Exploring the experiences and perceptions of young people’s recreational nitrous oxide use Open Access

Nitrous oxide (N₂O) is a dissociative anaesthetic that was developed for recreational use in 1722 (Miller, 1941). Now used to aid medical procedures, particularly in dentistry and childbirth (Xiang et al., 2021), reports of physical, social and environmental problems associated with non-medical use are increasing around the world (Frank et al., 2020). Alcohol and other drug use (AOD) is an enduring and complex issue that can negatively impact peoples’ mental health and well-being (Department of Health, 2017). Substance dependence is the third most common mental health condition in Australia (Australian Bureau of Statistics, 2023). As AOD generally starts in adolescence, young people are at particular risk and increasing use correlates with deteriorating mental health and the onset of serious conditions (Marel and Mills, 2017; Winters et al., 2014; Sheidow et al., 2012; Rodriguez-Cano et al., 2023; Peach et al., 2024).

Research has informed the implementation of safety measures to reduce substance-use related harm, such as drink driving laws and school-based prevention programmes (Das et al., 2016). However, research on N₂O has been limited, with most published studies comprising individual case reports of hospital presentations (Allan et al., 2022; Back et al., 2024). Some studies have indicated that recreational use of N₂O is increasing rapidly among young people, and harms are also increasing as a result (Desmedt et al., 2024; Dumbili and Ebuenyi, 2024; European Monitoring Centre for Drugs and Drug Addiction, 2022; Hussain, 2022), including Australia where the number of calls to Australian poisons helplines increased sixfold (Sutherland et al., 2023). However, the limited research attention to N₂O use means that the scope of all risks and harms has not been comprehensively identified (Allan et al., 2022; Back et al., 2024). Recent commentaries have explored the “addictive” nature of N₂O (Brunt, 2023; Winstock, 2023; Back et al., 2024; Victorri-Vigneau and Grall Bronnec, 2024).

While existing harm reduction strategies for other recreational substances can guide harm reduction advice for N₂O, they are not sufficient for this emerging health crisis (Victorri-Vigneau and Grall Bronnec, 2024). The unique effects and methods of N₂O use require a more nuanced and contextualised approach.

N₂O was rediscovered as an intoxicant in the emerging alcohol and other drug scene of the late 1960s (Jay, 2008). In a recreational context, N₂O is often referred to colloquially as “nangs” (Australia) or “whippits” (UK) and is generally inhaled directly through a whipped cream dispenser (known colloquially in Australia as a “nanginator”) or through a balloon (Frank et al., 2020). Once inhaled, users typically experience brief euphoria, relaxation and mild perceptual changes for around 1 min (Sumnall, 2022). N₂O use often takes place at parties, nightclubs and festivals (Hussain, 2022). In most Australian jurisdictions, N₂O is accessible and costs little (Frank et al., 2020; Sutherland et al., 2023). N₂O cannisters, which are inserted into whipped cream dispensers, are legal and can be purchased online and at most general stores and supermarkets for approximately AU$1 (Allan et al., 2022; Hussain, 2022).

Despite the increasing use of N₂O and its euphoric effects, a range of health issues are associated with it (Oulkadi et al., 2022). These are emerging as prevalence of use increases (Hussain, 2022). For example, increasing numbers of N₂O-related emergency presentations in Australia have been reported (Bethmont et al., 2019). Frequent use of N₂O can result in low levels of vitamin B12, and because of this deficiency, users may suffer neurological disorders (Perino et al., 2022). Some consequences include megaloblastic anaemia, (myelo) neuropathy, thromboembolic complications (Oulkadi et al., 2022) and degeneration of the spinal cord (Paris et al., 2023). If not treated early on, these effects can cause permanent disability (Paris et al., 2023).

N₂O use may cause reproductive harms (Amsterdam and Brink, 2022) and has been linked to serious road accidents, including 63 deaths in The Netherlands in the past three years (Aerts et al., 2022). Death by asphyxiation has resulted from methods used to inhale N₂O (Bäckström et al., 2015). Recent research has also found that passive inhalation of N₂O can affect bystanders known as “accidental users” (Sluyts et al., 2021). However, many people remain unaware of N₂O harms and risks. While practitioners, decision-makers and young people remain uneducated about N₂O, harm reduction strategies cannot be effectively established (Allan et al., 2022).

