1. New products targeted at the young?

Electronic cigarettes (e-cigarettes) allow the user to inhale nicotine in a vapour rather than a smoke. This is known as vaping. Nicotine is the primary addictive component of tobacco cigarettes. E-cigarettes work by heating a liquid that typically contains nicotine and flavourings among other chemicals. They do not burn tobacco and do not produce tar or carbon monoxide, two of the most damaging elements to health in tobacco smoke. There are multiple generations of e-cigarettes that come in both refillable/rechargeable and disposable forms.

Research has suggested that e-cigarette use by young people is increasing. A recent study by University College London found that, in January 2022, 15% of 18-year-old survey respondents in Great Britain used e-cigarettes, up from 11% in January 2021. This compared to 8% among all adults. The proportion of 18-year-old vapers using disposable e-cigarettes increased markedly over the same period from 1% to 57%.

There is concern that e-cigarette marketing is being targeted at teenagers who do not smoke rather than smokers trying to quit. Research has shown that young people who had never smoked or vaped noticed e-cigarette marketing at a consistently higher rate than adults who smoked. The Times suggests that bright colours common to e-cigarettes, and a range of flavours including “cotton candy” and “lemon tart”, appeal to young people. Deborah Arnott, chief executive of the public health charity Action on Smoking and Health, has said the charity is concerned about the promotion of e-cigarettes to children on social media platforms including TikTok.

The sale of e-cigarettes containing nicotine to under 18s is prohibited. However, commentators have highlighted instances of under 18s using e-cigarettes. Trading standards officers have noted that e-cigarettes are sold in shops that have not previously sold alcohol or tobacco and staff were not always aware of age-verification requirements. E-cigarettes are also reportedly available online from sites including Amazon and eBay, where they are sometimes miscategorised as products that do not require age verification.

2. A risk to health?

E-cigarette use can have negative effects on respiratory health. Research has shown that young people using e-cigarettes are twice as likely to suffer from a chronic cough than non-users. Vaping can reduce the function of the lungs via disturbance of gas exchange and tissue inflammation. It can also lower immunity, increasing the risk of respiratory infection. Lung damage due to vaping is referred to as e-cigarette or vaping associated lung injury (EVALI). A public health investigation in Illinois and Wisconsin in the US found the median age of patients suffering from EVALI was 21.

Nicotine can also have detrimental health effects. Adolescents are more vulnerable to nicotine dependency than adults. Chronic nicotine exposure can impact brain development. This can contribute to cognitive and attention deficit conditions and worsen mood disorders, including depression and suicidal thoughts. Popular disposable e-cigarettes often contain the maximum permitted nicotine strength of 20 mg/ml. One brand suggests their disposable e-cigarette contains a nicotine content equivalent to approximately 40–50 cigarettes.

Regular e-cigarette users are increasingly reporting oral health problems. A study in South Korea found that e-cigarette use was significantly associated with gum disease and that vaping may not be a safe alternative to smoking for oral health.

Some health experts have raised concerns that e-cigarettes could be a gateway to tobacco smoking for young people. One study found that young people who used e-cigarettes were over three times more likely to become cigarette smokers than those who had never used e-cigarettes. However, other researchers have argued that individuals who try e-cigarettes are more likely to try tobacco smoking anyway. A study published in the academic journal Addiction found no statistically significant association between the prevalence of e-cigarette use and ever having smoked regularly among those aged 16 to 24.

Cancer Research UK argues e-cigarettes are beneficial for those who have smoked, although they should not be used by people who haven’t smoked as their long-term health effects are unknown. They call for ‘effective regulation’ to ensure “they are only used by smokers when making a quit attempt or to prevent relapse”, and say that “non-smokers should never use e-cigarettes”.

3. How are governments responding?

In 2019, the UK government announced an ambition for England to be ‘smoke-free’ by 2030. ‘Smoke-free’ is defined as only 5% of the population smoking. The government has said it will publish a new tobacco control plan for England. This will include measures on alternatives to smoking, including e-cigarettes. Responding to a written question on 23 June 2022, Parliamentary Under Secretary of State at the Department of Health and Social Care Maggie Throup said “the government’s regulatory framework aims to maximise the opportunities for smokers to use vaping as a tool to quit”. Ms Throup added that the government wanted to prevent “non-smokers and young people” from using vaping products.

In June 2022, the government published an independent review by Dr Javed Khan into its ‘smoke-free’ ambition. The Khan review said that “offering vaping as an alternative to smoking” was a “must do” to achieve ‘smoke-free’ by 2030. The review also noted that school and college leaders had said that vaping had become a problem in playgrounds and common rooms. School and college leaders said that vapes were “too easily available to young people under 18” and that they had observed “a rise in related disciplinary action”. Linda Bauld, professor of public health at the University of Edinburgh, said it was “essential to get the right balance between helping smokers quit while protecting the young from starting to vape”.

The government has said it is considering recommendations made in the Khan review to discourage uptake of vaping among young people. Responding to a written question on 28 June 2022, Parliamentary Under Secretary of State at the Department of Health and Social Care Lord Kamall said the government would “monitor the evidence on use among young people and vaping regulations are kept under review”.

The Scottish government launched a review on 29 April 2022 on tightening the rules on advertising and promoting vaping products.

Other countries have taken steps to restrict the use of e-cigarettes. An e-cigarette brand popular with young people, named Juul, was recently banned in the US. The US Food and Drug Administration (FDA) said it did not have enough data to be sure that marketing the firm’s products was “appropriate for the protection of public health”. However, a federal survey found three other brands were more popular than Juul among middle and high school students.

Cover image by Saj HZ on Unsplash (cropped).