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.