Peer-to-peer conversation about alcohol and other drug experiences, benefits and harms is typically how AOD techniques and safety measures are shared. A platform where recreational N₂O use is frequently discussed is via the social news and discussion site, Reddit. A recent study by MacLean and colleagues (2022) analysed conversation threads of Reddit users asking and answering questions related to N₂O use, and from this, identified existing strategies by users to “minimise harms and maximise pleasures”. Discussions included questions and advice on practices such as inhalation techniques, substances that enhance the effects of N₂O and ways to minimise harms according to user experiences. In formulating harm reduction advice and psychoeducation for young people, it is important to include these sources of communication as they offer insight, and the forums provide a dissemination point for health-related advice.

The aim of this pilot study was to explore young people’s perceptions, motives and experiences of N₂O use by identifying the positive and negative effects of N₂O, motives for use, practices and methods and suggested advice, to inform targeted harm reduction resources that will be developed by the authors to support young people aged between 18 and 24.

This pilot study used qualitative methods to explore the experience of young people using N₂O. The study was completed in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., 2007) (see  Appendix 1). Ethics approval was granted by the University of Wollongong Human Research Ethics Committee (2022/008).

Participants eligible for the pilot study were aged between 18 and 25, who identified using N₂O for non-medical purposes on at least ten occasions and resided in the Wollongong region. Wollongong is a regional town located 1 h from Sydney with a population of 302,739. Wollongong is also a university town with a large cohort of young people from many rural and regional areas coming to study. This age group was chosen as research indicates recreational N₂O use is the most common in young people (Yu et al., 2022).

Participant recruitment took place between April and August 2023, both online (social media) and in-person via posters advertised around student accommodation and a university bar. Given the sensitivity of the topic, snowball sampling (Naderifar et al., 2017) was also used to recruit participants outside the university community. This was done by asking initial participants whether they knew any other people who use N₂O and inviting them to participate.

This research was purposively designed as a peer-led pilot study whereby the primary researcher (HW) was a young adult who had used N₂O and university student themselves. Peer researchers have an insider connection with the hidden practice of AOD and a more nuanced understanding of its socio-cultural environments (Greer et al., 2016). Peer researchers can also build trust more quickly and effectively than outsider researchers (Greer et al., 2016). As such, interviews were conducted by two team members. They were led by HW, with another experienced qualitative researcher. In this way, if participants experienced any distress, they could be supported. Following each interview, HW reflected on the context, her connection with participants and what occurred in a reflective diary in line with COREQ (Tong et al., 2007). No adverse events occurred. Interviews were conducted online via Zoom or in-person (in a safe place at the university). All data, including interview transcripts and the reflective journal, were uploaded to qualitative analysis software “NVivo” (Lumivero, 2023).

A thematic analysis was used to identify emerging themes while also ensuring that the research was guided rather than derived from assumption (Hansen, 2006). Clarke and Braun’s (2013) six-step framework for thematic coding was used beginning with a line-by-line assessment of the transcripts by HW. Following this, deductive codes were used to create a coding tree. Following this, HW used deductive coding to link participant statements with literature review concepts and form a coding tree (Braun and Clarke, 2022b). Examples to weekly meetings with three research team members to discuss noting similarities and exceptions in each interview as it was coded, and common perceptions of the research team regarding Nangs use and safety strategies were developed to become inductive codes. Finally, these codes were refined to become themes and reported in the findings. This iterative approach allowed for new concepts and themes to emerge from the data (Braun and Clarke, 2022b). The review of concepts by a larger number of researchers also meets COREQ (Tong et al., 2007).

