents aged 11–17 years has increased by 50% annually,2 while usage among those aged 16–24 years rose by 40% between 2021 and 2022.3 In contrast, vaping prevalence among the general adult population increased by only 10% over the same period.1 Notably, a substantial proportion of young adults who vape have never smoked conventional cigarettes. Among adolescents aged 11–17 years, 48% of e-cigarette users had never previously smoked, compared to only 6.7% of adults who vape.1,2 Evidence also suggests that adolescents who vape are more likely to progress to smoking conventional cigarettes, while those who smoke are more likely to experiment with e-cigarettes, reinforcing the bidirectional gateway risk.4 Due to the gateway effect and the rising uptake of e-cigarette use among adolescents, particular concern lies with those who have never previously smoked. While e-cigarettes are recommended as a cessation tool for existing people who smoke, their use in those who have never smoked previously introduces new nicotine dependence rather than reducing harm.
GPs play a pivotal role in addressing public health challenges through preventive care and patient education. Research conducted in the UK indicates that 96% of GPs consider smoking cessation intervention part of their role.5 A similar proactive approach could be extended to vaping cessation efforts. However, emerging international literature highlights deficiencies in GPs’ knowledge and confidence when screening and counselling patients on e-cigarette use, which may also be linked to scarcity in literature surrounding the long-term health risks of e-cigarettes.6–9 Addressing these gaps is essential to ensure that primary care professionals are adequately equipped to manage the increasing vaping prevalence, particularly among young individuals who have never previously smoked.
This study aimed to explore GPs’ views on their role as first-line responders to adolescent vaping, their perceived preparedness, current management approaches, challenges, and potential improvements at personal and national levels.
Method
Qualitative approach and paradigm
We conducted semi-structured interviews (SSIs) with UK GPs using a two-interviewer, one-participant format to explore GPs’ views on tackling adolescent vaping. Transcripts were analysed thematically using the Gioia methodology. Participant-led first-order concepts were grouped into researcher-interpreted second-order themes and integrated into broader aggregate dimensions, systematically organising the data while preserving participants’ voices.
Context
SSIs follow a structure of open-ended questions but allow for further exploration of discussion topics.10 We employed a framework established by Kallio et al to develop our SSI guide.9 We also questioned GPs on their current approach as part of our interview, as the National Institute for Health and Care Excellence (NICE) guidance on ‘Practical steps to improving quality of care and services’ 11 highlights the importance of uncovering current practices to establish a baseline before trying to create or implement new guidance. The closing stages of the interview were designed to allow GPs to consider recommendations based on previously discussed challenges. Our format for SSIs can be found in Supplement 1.
Researcher characteristics and reflexivity
We piloted our SSI guide to enhance reflexivity, refining questions to reduce bias and improve conversational flow. An utterance chart (Supplement 2) validated the effectiveness in facilitating meaningful discussions. While no changes were made to the SSI guide, the utterance chart confirmed that our questions remained open and neutral, supporting credible data collection and interpretation. As the research team’s age group (22–24 years) belonged to the studied age group, our familiarity with vaping may have led to assumptions about GPs’ knowledge and attitudes, introducing potential bias. To mitigate this, we adopted a reflexive stance with regular meetings to surface assumptions, minimise interpretive bias, and iteratively refine the coding framework through collective review and consensus.10,12
Data collection methods
Invitations were distributed via email and newsletters through several Primary Care Networks (PCNs) across the UK, and additional outreach was conducted via LinkedIn to maximise geographic diversity. GPs were invited to volunteer for a 30-minute interview, after which participants were purposively selected based on location, years of experience, and sex to reflect national GP demographics and meet the inclusion criteria (see Tables 1 and 2).
