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https://en.wikipedia.org/w/index.php?title=Usage_of_electronic_cigarettes

Various types of e-cigarettes.
Various types of e-cigarettes

Since the introduction of electronic cigarettes to the market in 2003,[1] their global usage has risen exponentially up to at least 2014.[2] The global number of adult e-cigarette users rose from approximately 7 million in 2011 to 41 million in 2018.[3] It is estimated there were 82 million e-cigarette users worldwide in 2021[4] compared with approximately 1.1 billion tobacco smokers in 2019.[5] The prevalence of adult e-cigarette use in the US increased from 2.8% in 2017 to 3.2% in 2018.[6] In 2020, 19.6% of US high school students (3.02 million) and 4.7% of US middle school students (550,000) reported current e-cigarette use.[7] In the UK, current e-cigarette use increased from 1.7% of adults in 2012 to 7.1% in 2019 and then decreased to 6.3% in 2020.[8] As of 2020, 58.9% of UK adult e-cigarette users are former smokers, 38.3% currently use both combustible tobacco and e-cigarettes, and 2.9% of never smokers are e-cigarette users.[8] E-cigarette use in the US and Europe is higher than in other countries,[9] except for China which has the greatest number of e-cigarette users.[10] Targeted advertising strategies by the tobacco industry has led to an increase in e-cigarette use among youths, people of color, and people of the LGBTQ+ community.[11] A 2016 review states that the growing prevalence of e-cigarette use may be due to heavy promotion in youth-driven media channels, their low cost, and the misbelief that e-cigarettes are safer than traditional cigarettes.[12]

The prevalence of vaping among minors has increased worldwide,[13] though there is substantial variability in vaping among minors worldwide.[14] Vaping among adolescents has grown every year leading up to 2017.[15] As of 2014, there appears to be an increase of one-time e-cigarette use among young people worldwide.[16] Most e-cigarette users among youth have never smoked.[17] Many youth who use e-cigarettes also smoke traditional cigarettes.[18] Youth who use e-cigarettes are more likely to go on to use traditional cigarettes.[19][20] The evidence suggests that young people who vape are also at greater risk for subsequent long-term tobacco use.[21] E-cigarettes are expanding the nicotine market by attracting low-risk youth who would be unlikely to initiate nicotine use with traditional cigarettes.[22] Adolescents were more likely to initiate vaping through flavored e-cigarettes.[23] Vaping seems to be a gateway to using traditional cigarettes in adolescents.[24]

There are varied reasons for e-cigarette use.[9] Most users' motivation is related to trying to quit smoking, but a large proportion of use is recreational.[9] Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking cessation, as a safer alternative to traditional cigarettes, and as a way to conveniently get around smoke-free laws.[22] Many users vape because they believe it is healthier than smoking for themselves or bystanders.[25] Usually, only a small proportion of users are concerned about the potential adverse health effects.[25] Seniors seem to vape to quit smoking or to get around smoke‐free policies.[26]

There appears to be a hereditary component to tobacco use, which probably plays a part in transitioning of e-cigarette use from experimentation to routine use.[27] Adolescent experimenting with e-cigarettes may be related to sensation seeking behavior, and is not likely to be associated with tobacco reduction or quitting smoking.[28] The introduction of e-cigarettes has given cannabis smokers a different way of inhaling cannabinoids.[29] Recreational cannabis users can individually "vape" deodorized or flavored cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as "stealth vaping".[29] There is wide concern that vaping may be a "gateway" to smoking.[30] Vaping may also act as a gateway to illicit drug use (recreational use of illegal drugs), is an area of concern.[31]

Usage

Prevalence

Aerosol (vapor) exhaled by an e-cigarette user using a nicotine-free e-cigarette.
Aerosol (vapor) exhaled by an e-cigarette user using a nicotine-free e-cigarette

Since their introduction to the market in 2003,[1] global usage of e-cigarettes has risen exponentially up to at least 2014.[2] By 2013, there were several million users globally.[32] The global number of adult e-cigarette users rose from approximately 7 million in 2011 to 41 million in 2018.[3] It is estimated there were 82 million e-cigarette users worldwide in 2021[4] compared with approximately 1.1 billion tobacco smokers in 2019.[5] E-cigarettes rapid growth in popularity has been accompanied by a commensurate decrease in traditional cigarette use.[33] Although tobacco consumption had been dropping globally for more than 50 years, vaping among young adults and teenagers has been exploding, a 2020 review states.[34] With the use of enticing flavors and packaging, these e-cigarette devices has produced an ensuing generation of nicotine users.[34] With the onset of vaping devices, directions in nicotine consumption have reversed, and over the last two decades leading up to 2022, there has been a steady usage of these devices among young people who have never smoked.[35]