A total of seven qualitative interviews were conducted at Wollongong University between April and August 2023. Six were in-person, and one was online. The response from the online recruitment was lower than anticipated, suggesting that people who use alcohol and other drugs recreationally remain a hard-to-reach population for research (Stetina et al., 2008). Resultingly, majority of the participants were recruited through snowball sampling. An inevitable limitation of snowball sampling is that participants are more likely to recruit from their social networks who are similar to themselves (Tracy, 2013). As shown in Table 1, majority of the participants were male and university students. The primary aim of the research was to develop an in-depth understanding of the use of N₂O among young people, rather than generalisable results. Therefore, data saturation was judged by the quality of data (Morse, 2015) and when key ideas and experiences become recurrent in the data set with no significant information emerging as new findings (Guest et al., 2006; Malterud et al., 2016; Vasileiou et al., 2018). Interview duration ranged between 30 and 60 min, with an average time of 43 min. Participants were asked to complete a short demographic survey (see Table 1) of age, gender, education and patterns of N₂O use. Young people who participated in the pilot study are referred to as “participants” and identified by their allocated number e.g. (#1) refers to Participant 1. The research team ensured no names, locations, dates or times were associated with any quotes to avoid participant identification.

We present four overarching themes about N₂O use: the nature of N₂O use; the appeal of N₂O; influences of N₂O use; and perception of risk and harms of N₂O use. An overview of the themes and how the coding was developed is presented in Table 2.

This theme relates to where and how participants use N₂O, including the nature of settings and described methods of use. This theme has two subthemes: settings and method of use.

Participants cited regularly using N₂O with “small group[s] of friends” (#1) sitting together in parks, cars, at “home, house parties, small gathos [1], or sessions (#6)”. This most frequently occurred in the evening and at the end of the night:

Participants stated these environments facilitated the co-use of N₂O with other substances like alcohol, marijuana, ketamine, LSD and MDMA for “prolonging” (#1) and “intensifying” (#4) N₂O other substances’ effects:

In the demographic survey (Table 1), all seven participants selected “in combination with another substance” or “substances” to describe their typical N₂O use. Overall, this suggests that singular use of this substance is not typically condoned by participants.

Participants described inhaling N₂O in two ways – by inserting a N₂O canister into a whipped cream dispenser, dubbed a “nanginator” or “cracker”, then inhaling from the dispenser mouthpiece or a balloon inflated with N₂O from the dispenser. When inhaling through the balloon, users stated they breathed N₂O to and from the balloon until they “physically cannot anymore” (#6). This was the preferred method for the six participants because the nangs “last[Ed.] longer” (#2) and they obtained a stronger “hit” as “inhaling and then exhaling into the same thing, there’s gonna be very limited oxygen you’re getting” (#7) compared to a singular hit from a dispenser. Participant 6 cited favouring inhaling from the dispenser and then incorporating a balloon, so as not to “lose a lot of nitrous” when fitting the balloon to the dispenser.

Additional methods participants described to extend the short-lived euphoric effects of N₂O including “chaining” (#6) or unremittingly breathing N₂O through a series of balloons:

Or inflating the balloon from more than one cannister, colloquially known as a “double or triple nang”:

Highlighted here is the elevated risk with seeking prolonged N₂O effects, or, as stated by some participants, achieving a high like their first N₂O use because they reached “a point where you only ever do two at a time because one would do nothing” (#4). While no one linked peer pressure with their initial uptake, some associated competition with N₂O use. According to Participant 3, this surrounds the longitudinal “unwritten rule” when breathing through a balloon whereby users “don’t want to be the first to stop”. This is almost “a competition […] I remember a lot of the boys passing out just to try and beat each other”.

Participant 1 also recalled observing “who’s gonna be lasting the longest”. These reflections from both male and female participants demonstrate the competitive nature of N₂O may not be gender specific.

Overall, we found N₂O rarely occurred alone and in combination with other substances. This was consistent regardless of age, social groups and location. Lastly, the quest for stronger “highs” led to innovative practices, which increased risk.

The second theme surrounds why people use N₂O in the short and long term. Whilst participants struggled to explain what using N₂O specifically feels like due to its “distinct unique feeling” (#3), they labelled it as: “euphoric” (#1, #2, #4), producing “dizziness” (#1, #2, #4), “disorienting” (#1, #3), “a fifth dimension” (#5), “numb[ing]” (#6), “dissociated” (#1, #3, #7), an “echo feeling” (#1, #7) almost like a “wahwahwahwah noise in your head” (#6), and “feeling like you’re trying to chase something that you cannot actually get a hold of” (#4). Most participants claimed they enjoyed its short-lived buzz, disorientation and connection but highlighted this may not be the case for everyone due to its intense, short-lived effect.