Data collection instruments and technologies
Interviews were conducted online through Microsoft Teams.13 Two-to-one interviews were conducted, split between two investigators who were briefed using our interview guide to ensure standardisation. Interviews lasted a mean of 32 minutes, and data were collected from April 2024 to May 2024. Co-interviewing allowed one researcher to lead while the other probed deeper or clarified responses in real time. This enhanced understanding of GPs’ nuanced perspectives on vaping, improving data accuracy.14,15 The interviews were recorded with the participant’s consent, transcribed manually and anonymised to maintain accuracy, avoiding decontextualisation.16
Units of study
Table 2 lists the n = 11 GP participants’ sex, UK region and years in practice (GP trainees are marked) to contextualise quotations and the analysis.
Data processing
Investigators thoroughly reviewed the entire dataset.17 All transcripts were coded using NVivo (version 10) and open coding.
Data analysis
Axial coding was performed to categorise the emerging codes into first-order concepts based on pattern matching. Data were then further categorised into second-order themes using this method. Each investigator performed this process blind to the practices of the other investigators. Following each SSI, these first and second-order themes were discussed and iteratively improved to ensure clarity. The SSIs were performed until all investigators agreed that theoretical saturation had been achieved (n = 11), to ensure no new themes could be elicited, as seen in Supplement 3. Selective coding was employed to collect and position second-order themes into four aggregate dimensions, allowing us to formulate our data structures (Supplement 4).
Data model
In line with the Gioia methodology, a data model was created to identify the interdependence between themes (Figure 1).18 This visually represented how the aggregate dimensions interacted with the aims and objectives of our research question.
The figure presents a data model showing the interdependence between themes identified in a qualitative study of GPs’ perspectives on vaping among adolescents with no prior history of smoking. On the left, a dark-blue box labelled “Current practices” contains three themes: maintaining knowledge base, screening, and counselling. Arrows connect current practices to three central boxes: “Drivers for change” at the top, “Recommendations” in the middle, and “Barriers to change” at the bottom.The drivers for change are problems with current practices and GP concerns. A downward arrow connects drivers for change to recommendations. The recommendations are improving education, improving current practices, and engaging key stakeholders. The barriers to change are challenges faced by GPs, systemic challenges, and challenges associated with young patients. An upward arrow connects barriers to change to recommendations.An arrow leads from the recommendations to a light-purple box on the right labelled “Improving practices for e-cigarette use”. A green line marked with a plus sign also connects drivers for change to this outcome, indicating a positive influence. A red line marked with a minus sign connects barriers to change to the outcome, indicating a negative influence. Together, the connections show that current practices inform the drivers, barriers, and recommendations; drivers and barriers shape the recommendations; and these interacting themes influence efforts to improve GP practices concerning adolescent e-cigarette use.
Techniques to enhance trustworthiness
To ensure trustworthiness, we applied Lincoln and Guba’s (1985) Four Dimensions Criteria: dependability, credibility, transferability, and confirmability. Member checking, debriefing, and clear code tables were used to enhance transparency and reliability (Supplement 5).19–21 Three researchers independently coded the data and collaboratively refined themes. Investigator triangulation further reduced individual bias and strengthened internal validity.22
Results
Synthesis and interpretation
A total of n = 11 GPs working in UK primary care took part in SSIs. Data analysis identified four overarching themes: current practices, drivers for change, barriers to change, and recommendations for change. The results first outlined how vaping is currently screened and discussed in consultations, then considered motivations for change, before detailing clinician, patient, and system-level barriers, and finally practical steps that could be implemented in routine care. These themes and their subthemes are outlined in Table 3, showing 29 first-order themes and 11 second-order themes. Quotations are used selectively to illustrate key points; participant identifiers accompany quotes, with the analytic framework presented in Supplement 6 and the data model in Figure 1. Participant identifiers, for example, ‘Participant [P] 8, 3 years’, correspond directly to Table 2; years of experience are self-reported.
Link to empirical data
Figure 1 maps the relationship between domains. Current practices give rise to both drivers for change, for example, growing clinical concern, and barriers to change, for example, time, knowledge, and system. These streams inform the recommendations (education, workflow tools, stakeholder engagement). In implementation, drivers tend to accelerate adoption (+), while barriers dampen progress (−); the recommendations are designed to amplify the former and mitigate the latter to improve practice.