Awareness and use of e-cigarettes greatly increased over the few years leading up to 2014, particularly among young people and women in some parts of the world.[36] A 2013 four-country survey found there was generally greater awareness among white adult smokers compared with non-white ones.[37] As of 2017, vaping is increasing in the majority of high-income countries.[38] E-cigarette use in the US and Europe is higher than in other countries,[9] except for China which has the greatest number of e-cigarette users.[10] Growth in the US had reportedly slowed in 2015, lowering market forecasts for 2016.[39] Growth in the UK as of January 2018 had reportedly slowed since 2013.[40] In 2018, it was estimated that there were 35 million e-cigarette users globally (including heated tobacco products), with this rapid growth predicted to continue.[41] As of 2022, the use of e-cigarettes among young people, including adolescents and emerging adults, is a rising concern worldwide.[note 1][42] There has been in an explosion in vaping in the last few years leading up to 2023.[43]

Worryingly decreased use of smoking cessation services and medically tested pharmacotherapy has been observed in parallel with an increase in the use of e-cigarettes, indicating that alternative nicotine-containing products may be replacing evidence-based, effective smoking cessation tools.[44]

 —Jayesh Mahendra Bhatt and colleagues, Paediatric Respiratory Reviews[44]

Surveys in 2010 and 2011 suggested that adults with higher incomes were more likely to have heard of e-cigarettes, but those with lower incomes may have been more likely to try them.[45] Most users had a history of smoking regular cigarettes, while results by race were mixed.[45] At least 52% of smokers or ex-smokers have used an e-cigarette.[46] Of smokers who have, less than 15% become everyday e-cigarette users.[47] Though e-cigarette use among those who have never smoked is very low, it continues to rise, as of 2014.[48] Daily vapers are typically recent former smokers.[49] E-cigarettes are commonly used among non-smokers.[50] This includes young adult non-smokers.[50] Vaping is the largest among adults between 18 and 24 years of age, and use is the largest among adults who do not have a high school diploma.[51] Young adults who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.[17] A worldwide survey of e-cigarette users conducted in 2014 found that only 3.5% of respondents used liquid without nicotine.[52] The COVID-19 lockdowns resulted in a rise in vaping in the majority of studies.[53] With the implementation of social distancing due to the COVID-19 pandemic, isolation from the school environment, loneliness, stress, and poor social support could contribute to an increase in e-cigarette use, particularly in adolescents with pre-existing mental health conditions.[54] E-cigarette use among people with schizophrenia is high.[55]

Greater than 10 million people vape daily, as of 2018.[56] Everyday use is common among e-cigarette users.[25] E-cigarette users mostly keep smoking traditional cigarettes.[18] Adults often vape to replace tobacco.[45] Most vapers still use nicotine liquids after stopping smoking for several months.[57] Most e-cigarette users are middle-aged men who also smoke traditional cigarettes, either to help them quit or for recreational use.[9] Older people are more likely to vape for quitting smoking than younger people.[58] Men were found to use higher nicotine doses, compared with women who were vaping.[23] Among young adults e-cigarette use is not regularly associated with trying to quit smoking.[45] E-cigarettes are frequently the first nicotine-containing product used by young people.[59] The research indicates that the most common way people try to quit smoking in the UK is with e-cigarettes.[60]

Dual use of e-cigarettes and traditional tobacco is still a definite concern.[28] Dual use of e-cigarettes with cigarettes is the most frequent pattern.[61] A high prevalence of dual use of e-cigarettes and conventional cigarettes has been reported across the world.[4] In some countries, most users of e-cigarettes are dual users.[4] One-time e-cigarette use seems to be higher in people with greater levels of educational achievement.[62] Women smokers who are poorer and did not finish high school are more likely to have tried vaping at least once.[63] Vaping is increasing among people with cancer who are frequent smokers.[64] Above two-thirds of former cancer patients who are smoking cigarettes are also vaping, and vaping was greater among young former cancer patients than older former cancer patients.[65]