Most participants stated their favourite aspect of N₂O use is its sociability. Whilst five in seven participants had used N₂O alone, most preferred doing it with others for social reasons. Some emphasised they would not use N₂O alone:

This social aspect to nangs was reflected in rituals surrounding its use:

In this sense, nangs were perceived to be “communal” (#3), something linguistically exemplified in the phrase “cheers a nang” (#1), which is where users cheer a Nang balloon before inhaling in the same ways others cheer alcohol before drinking.

Only two participants described regularly using N₂O alone. This was for its dissociative and numbing effects:

Theme 3 further explores social facilitation, accessibility and substances’ co-usage as key factors in the N₂O experience.

Before using N₂O, participants stated they learnt about AOD from peers, family and/or independent research. Peers were the most common point of contact, providing verbal commendation or practical demonstration, as explained by Participants 1 and 5.

These statements highlight social initiation, but participants also cited online sources:

Participant 1’s father “normalised it” by sharing stories about his own use when he was younger. Participant 3 similarly was introduced by his boss’ stories of taking it whilst working in hospitality, aged 14.

Social stories also appear to have mitigated knowledge of side effects for some:

As is evident in quotes above, the normalisation of N₂O use via family members and role models appeared prominent amongst participants, who described socialisation processes that infer N₂O use to be a safe and acceptable transition into adulthood.

Participants also liked the accessibility and cost of N₂O, which can be bought through local cooking stores, petrol stations and online delivery services. All participants in this pilot study noted N₂O is both “accessible” (#3) and “easily obtained” (#2). None could recall having purchases denied, although some suppliers asked usage questions such as:

Participants also ordered N₂O 24/7 online delivery services that delivered, facilitating orders at night when shops were closed. These delivery services were stated to be so easy to use: Whenever we start doing nangs someone’s like “oh let’s order more” (#1).

Notably, nangs were claimed by some participants to be easier to source than alcohol, particularly if they were under 18 years of age, “You can get like 50 for $50…or like a box of 10 for $11.00” (#2).

The legal dichotomy surrounding N₂O was acknowledged by participants:

Although some stated illegality may not affect them trying to access or use them:

It was also noted by one participant that being able to access easily reduced the “se” aspect.

This suggests at least some participants do not consider N₂O a serious recreational substance and may deem it as less harmful than illicit substances. It also highlights that young people’s use of N₂O is not entirely driven by its accessibility.

The final theme relates to participants’ perceptions of N₂O risk and the strategies used to mitigate this. Participants recounted several negative effects experienced by themselves and peers. These included the urge for more, loss of control, reduced concentration and memory and burns and infections.

The short-lived effects of N₂O were described by some participants as leaving them wanting more:

Whilst this was not seen by participants as a dependence in themselves, they recognised it as such in others:

Feelings of euphoria and dizziness also came with a lack of control and risk of falls, with participants reporting “falling over” (#6), “spasming” (#2) and falling “unconscious” (#4) when using N₂O. Many attributed this to reduced oxygen:

Others described observing their friends’ induced reactions:

Regardless, participants acknowledged continued use of N₂O. This suggests indifference towards observed negative consequences. Although not directly asked, some participants did comment they reduced use after negative experiences. The aftereffects of usage reported by several participants include “brain fog” (#2, #3, #4), “short term memory loss” (#2), “super dumb and a haze over my head” (#3) and “a little less human” (#5). Effects were described as lasting up to a week:

These effects were stated to occur when N₂O was frequent, with use on most weekends. Others experienced “brain zap[s]” (#2, #4), which lasted from days to weeks when using large quantities of N₂O over short periods:

The use of smaller Nang crackers by many participants, rather than whipped cream dispensers, whilst “convenient and inconspicuous” (#5), was understood to risk cold burns on hands and lips:

Participant 7 displayed resulting scars.