Current practices
Maintaining knowledge base
GPs described gaps in education about device types and practical screening approaches. When asked about specific teaching, it tended to be ad hoc or specialty-driven rather than routine GP training. GPs also reported that patients distinguish vaping and smoking in consultations. Relying on smoking status alone often failed to elicit vaping history:
‘They’re like, “Oh, I’m a non-smoker.” And then when you ask specifically, they say, “Oh yes, yes, I vape.” They’re not considered to be the same thing.’ (Participant [P] 8, 3 years)
Screening
GPs reported that disclosure of e-cigarette use is often initiated by patients rather than prompted by a systematic screening question. It was apparent, however, that GPs could initiate this conversation if they deemed it to be medically relevant or opportunistically concurrent with tobacco use. GPs were also uncertain as to whether vaping directly precipitates the presenting problem or constitutes a risk factor, which discourages routine screening; questions are typically asked only when vaping directly exacerbates symptoms:
‘Somebody comes in with a chest infection and asthma attack or something. You really need to know whether they’re vaping or whether they're smoking.’ (P9, 33 years)
Most importantly, rather than quantifying frequency, strength, or device type, screening was commonly reduced to a binary (yes/no) declaration of use:
‘I really don't know [how to quantify]. At the moment I'm working at the level of vaping or not vaping.’ (P9, 33 years)
Counselling
Some interviewed GPs took a ‘motivational’ approach to explore reasons for e-cigarette use. They were usually conscious of ‘scaremongering’ young adults with risks and possible health effects while encouraging cessation:
‘I don’t want to be scaremongering or frightening people, but I think it’s certainly worth mentioning that there are anxieties and increasing anxieties about the effects [of vaping].’ (P3, 30 years)
Most GPs emphasised the uncertainty around constituents and long-term harms as a means of counselling patients. Some GPs anchored counselling to the presenting diagnosis, framing vaping as an exacerbating factor, for example, in wheeze or chest infection, to motivate reduction or cessation.
Drivers for change
Problems with current practices
A key finding of our SSIs revealed that some GPs believe that counselling falls outside the scope of their job:
‘I don’t think it [vaping] should be anything to do with us.’ (P9, 30 years)
Increasing concerns with the vaping population
GPs reported growing concern about vaping uptake among young people who had never smoked previously. Rising prevalence was viewed as a potential ‘gateway’ to cigarette smoking and, for some, to other drug use:
‘Apart from the dangers of vaping itself, [some] may then go on to smoke or use other drugs because of this kind of, I suppose, slippery slope.’ (P3, 30 years)
Negative perceptions of vaping among GPs
An additional driver for change was clinicians’ increasingly negative perceptions, shaped by first-hand encounters with young people aged ‘16/17’, ‘quite wheezy’, and with ‘no history of asthma’, where the routine ‘do you smoke?’ was followed by ‘I vape’.
One GP expressed a strongly negative view, perceiving e-cigarettes as dangerous, even for smoking cessation, contrary to current NICE Guidelines (Section 1.12.2):23
‘In both my [GP] practices, if people are smoking and they want to cut off or even start vaping, we say a straight no.’ (P10, 12 years)
Barriers to change
Challenges faced by GPs
Counselling was constrained by three recurring knowledge gaps. First, many GPs were unsure about device types and specifications, knowing ‘not that much… about the different varieties’ (P4, 23 years). Second, they were uncertain what support to offer or even ‘whether… help is available’ for stopping vaping (P3, 30 years). Third, the evidence on harms felt comparatively thin, leaving some with ‘weaker evidence’ when it came to vaping (P5, 6 years). Together, these gaps reduce confidence and make tailored advice, clear signposting, and follow-up plans harder to deliver.
