Associate Professor Chandrashekhar T. Sreeramareddy does research in epidemiology and control of tuberculosis, tobacco use and tobacco control issues.
Why are electronic cigarettes (e-cigarettes) becoming so popular among young people?
Chandrashekhar T. Sreeramareddy: First and foremost, e-cigarettes are very well marketed on many online media platforms, including social media, which younger people widely use. Secondly, they are portrayed as cool things.
When looking at websites that display information about e-cigarettes, we see that vaping products are displayed attractively, with positive messages. For example, with claims that they are clean and healthy. These websites even say the nicotine in e-cigarettes is much safer than the nicotine present in traditional cigarettes. They offer promotions, they give away freebies and they have discussion forums. They focus on the positive aspects, such as that e-cigarettes smell good and are easy to use. Therefore, the messages getting across to the younger generation are very positive.
But the most important factor is flavour. There are many flavours, making them even more attractive to young people.
What role does marketing, including social media, play in attracting young people to e-cigarettes?
Chandrashekhar T. Sreeramareddy: There are different types of online shops and I’m unsure if similar shops exist in Europe. However, in South-East Asia, particularly in Malaysia, where I am based, we have popular e-commerce apps such as Lazada and Shopee. While there are many emerging e-commerce platforms, these two are among the most well-known.
I am currently analysing these platforms and I’ve seen that the only thing they do is put a note indicating that these products are not meant for kids. However, it seems that anyone can access, create an account for and order from these shops, regardless of their age. There’s no requirement for identification, such as a national identification number, to make a purchase. Even if someone is underage, they can simply click a button to indicate that they are over 18 and proceed with their order.
Many countries don’t have very strict regulations on advertising, promotion, sponsorship, offering discounts and freebies, marketing online or selling to minors. There aren’t even any restrictions on the content. For example, what these products contain and the fact that their contents could potentially be harmful isn’t fully clear. Evidence is increasingly emerging about possible health effects of e-cigarettes.
What are the primary health risks of e-cigarette use for teenagers and how do these compare to traditional smoking?
Chandrashekhar T. Sreeramareddy: Let me make a statement here. E-cigarettes are for those who want to quit smoking. It’s better if they can do so without smoking in general and be free from nicotine, but it’s better for them to smoke e-cigarettes rather than conventional cigarettes. So, for smokers, e-cigarettes are a harm reduction product that does less damage.
However, e-cigarettes are not for people who don’t already actively have nicotine in their bodies. By this I mean they could still have it in their bodies due to second-hand smoke exposure, but not actively. For them, the harm caused by e-cigarette use is the first step, which then starts a nicotine addiction and can become a gateway to other addictions, for example cigarette smoking. So, people who try e-cigarettes become used to the nicotine and may be tempted to switch to normal cigarettes.
The other concern regards the various flavours that can be found in vaping products, which may contain a wide range of chemicals. It’s important to note that there are plenty of different flavours available. Currently, there are not enough studies to definitively state that these flavours can cause harm. The existing evidence is limited, but preliminary findings suggest that certain chemicals may potentially damage the alveoli in the lungs. One reported condition associated with this is EVALI, which stands for e-cigarette or vaping product use-associated lung injury.
However, the greatest harm caused by e-cigarettes is nicotine addiction. Nicotine changes certain physiological parameters in the body. The nicotine content in e-liquids is very high, but it is synthetic nicotine, high levels of which can make consumers of these products addicted to it. This is a trick played by tobacco companies to get smokers hooked on nicotine.
So, the high levels of synthetic nicotine in some e-cigarettes could potentially increase the risk of cardiovascular disease as nicotine can cause increased heart rate and increased blood pressure. There are also some studies showing that they may change the bacterial flora in the oral cavity and damage the gums.
What role should schools and educational institutions play in raising awareness about the dangers of e-cigarettes?
Chandrashekhar T. Sreeramareddy: Teachers can go the extra mile by teaching students about the harm caused by e-cigarettes, but this should be part of the curriculum. I’m currently unsure about the norms in European countries regarding tobacco education in primary and secondary schools. It’s important to highlight the harm caused by tobacco use and future educational modules should also address the dangers of e-cigarettes. This should be part of a comprehensive approach.
Furthermore, it’s essential for various ministries, especially education and health, to collaborate and take responsibility for promoting anti-smoking and anti-vaping messages. A social media campaign could be an effective method for delivering this message. I am planning a project focused on disseminating these messages through social media, as this is where students are most likely to encounter the influences that encourage them to start vaping.
We need to outsmart those who promote vaping. First, we should analyse their messages and the implications of the methods they use. They often rely on visual images, influencer endorsements and attractive visuals that appeal to young people. By studying these tactics, we can create counter materials to effectively convey anti-vaping messages and spread them through social media and educational programmes in schools.
Your study highlights a significant gender gap in e-cigarette usage. Why is use higher among boys than girls and how does this trend manifest in Europe compared to other regions?
Chandrashekhar T. Sreeramareddy: This pattern is generally observed worldwide, but the differences are more pronounced in Asian and more conservative countries, where substance use is significantly lower. In these regions, there is a notable gender gap, with boys or men engaging in high-risk behaviours at much higher rates than girls. Although the gap also exists in high-income countries in Europe and America, it is much smaller compared to developing regions like Asia and Africa. Additionally, in some countries, it is socially unacceptable for women to smoke, which contributes to these differences.
If you could suggest one urgent policy change to reduce youth e-cigarette use, what would it be?
Chandrashekhar T. Sreeramareddy: E-cigarettes are not as harmful as conventional cigarettes, but they are not suitable for people who have never smoked, particularly young people. Research indicates that the earlier someone is exposed to nicotine, the more likely they are to become addicted, as nicotine attaches to certain receptors in the brain. Therefore, young people should never be exposed to nicotine-containing products.
Most countries have banned smoking conventional cigarettes in public spaces due to their distinct smell. In contrast, e-cigarettes often come in various flavours and do not have a strong odour. As a result, this allows users to circumvent smoking bans by using e-cigarettes in places where traditional smoking is prohibited.
The policy should be to ban vaping for recreational use and restrict it to prescription only for smokers who wish to reduce harm or potentially quit smoking. While there isn’t enough evidence to conclude that vaping helps people quit smoking, some people may use it to cut down. However, vaping should not be accessible to non-smokers or young people. E-cigarettes should only be available through a prescription from an authorised professional and should not be sold openly in physical shops, through online retailers or on e-commerce platforms.