Subsequent smoking initiation

E-cigarette use is associated with higher odds of starting smoking and continuing smoking.[66] There is compelling evidence that starting to vape leads to starting cigarette smoking, in addition to previous 30-day vaping leads to resulting previous 30-day cigarette smoking, among young adults and adolescents.[67] There is strong evidence for young adults and youth that e-cigarette use increases the chance of one-time traditional cigarette use.[68] The evidence indicates that the pod mods such as Juul that can provide greater levels of nicotine could increase the chance for users to transition from vaping to smoking cigarettes.[69] Higher levels of nicotine in e-cigarettes have been associated with an increase in the frequency and intensity of combustible cigarette smoking.[70] Ethical concerns have been raised about minors' e-cigarette use and the potential to weaken cigarette smoking reduction efforts.[30] Protective factors from using e-cigarettes were better ability to read and write, exercising, being female, and not smoking.[71]

There is concern regarding that the accessibility of e-liquid flavors could lead to using additional tobacco products among non-smokers.[72] A 2015 review argued for the implementation of the precautionary principle because vaping by non-smokers may lead to smoking.[73] There is a concern with the possibility that non-smokers as well as children may start nicotine use with e-cigarettes at a rate higher than anticipated than if they were never created.[74] In certain cases, e-cigarettes might increase the likelihood of being exposed to nicotine itself, especially for never-nicotine users who start using nicotine products only as a result of these devices.[75]

Because those with mental illness are highly predisposed to nicotine addiction, those who try e-cigarettes may be more likely to become dependent, raising concerns about facilitating a transition to combustible tobacco use.[76] Even if an e-cigarette contains no nicotine, the user mimics the actions of smoking.[77] This may renormalize tobacco use in the general public.[77] Normalization of e-cigarette use may lead former cigarette smokers to begin using them, thereby reinstating their nicotine dependence and fostering a return to tobacco use.[78] There is a possible risk of re-normalizing of tobacco use in areas where smoking is banned.[77]

Pregnancy

E-cigarette use was also rising among women, including women of childbearing age as of 2014.[79] Many woman still vape during pregnancy because of their perceived safety in comparison with tobacco.[26] In one of the few studies identified, a 2015 survey of 316 pregnant women in a Maryland clinic found that the majority had heard of e-cigarettes, 13% had ever used them, and 0.6% were current daily users.[80] These findings are of concern because the dose of nicotine delivered by e-cigarettes can be as high or higher than that delivered by traditional cigarettes.[80] Vaping prevalence in pregnant women has been estimated to stand between 0.6 and 15%.[81] The rate of e-cigarette use among pregnant adolescents is unknown.[80] Vaping during pregnancy is associated with cigarette smoking.[82]

Youth

Currently in the US, more high school students use e-cigarettes than regular cigarettes. The use of e-cigarettes is higher among high school students than adults.
Currently in the US, more high school students use e-cigarettes than regular cigarettes.[83] The use of e-cigarettes is higher among high school students than adults.[83]

The prevalence of vaping among minors has increased worldwide,[13] though there is substantial variability in vaping among minors worldwide.[14] For example, one-time e-cigarette use among minors went up in Poland, Korea, New Zealand, and the US; went down in Italy and Canada; and was about the same in the UK, in 2008 to 2015.[14] Vaping among adolescents has grown every year leading up to 2017.[15] In contrast with a consistent decline in smoking prevalence among youth, over the past few years leading up to 2019 e-cigarettes have rapidly gained popularity to the point of becoming the most common tobacco product in this age group.[81] Their social acceptance, together with their widespread availability, contributed to drastically increase primary use by adolescents and second-hand exposure in children.[81] The prevalence of vaping among children has grown.[84] As of 2014, there appears to be an increase of one-time e-cigarette use among young people worldwide.[16] The prevalence of vaping in youth is common.[69]

Most e-cigarette users among youth have never smoked.[17] Some youths who have tried an e-cigarette have never used a traditional cigarette; indicating e-cigarettes may be a starting point for nicotine use.[18] Adolescents who would have not been using nicotine products to begin with are vaping.[85] Twice as many youth vaped in 2014 than also used traditional cigarettes.[86] E-cigarettes are expanding the nicotine market by attracting low-risk youth who would be unlikely to initiate nicotine use with traditional cigarettes.[22] Data from a longitudinal cohort study of children with alcoholic parents found that adolescents (both middle and late adolescence) who used cigarettes, marijuana, or alcohol were significantly more likely to have ever used e-cigarettes.[80] Adolescents were more likely to initiate vaping through flavored e-cigarettes.[23] Among youth who have ever tried an e-cigarette, a majority used a flavored product the first time they tried an e-cigarette.[80] In adolescents, the green apple flavorant was found to increase vaping behavior compared to both menthol-flavored and unflavored e-cigarettes.[87] Vaping is the most common form of tobacco use among youth, as of 2022.[88] Pod mod devices are very popular among youth.[89]