A ‘lesser evil’ view of vaping, relative to smoking, alcohol, or other substances, appeared to dampen clinicians’ impetus to intervene, making structured counselling and improvements to screening less likely. Time-pressured consultations were the main barrier reported; under these constraints, the ‘lesser-evil’ framing meant vaping was deprioritised in history taking and advice:
‘You're dealing with a profession which is hanging by a thread who just wants to get through the day, and any additionality is going to be challenging.’ (P5, 6 years)
Systemic challenges
GPs noted system-level barriers to change; limited resources, absence of dedicated e-cigarette cessation services, and insufficient government guidance. Participants perceived ‘no direction’ from government or public health bodies on tackling vaping, which, contrasting with prominent alcohol and smoking campaigns, signalled vaping to be of a lower public-health priority, dampening urgency in primary care:
‘I think it’s just something that’s not pushed as heavily as kind of like alcohol [or] smoking drugs in the population.’ (P6, 4 years)
It was apparent that GPs believe the NHS is taking a pro-vaping stance. GPs noted that the NHS fails to emphasise to patients that the ‘benefits’ of vaping are only in the context of cigarette cessation:
‘They say that it’s much better and it’s much safer. Which again is sort of encouraging the smokers to move across, but it is also, inadvertently, reassuring kids that it’s fine.’ (P4, 23 years)
Challenges associated with young patients
GPs noted that young people often use e-cigarettes as a lifestyle choice rather than a cessation aid, which poses additional challenges, such as reducing the traction of standard ‘quit’ counselling, normalising ongoing use, and shifting focus toward prevention that targets identity and peer norms/influence.
GPs felt young people were particularly receptive to industry marketing; when coupled with messages that the evidence is limited or still emerging, this seemed to leave many adolescents and young adults relatively unconcerned about potential health consequences:
‘They may say, “Oh, there’s no research that it will cause cancer. There’s no research, it will cause heart disease.”’ (P8, 3 years)
Recommendations for change
GPs identified three broad areas that require specific attention: education, current clinical practices, and engagement of key stakeholders.
Improving education
Most GPs requested further education on how to document the volume of e-cigarette use and which method to use for this quantification:
‘Resources like […] Royal College of General Practitioners (UK GP professional body) or Red Whale (UK Primary Care Education Provider) or […] British Medical Journal (publishing group), they can maybe have some articles or some bite-size learning kind of thing, or maybe podcasts [on vaping].’ (P8, 3 years)
Other GPs saw more value in face-to-face training, such as conferences. Some suggested that the Integrated Care Board (ICB) could commission local education to improve knowledge:
‘We could do with some in-house education or some local education at the ICB level. We have protected learning events regularly once a month that we’re encouraged to attend, so something about vaping would be very interesting […]’ (P3, 30 years)
Improvements to current practices
Suggested improvements related to four key areas of practice: counselling, guidelines, screening, and quantification. Many GPs supported the need for digital solutions to improve counselling. These recommendations target the adaptation of current digital tools used for other addictive behaviours to make links to helpful websites more accessible:
‘So, to be able to ping them a bit of information through AccurX about it and say have a read of this when you’ve got 5 minutes and then there’s some links there if you’re interested in finding out more or getting some help.’ (P3, 30 years)
Interviews revealed the heavy interdependency between counselling efforts and the effectiveness of guidelines. Some GPs reported that, at present, there are no guidelines to aid clinicians. Over half of the interviewed GPs suggested digital tools would improve screening practices. Clinical templates were commonly suggested to trigger documentation using ‘prompts’ within the ‘clinical system’ while screening, offering a standardised approach. Several GPs suggested that current frameworks do not sufficiently incentivise adequate screening rates of e-cigarette use. For primary care, the Quality of Outcomes Framework (QOF) was most often mentioned. Above all, GPs revealed that more time was needed to implement health-promotion behaviours.
Key stakeholders required
Most GPs felt themselves to be key stakeholders but remained uncertain on what their role is. Smoking cessation services were also identified as key stakeholders for e-cigarette cessation efforts.