Although most participants reported receiving cold burns, only one participant (#3) recalled a friend seeking medical advice when their hand became infected. Other concerns identified by participants related to general health:

While another was concerned about usage by-products:

Despite describing a range of negative effects, participants’ perceptions of N₂O risk were low. Participants linked this to a lack of information regarding N₂O harms,

Moreover, some participants considered N₂O a lower risk because it is legal:

When reflecting on N₂O’s negative effects of use, most did not appear concerned:

Several participants found negative instances humorous.

Despite participants stating they use Nangs in the car, many did not think it affected their driving ability:

The only time participants identified where they would consider seeking medical assistance was where a friend was unconscious:

Yet, this appears paradoxical, given that most acknowledged co-partaking of N₂O – meaning everyone present concomitantly high or passed out.

Many participants advised ways to reduce N₂O harms, including being seated and in a comfortable environment, administering it via balloons, inhaling smaller quantities, moderating use over time and having a “sober” person present.

When asked if participants would do nangs in the future, most answered yes.

Those who responded with no associated this with changed responsibilities or perspectives towards alcohol and other drug taking:

^[1] Gathos: means small gatherings.

Only one of the participant described a friend with mental health issues who used regularly, and while this participant did not deem themselves as having a dependence problem, they explained that their friend may have been using this quantity due to mental health issues experienced at the time.

This pilot study set out to examine the experiences and perceptions of young people who use N₂O recreationally, with an aim to inform harm reduction resources. This study highlights a range of reasons why young people are using N₂O. The participants reflect how N₂O use is related to both personal and public factors. The results indicate that young people are not fully aware of the harmful consequences of N₂O use and their perception of risk is low.

Similar to two previous studies (Frank et al., 2020; Nabben et al., 2021), seeking relaxation with friends, easy access and minimal negative aftereffects are some motives for N₂O use.

However, the findings from the present pilot study identify three core factors (Figure 1) that underpin N₂O consumption. This discussion will focus on social influences; other substances and accessibility.

A key finding in this study identified that using N₂O was social in nature. While existing literature (Allan et al., 2022) highlights recreational aspects of N₂O, the social influences of use have not been thoroughly investigated. N₂O use is almost always reported as being conducted in the company of at least one other person, and the study findings suggest this is primarily due to the amusing effects of watching friends use N₂O or the social act of doing a nang at the same time. Among the seven participants, this social factor is identified as the most appealing feature of N₂O use and suggests that further research is needed to gain a deeper understanding of the habits and positive perceptions young people have towards N₂O.

The “other substances” code is the single code that overlaps across all four themes. Qualitative research (Frank and Herold, 2023) in Denmark highlights how some young people would use N₂O in combination with alcohol and cannabis but finds that other illicit substances are not commonly used with N₂O, although MacLean and colleagues (2022) identified use with psychedelics. In the present study, while several participants recall using alcohol and cannabis with N₂O, most of the interviewees indicate that other illicit substances such as ketamine, LSD and MDMA were used with N₂O frequently. Poly-substance use is a risk factor for both mental health conditions and substance dependence (Rodriguez-Cano et al., 2023).

Similarly, recent research (MacLean et al., 2022) analyses online Reddit discussions and identifies that users would often use a range of psychedelic substances concurrently with N₂O. Ketamine is a particularly prevalent substance among participants in the present study, and one participant (#7) describes the subjective effects of N₂O to mirror a strong dose of ketamine. This may be due to ketamine being a dissociative substance, similar to N₂O, making it more appealing to users who seek this effect. Contrary to these findings, a recent study in France by Inquimbert and colleagues (2022) finds that N₂O users do not use ketamine in combination with N₂O but instead alcohol and “poppers” (amyl nitrate) are significantly associated with lifetime N₂O use. These geographic differences further support N₂O use being contextualised according to cultural practices in a specific location.

Another key element related to N₂O consumption is accessibility. Access to N₂O is depicted as effortless and inexpensive by participants, with many reflecting on obtaining N₂O through online delivery services late at night. This finding is consistent with the work of Grigg and Lenton (2020) who also note easy accessibility. However, overall, there has been limited research interrogating N₂O accessibility; the participants in this study outline this as a key factor in their consumption.

In contrast to the findings of Winstock and Nutt (2023), who explore recent UK government bans of N₂O to stop recreational use, several of the participants in the present study identify that making N₂O illegal would not change their motivation to access it. These findings support the validity of a harm reduction approach towards N₂O use.

