E-cigarette use is increasingly widespread among adolescents worldwide. In 2022, 11·3% of middle and high school students (3·08 million) in the USA reported past 30-day use of any tobacco products, with the vast majority (9·4%) using e-cigarettes and 3·5% using multiple products. Among young e-cigarette users, 28% were using it daily, nearly 85% used flavoured ones (eg, fruit or candy), and more than half used disposable ones. These trends are particularly worrying for countries that already have a high smoking prevalence—in Viet Nam, where one in two adult men are current smokers, e-cigarette use among 13–15 year olds has increased from 2·6% in 2019 to 3·5% in 2022. A new UK study found that young people are more likely to experiment with e-cigarettes than cigarettes, and 14·3% of e-cigarette users transitioned to cigarette smoking a year later. The growing popularity of e-cigarettes seriously undermines tobacco control efforts and highlights how tobacco and e-cigarette companies have turned adolescents into a sweet target for profit.
Despite being marketed as a safer alternative to cigarettes, e-cigarettes are highly addictive and harmful. The high nicotine content (even in some products labelled “nicotine-free”) can lead to dependency over time, posing a unique risk to the developing brain. Emerging evidence suggests adverse effects on long-term development of brain structure and function, as well as potential changes in neurocognition and behaviour. E-cigarettes also contain chemicals harmful to young lungs (eg, ultrafine particles, volatile organic compounds, heavy metals), resulting in adverse cardiopulmonary effects, chronic bronchitis, asthma exacerbations, and lung damage.
But unlike cigarettes and other tobacco products, vaping is difficult to detect, and parents might struggle to know if their child is vaping. In a March 2023 Mott Poll Report, more than 80% of parents said they would “definitely” or “probably” know if their child was vaping, believing that their child would tell them (67%) or that they would find vaping supplies in their child’s things (57%), detect it by smell (48%), or find out from others (37%). In contrast with youth-reported survey data, very few parents in the poll believed their own child vapes. In addition to the lack of obvious olfactory or behavioural signs of vaping, the difficulty is compounded by predatory commercial practices. Manufacturers have made e-cigarettes easy to conceal, with designs resembling everyday objects such as pens and USB drives, and there is also a growing market of camouflage fashion items that enable discreet usage. Disposable vapes—packaged with bright colours and delivering sweet flavours like “cotton candy”—are cheap and easy to use and discard. Their appeal to young people is also driven by their prominence on social media.
Given these challenges and that nearly all tobacco use begins in adolescence and young adulthood, preventing e-cigarette use in youth is key to global tobacco control. Clinicians and teachers have a crucial role in educating adolescents and their parents about the health risks of vaping, dispelling misconceptions, and providing positive reinforcement of not using e-cigarettes. Paediatricians can incorporate a brief screening, detection, and prevention and intervention framework in clinic visits. It is important to ask open-ended questions, assess peer use of e-cigarettes, consider demographic and psychosocial risk factors (eg, gender, age, parental substance use), and be aware of the immediate and acute post-use indicators (eg, dry mouth, dental symptoms, and fruit or sweet-like smells). Clinicians can also sensitise parents to the issue, encourage them to have warm and empathetic conversations with their adolescents about the risks of vaping, and provide advice for parental monitoring and supervision.
Ultimately, tighter regulations, stricter enforcement, and bolder reforms in tobacco control are needed to counter the predatory practices of the tobacco industry. Although it is illegal to sell vapes to anyone under age 18 years in many countries, the reality is that minors are still able to access them. Banning the sale and marketing of e-cigarettes to minors is necessary, but it will not be enough. As brain development continues until age 25 years, older adolescents must also be protected against the harmful effects of e-cigarettes. Designed to appeal to young people and first-time users, flavoured and disposable vapes must be a priority target for health authorities.
We urge governments and WHO to be ambitious and forward-thinking in their tobacco control strategies and place adolescents at the core. A comprehensive and coordinated approach is needed to stifle the tobacco industry and stop it from using adolescents as a sweet target for profit.