E-cigarettes tend to be particularly popular among younger people. But how dangerous are they?
Modern electronic cigarettes (e-cigarettes) were introduced two decades ago, becoming commercially available in Europe and the USA around 2006. They were viewed as a potentially less harmful alternative to traditional tobacco products.
However, while the long-term health effects remain unclear, other health issues linked to e-cigarette use – such as lung disease and nicotine addiction – have been reported. The potential health issues for younger people are particularly concerning, as they are often the target audience for vaping product advertisements and appear to be using e-cigarettes at an increasing rate. What are the risks associated with these products and what measures can be taken to safeguard young people in Europe and beyond?
Electronic nicotine dispensing systems (ENDS), generally known as e-cigarettes, are electronic devices capable of heating an e-liquid and turning it into an aerosol that can be inhaled through a mouthpiece. One of the main differences from conventional cigarettes is that e-cigarettes do not contain tobacco. The process of tobacco combustion is replaced with the heating of a liquid, which produces a similar sensation to smoking tobacco, but is supposedly less harmful.
Typically, these products contain nicotine, a chemical found in tobacco that is known to cause addiction. However, not all e-cigarettes contain nicotine and the amount varies depending on the type of vaping product. Despite this and the fact that the long-term effects of prolonged e-cigarette use are not yet known, they are often advertised in a positive light as healthier alternatives to traditional tobacco products.
E-cigarettes tend to be particularly popular among younger people. A 2024 report from the World Health Organization Regional Office for Europe revealed that over 30% of 15-year-olds have used e-cigarettes at some point in their lives, with 20% reporting having used e-cigarettes in the past 30 days. An analysis of Global Youth Tobacco Surveys found that e-cigarette use was higher among young people in Europe than among those in low- and middle-income countries and those with stricter regulations on these products.
According to Dr Raffaella Nenna, Associate Professor at the Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome: “There is a misperception of the real harm caused by these products among a younger audience. They think that it is something sweet, something new and accessible that is not as bad as a normal cigarette. So, they want to try the different vaping flavours, thinking that it is at the same level as tasting a new chewing gum or something similar”. – Read the full interview with Raffaella Nenna
Health risks
Tobacco use remains the primary cause of preventable deaths in the EU, causing the loss of nearly 500 000 lives in 2021 alone. If we look at global statistics, this number rises to 7 million deaths caused by direct tobacco use, plus 1.3 million deaths as a result of being exposed to second-hand smoke. The World Health Organization clearly states that exposure to any form of nicotine or tobacco product is harmful to human health. Even though e-cigarettes do not contain tobacco, they typically contain nicotine, which is highly addictive. This poses greater risks for young people whose brains are still developing.
Dr Nenna explains: “During adolescence, our brains aren’t yet fully mature and undergo significant developmental changes, which is why teenagers are more susceptible to the negative effects of nicotine and to the possibility of developing addictions when using products containing nicotine”.
In particular, the prefrontal cortex, an area of the brain that plays a crucial role in cognitive function and is one of the last to develop, can be significantly affected by nicotine exposure during adolescence. Studies show that this exposure may lead to attention deficits, cognitive impairments and an increased severity of mood disorders.
According to Dr Chandrashekhar T. Sreeramareddy, Professor at the Department of Community Medicine and Public Health, IMU University, Kuala Lumpur, Malaysia, “nicotine addiction can become a gateway to other addictions, for example cigarette smoking. So, people who try e-cigarettes get used to the nicotine and may be tempted to switch to normal cigarettes”. – Read the full interview with Chandrashekhar T. Sreeramareddy
A key factor in the gateway effect of e-cigarettes is the increase in dopamine in the subcortical brain structure called the nucleus accumbens. This dopamine boost plays a role in the pleasurable effects of nicotine and other substances and can lead to the initiation and continuation of substance use disorders. For example, a study conducted by researchers at Columbia University Mailman School of Public Health involving 51 872 American adolescents showed that those who vaped were around 20 times more likely to smoke cannabis than those who had never used nicotine before.
Dr Nenna: “What we also know is that using vaping products, certain types in particular, can cause a severe injury to the lungs, known as EVALI (e-cigarette or vaping use-associated lung injury). While we have substantial information about this acute lung injury, there are also suggestions that vaping could lead to other types of lung disease. For example, for individuals with asthma, using these products can cause them to have acute asthma attacks”.
According to Dr Sreeramareddy, “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 also damage the gums”.
What can be done to reduce the use of e-cigarettes among young people?