Understanding why young people use N₂O and the different factors that influence its use will ultimately assist in development of harm reduction knowledge such as target populations and specific habits and motivators. To extend on this knowledge, further investigation on social influences, concurrent substance use and accessibility perceptions needs to be conducted to identify those at most risk of harms.

A key strength of this study was the peer-led approach (although we acknowledge the small number of participants) that used a peer researcher to conduct the interviews and lead the data analysis and interpretation. This allowed a more nuanced understanding of the participants’ lived experience. This study contributes to the evidence base regarding N₂O use among young people. Semi-structured qualitative interviews provided flexibility to modify interview questioning to explore new curiosities. This is exemplified by the interview times, which increase as the study progresses and researcher confidence grows.

A limitation of this pilot study is its sample size, which we acknowledge is small; however, information-rich and relevant data was collected to achieve the research aim and enhance research rigour (Guest et al., 2006). This is because this study used a perspective-based research methodology (Braun and Clarke, 2022a) whereby responses were not intended to be measured, but instead to provide rich details surrounding the way N₂O users partake in AOD, in what they perceive are safe ways.

By collecting the lived experiences of young people and first-hand insights, this research will not only inform future research into N₂O but also provide insight into the research practice of using peer researchers to develop and test harm reduction resources. It supports the need to address the gap identified in this study as participants had low identification of harms, even as they recounted them, despite this, we acknowledge the risk to occasional users is limited.

Despite describing harms from N₂O use, including seizures and unconsciousness, participants minimised these events. This is likely because people involved recovered. Given the general perception of low risk in using N₂O, it is critical that young people are made more aware of harms and how to reduce them. For example, increasing the intake of oxygen instead of “chaining” would be a strategy that would directly address the described harms. As most participants were male, it is possible there is some gender-based competitive element to this behaviour. However, without more female participants, this is unable to be ascertained at this time and should be explored more in the future.

Future studies could recruit multiple peer researchers with different backgrounds and offer renumeration for participants which may increase the sample size. Recruitment could use social media, e.g. Instagram ads, to facilitate recruitment nationally from a wider group of people. Despite these limitations and challenges, we still believe this is an appropriate methodology and approach.

Moreover, future research could replicate this study to explore and develop harm reduction resources for other age groups, including young people under 18 years as well as explore the comorbidity of N₂O use and mental health problems as this is an area that is also under-researched.

Young people who use N₂O need advice and information about effective harm reduction strategies from experts in the field. A future project will take this expert advice to groups of young people to co-design harm reduction messages using accessible language and social media materials.

There are several practice implications. Harm reduction advice has been developed from this study but will be tested with focus groups of young people before being disseminated. Young people who use N₂O are unlikely to be engaged with drug and alcohol treatment services where the average age of clients is 38, and the most commonly used substances are alcohol and methamphetamine (Australian Institute of Health Welfare, 2023). Typical AOD treatment services are not designed to support young people seeking information and advice about substances such as N₂O. Other avenues for providing this information and support need to be found; hence, bespoke harm reduction material created by young people is warranted.

This is the first pilot research conducted in Australia exploring the experiences of young people’s recreational N₂O use. The findings from this study identify that young people use N₂O to enhance the effects of other alcohol and other drugs, add to the social activity of an occasion and to reach a state of intoxication in an accessible and cheap way. Young people in the study describe their experiences as positive for the most part. However, several identified harms they or friends had experienced. Regardless, perception of N₂O risk is low among young people in the study. Accessibility and short-lived effects of N₂O suggest that N₂O harms are minimised. Through analysis of N₂O effects and consideration of previous harm reduction advice for other substances, N₂O is unique to any other recreational substance and should be thought of as separate. Appropriate harm reduction strategies and psychoeducation must be used in ways that are accessible to young people to ensure they can mitigate harms.

Declaration of interest: This paper has been submitted to Qeios as a pre-print citation below:

Hannah Walter, Jacqui Cameron, Helen Simpson, Kenny Kor et al. (2024). Exploring the Experiences and Perceptions of Young People’s Recreational Nitrous Oxide Use. Qeios. doi:10.32388/011IWW.

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