Introduction
Tobacco smoke undoubtedly remains world’s leading cause of preventable disease1. Over the last decade, reducing cigarette consumption has become a Public Health goal, therefore prevention campaigns intensified and restrictions on their marketing and access escalated2.
Electronic cigarettes (also known as E-cigs, Electronic Nicotine Delivery Systems-ENDS, vaping device or e-vaporizers) are an electronic device that can vary in size and shape, consisting of a battery, an electrical heater and a liquid, which is aerosolized to be inhaled. Liquid composition can include nicotine, a solvent and an utmost variety of flavorants3. Taking shape as a smoking cessation strategy or – in actual fact – as a legal alternative where conventional smoking was prohibited, e-cigarettes, invented by Hon Lik (a Chinese pharmacist), were patented in 2003. However, only in 2007 they became commercially available in USA and Europe4.
In contrast with a consistent decline in smoking prevalence among youth5, over the past few years electronic cigarettes have rapidly gained popularity to the point of becoming the most common tobacco product in this age group6. Their social acceptance, together with their widespread availability, contributed to drastically increase primary use by adolescents and second-hand exposure in children, outlining the need for an assessment of their health effects in these categories7.
In 2018, the National Youth Tobacco Survey reported that 20.8% of high school students and 4.9% of middle school students currently used e-cigarettes8. Since the introduction of pod-based devices, vaping prevalence has tremendously increased, reaching 28% in 20199 and even 40.5% among 12th graders10. In Great Britain, during 2020 16.4% of 11–18-year-old students had tried (at least once) e-cigs, compared to 15.4% in 2019 and to 12.7% in 2015. Also current use increased since 2015 from 2.4% to 4.8% 11. Prevalence of current e-cigarette smokers in Italy doubled from 2014 (8%) to 2018 (18%), whereas the number of ever smokers has risen by 60% (from 28% to 44%)12. According to forecasts, e-cigarettes sales will surpass those of traditional tobacco by 202313.
Marketing has certainly played a major role in vaping prevalence inflection among children and adolescents. E-cigarettes can be purchased in vape shops, tobacco vendors, gas stations, groceries, pharmacies and even online14. The manufacturing companies, often owned by tobacco firms, address their products to youth by promoting appealing flavours and using multiple communication channels: television advertisings; targeted advertisements at the point of sale; web sites and social media; celebrity partnerships; free samples at youth-oriented events15–17. In 2016, 78.2% of middle and high school students have been exposed to e-cigarette advertisements from at least 1 source and increasing exposure seemed associated with higher odds of use17. Social media are easily accessible by teenagers and convey the use of e-cigarettes as socially acceptable18; despite ENDS being born as a smoking cessation strategy, less than 1% of twitter posts concerning vaping are related to smoke cessation19. Apparently, only 8% of adolescents take up e-smoking as a nicotine replacement strategy20 whereas the most common reasons underlying vaping experimentation in pediatric population are: curiosity, social influence, availability at low cost, enjoyable flavors, ease of concealment21–23. Sustained use is then encouraged by misperceptions about safety, nicotine content and social prevalence21,24–26.
A cross-sectional analysis pointed out that positive expectancies regarding e-cigarette use (e.g. gaining respect of peers and chances of being liked by partners, reducing stress, enjoying throat sensation) are related with a greater prevalence of current use27. Users exhibit the lowest perceptions of harm and more positive attitudes towards e-cigarettes when compared with non-users28. Adolescents perceptions – which affect their decision-making process – are generally biased in the direction of their own experience, a phenomenon referred to as “false consensus effect”29: for instance, teens tend to overestimate actual smoking rate among peers30, therefore they may be more prone to develop such addiction. In this regard, Gorukanti et al.28 administered 9th and 12th graders from California an online survey to investigate their attitudes towards e-cigarettes and whether they differ by past use. Findings showed that prevalence of both e-cigarette and cigarette use among parents, siblings, and close friends was higher in adolescents who have ever used an e-cigarette. At the same time, vapers believed more peers and relatives smoke e-cigarettes than do non-users. A variable – but worrying – percentage of participants agreed that smoke from e-cigs was water, that they do not contain tobacco or tar and that vaping felt cleaner and safer than smoking. Ever cigs or e-cigs users were more likely to agree about. Nonusers, instead, were more prone to consider e-cigarette vapor harmful to children. Participants were more open to e-cigs use both indoor and outdoor, compared to traditional cigarettes.