GPs often observed youth vaping co-occurred with low mood, anxiety, and stress. Given that nicotine withdrawal may exacerbate symptoms, clinicians supported involving mental health services:
‘We should commission a service, and it should be integrated within a children’s mental health hub, which should be a free in and out thing.’ (P1, 5 years)
GPs viewed e-cigarette use as a population-level problem and argued that engaging public-health teams is essential for cessation and prevention, as it has been in stop-smoking campaigns and health screening campaigns. Other important medical stakeholders mentioned by GPs included nurses, pharmacists, and respiratory specialists.
Most GPs emphasised that leveraging in-school interventions would serve as a more effective solution for vaping prevention:
‘It has to come from schools, there’s almost a curriculum there that is a preventative curriculum – maybe it needs to be included within that. That will then go mainstream, and you almost catch the children before they start vaping.’ (P7, 18 years)
Finally, GPs listed some important public entities to involve, such as the Royal College of General Practitioners, Public Health England, and the Local Medical Council. GPs also cited the government as a crucial non-medical stakeholder, which could use national directives and legislation to cut the use of e-cigarettes.
Discussion
Summary
Interviews with GPs revealed that vaping is rarely addressed through routine, standardised processes in primary care. Screening and documentation were typically binary (vapes/does not vape), with uncertainty about meaningful metrics such as frequency (days/week), nicotine strength (mg/mL), device type (disposable/refillable), time to first vape, and duration of use. Patients often separated their identity as a ‘non-smoker’ from vaping, so smoking-status questions alone failed to elicit use. Time-limited consultations meant counselling was brief, anchored to the presenting condition, and delivered with cautious advice given the uncertainties of vape use. Knowledge gaps (device types, cessation pathways, and the evidence base on harms) reduced confidence. Clinicians were especially concerned about uptake among those who had never smoked in adolescence and early adulthood, peer/marketing influences, and clinical presentations attributed to exclusive vaping. System-level gaps, limited resources, absence of dedicated services, and lack of concise primary-care guidance, further dampened momentum for change.
The findings from this study suggest that there is a demand for simple, cost-effective measures like informational leaflets and teaching sessions to enhance GP readiness. GPs felt that addressing youth vaping requires collaboration between medical professionals, schools, public health, and digital health, warranting further research. The NHS must equip primary care professionals with the necessary training, resources, and support to tackle this growing public health issue and safeguard future generations.
Strengths and limitations
This is the first qualitative study in the UK examining how UK-based GPs encounter and manage vaping among adolescents and young adults, a group increasingly composed of those who have never smoked previously. Purposive sampling across multiple UK regions and career stages captured a spread of settings and experiences. Rigour was enhanced through independent coding by two researchers, investigator triangulation, an explicit analytic framework (Gioia), reflexive team discussions, and use of an audit trail and member-checking materials to support credibility and transparency.
However, the GP-only sample meant that the views of nurses, pharmacists, young people, and families were not captured. Recruitment via PCNs, newsletters, and LinkedIn may have favoured volunteers with greater interest, so some selection bias is likely, and we cannot know how views from non-participants may have differed. Interviews were conducted online and often with two interviewers, which may have shaped disclosure through fewer non-verbal cues, greater perceived formality, power asymmetry may have also encouraged socially desirable responses. Though we used a single lead interviewer, a standardised guide, clear ground rules, and reflexive debriefs, the format may still have influenced what participants chose to disclose. Data were self-reported and cross-sectional (April–May 2024), reflecting perceptions at one time point in a fast-moving area. We also did not observe consultations or link accounts to clinical records. This meant we could not verify clinicians’ self-reports against what actually happened in consultations or how vaping was documented in records, so reported practices may differ from real practice. Despite theoretical saturation, transferability beyond similar UK settings may be limited, and a comparative analysis including other primary-care professionals would have provided broader context.