One of the main reasons for young people’s growing interest in e-cigarettes is their wide variety of flavours, which increase their appeal and make them seem less harmful. A study conducted in the UK showed that one of the most popular reasons for vaping among young non-smokers was the attractiveness of flavours. Additionally, data from the Centers for Disease Control and Prevention show that more than 85% of young people who vape use flavoured e-cigarettes. The most common flavours are fruit, tobacco, menthol or mint, and candy.
Dr Nenna explains: “It’s a real problem because people may think that it is like smelling or eating a cake, but it’s definitely not the same because you are inhaling molecular particles. So, as more and more different flavours appear on the market, an increasing number of people, especially younger people, are drawn to trying them”.
“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”, added Dr Sreeramareddy.
In 2016, France implemented a comprehensive tobacco control policy that included an increase in tobacco product taxes, which led to a 41% rise in prices for these items. Additional measures included reimbursement for nicotine replacement therapies and annual social marketing campaigns encouraging people to stop smoking. Consequently, smoking rates declined and a greater number of smokers attempted to quit.
According to Dr Michele Cecchini, who oversees the Organisation for Economic Co-operation and Development programme on public health: “This set of interventions was undoubtedly a worthwhile investment for France and something that other countries can also regard as best practice”.
Read the full interview with Michele Cecchini
For him, the need for a comprehensive range of measures is a key lesson that we can also apply to tackling e-cigarette use among younger generations. There is no single policy that can address all of the factors contributing to tobacco or e-cigarette use.
Furthermore, we should not regard policy implementation as a one-off effort, but should instead aim to strengthen these policies over time. Ultimately, the most cost-effective solution is to prevent smoking initiation as much as possible.
Tobacco-free generation by 2024
In September 2024, the Commission recommended that EU countries extend smoke-free environment policies to key outdoor recreational areas, particularly those frequented by children, such as playgrounds and swimming pools. This initiative aims to better protect people in the EU, especially children and young people, from exposure to second-hand smoke and aerosols.
The proposal also suggested including emerging products in the ban, such as heated tobacco products and e-cigarettes. The aim is to achieve a tobacco-free generation in Europe by 2040, as set out in Europe’s Beating Cancer Plan. The Council of the EU adopted the recommendation in December 2024.
Measures such as this can help to prevent normalising the use of e-cigarettes in front of young people and children. As Dr Nenna points out: “The first time adolescents try vaping is usually around the age of 10, which means they are primary school students. A significant number of them have seen someone vaping at school or at home. Therefore, it’s important for us to approach schools and ask teachers not to vape in front of children, as well as encouraging parents to refrain from vaping at home and on school premises”.
Marketing
One factor influencing young people’s interest in using e-cigarettes is their increased exposure to marketing campaigns across various channels. For example, a study conducted by Cancer Research UK found that young people encounter e-cigarette marketing more frequently than adults. Another study published in the Journal of Medical Internet Research found that these advertisements target young people and successfully draw them to vaping by presenting e-cigarettes as an innovative and attractive way to address nicotine addiction.
According to Dr Cecchini, “Advertisement regulation, particularly regarding social media, … is becoming increasingly important as young people spend a significant amount of time on these platforms. However, this area is currently quite unregulated due to social media’s transnational nature. Some countries are taking positive steps to address this issue, not only regarding e-cigarettes but also tobacco and alcohol products. For instance, around ten years ago, Finland implemented a regulation targeting advertising of alcohol to young people on social networks”.
In 2015, Finland amended its Alcohol Act of 1994 to regulate alcohol advertising on social media, in particular to protect children and young people, who may be more susceptible to such content. Additional measures included prohibiting alcohol brands from using consumer-generated content for advertising, encouraging the deactivation of social sharing features and restricting interactive elements such as games and competitions. Nevertheless, it appeared that this initiative did not manage to significantly prevent alcohol brands from engaging customers.
As Dr Cecchini explains, “A significant gap in that regulation was how to control posts by private individuals who promote harmful alcohol consumption. For instance, consider a 16-year-old with no financial links to the alcohol industry who promotes the consumption of specific alcoholic products. This shows the need for further action in this area, which should happen in collaboration with other states. Implementing a Europe-wide regulation on this kind of transnational issue, including advertisements concerning tobacco and e-cigarettes, is undoubtedly the right approach”.
Related content:
• A scientist’s opinion : interview with Dr Raffaella Nenna on e-cigarettes and young people
• A scientist’s opinion: interview with Dr Chandrashekhar T. Sreeramareddy on e-cigarettes and young people
• A scientist’s opinion: interview with Dr Michele Cecchini on e-cigarettes and young people