Comparison with existing literature
Our findings align with previous UK work by Stepney et al,24 which described clinician ambivalence, uncertainty of long-term risk, pragmatic harm-reduction, and a desire for authoritative GP-facing guidance. Our study extends this literature by focusing on adolescents and young adults, who have frequently never smoked previously, which shifts the clinical emphasis from switching to prevention. Set alongside wider international evidence, the results converge on three recurring challenges: inconsistent screening, knowledge gaps, and variable counselling.25,26 Our data add an explanation of how vaping slips through routine workflows in UK general practice: patients commonly self-identify as ‘non-smokers’ while vaping, so reliance on smoking-status questions misses use; documentation is typically binary (vapes/does not vape), reflecting uncertainty about what to record; and severe time pressure means advice is usually brief and tied to the presenting problem, for example wheeze, rather than delivered as a structured discussion. We also show how a ‘lesser-evil’ framing can deprioritise vaping during short appointments.
In UK primary care, GPs are expected to ask about smoking status from early adolescence, provide very brief advice (VBA),27 and signpost support. These roles are set out in NICE NG209 and its evidence review, which covers ages ≥12 years and prevention of uptake in under-25s.23 Adapting this scaffold to vaping means adding a separate, explicit vaping-status question, delivering a 30–60-second ‘ask-advise-act’ script anchored to the presenting problem, and embedding simple EHR prompts to normalise recording, approaches that are consistent with VBA guidance and with clinicians’ calls for clear, GP-facing advice on e-cigarettes.24
Implications for practice
Our findings highlight the need for concise, primary-care-facing guidance on vaping, particularly for adolescents and young adults. At a system level, our interviews add UK-specific operational detail and consequently we suggest that the National Centre for Smoking Cessation and Training (NCSCT), in partnership with general-practice stakeholders, co-produce guidelines and practical resources: a brief separate screening vaping-status prompt distinct from smoking status; a simple quantification schema (frequency, nicotine strength, device type, duration); a short motivational-interviewing counselling script with signposting pathways; as well as EHR/Accurx templates to enable ‘micro-interventions’ within standard appointments.
Co-badging with GP professional bodies and periodic updates would help ensure consistency as evidence evolves. Embedding these tools in templates (and, where appropriate, incentives) is likely to improve uptake and consistency.
The youth focus of our study highlights roles for public health, schools, and Child and Adolescent Mental Health Services (CAMHS), reflecting co-occurring mental-health needs less prominent in earlier UK work. Clinicians advocated mental-health involvement because adolescent vaping often co-occurs with stress, anxiety, and low mood.
Addressing youth vaping will require a team approach. Beyond GPs, nurses and pharmacists can deliver opportunistic screening, brief advice, and follow-up, while education, public health, and digital health partners tackle peer norms, messaging, and workflow integration. A larger quality-improvement programme should refine and test components: co-design brief patient materials (leaflet/SMS links), strengthen GP education with concrete screening and counselling tools, and track outcomes via longitudinal EHR coding (detection, documentation beyond yes/no, referrals). Inclusion in undergraduate/postgraduate curricula should be considered alongside incorporation into templates/incentives, for example QOF. This will require coordination with NHS England/NHS Digital, medical schools, training hubs, and local commissioners (ICBs).
Notes
Funding
No external funding was received to perform this study's analysis.
Ethical approval
The Head of Research Governance and Integrity at Imperial College Research Ethics Committee (REC) granted full ethical approval on 12 February 2024. All interviewees provided their consent, and the participation information sheet clearly explained the purpose of the interview and a consent form which explained how their information would be used (Supplement 7).
Provenance
Freely submitted; externally peer-reviewed.
Data
The dataset relied on in this article is available from the corresponding author on reasonable request.
Acknowledgements
The authors would like to acknowledge all GPs who participated in this study.
Competing interests
The authors declare that no competing interests exist.
- Received October 10, 2025.
- Accepted November 11, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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