Most youth are not vaping to help them quit tobacco.[45] Many children who do not smoke are not vaping to help them quit tobacco.[44] Adolescent vaping is unlikely to be associated with trying to reduce or quit tobacco.[28] A 2015 study found minors had little resistance to buying e-cigarettes online.[90] An emerging concern is that nicotine, fruit flavors, and other e-liquid additives could incite teenagers and children to start using traditional cigarettes.[91] Teenagers may not admit to using e-cigarettes, but use, for instance, a hookah pen.[92] As a result, self-reporting may be lower in surveys.[92] Experts suggest that candy-like flavors could lead youths to experiment with vaping.[74] A 2014 survey stated that vapers may have less social and behavioral stigma than cigarette smokers, causing concern that vaping products are enticing youth who may not under other circumstances have used these products.[93] The prevalence of vaping is higher in adolescent with asthma than in adolescent who do not have asthma.[94] Childhood trauma may increase the odds of vaping in youth.[95]

Subsequent youth smoking initiation

National Institute on Drug Abuse director Nora Volkow discussing a study that shows teens using e-cigarettes are more likely to start smoking tobacco.[96]

Many youth who use e-cigarettes also smoke traditional cigarettes.[18] Vaping seems to be a gateway to using traditional cigarettes in adolescents.[24] Youth who use e-cigarettes are more likely to go on to use traditional cigarettes.[19][20] The evidence suggests that young people who vape are also at greater risk for subsequent long-term tobacco use.[21] Youth who use non-reusable and various reusable e-cigarettes is connected with a higher odds of using smokable tobacco products.[97] There is a consistent link between nicotine-free vaping and nicotine vaping and later tobacco use in people under the age of 20 across a multitude of studies worldwide.[98]

Adolescents who vape but do not smoke are more than twice as likely to intend to try smoking than their peers who do not vape.[17] Vaping is correlated with a higher occurrence of cigarette smoking among adolescents, even in those who otherwise may not have been interested in smoking.[99] Adolescence experimenting with e-cigarettes appears to encourage continued use of traditional cigarettes.[100] Flavor restrictions may successfully reduce e-cigarette initiation and remove a potential gateway to combustible tobacco use among youth.[101] Government intervention is recommended to keep children safe from the re-normalizing of tobacco, according to a 2017 review.[15] There is a greater likelihood of past or present and later cannabis use among youth and young adults who have vaped.[102] Youth and young adult one-time e-cigarette use is linked to an increased risk of later cannabis and other illegal drug use.[103]

Appeal to Young People

Youth and young adults cite a variety of reasons for using e-cigarettes.

These include:

  • Use by a friend or family member
  • Taste, including the flavors available in e-cigarettes
  • The belief that e-cigarettes are less harmful than other tobacco products
  • Curiosity

Flavored e-cigarettes are very popular among youth and young adults. In 2014, more than 9 of 10 young adult e-cigarette users said they use e-cigarettes flavored to taste like menthol, alcohol, candy, fruit, chocolate, or other sweets. In 2018, more than 6 of 10 high school students who use e-cigarettes said they use flavored e-cigarettes.

Content from the 2019 US Surgeon General's report entitled Appeal to Young People[104]

Device selection

Many users may begin by using a disposable e-cigarette.[105] Users often start with e-cigarettes resembling traditional cigarettes, eventually moving to a later-generation device.[106] Most later-generation e-cigarette users shifted to their present device to get a "more satisfying hit",[106] and users may adjust their devices to provide more vapor for better "throat hits".[63] A 2014 study reported that experienced users preferred rechargeable e-cigarettes over disposable ones.[23] The most commonly used e-cigarettes in the UK are devices with refillable tanks.[107] Most users used either closed systems or open systems, and rarely used both.[23] Women were found to prefer disposable e-cigarettes, and young adults were found to pay more attention to modifiability.[23] Modifiability also was found to increase the probability of initiating e-cigarettes among adolescents.[23] In 2019, pod mods may have been more preferable to youth than previous e-cigarette models.[69] In 2021, disposable vapes were the most commonly used device among youth in the US.[108]

A 2013 study found that about three-fourths of smokers used a tank system, which allows users to choose flavors and strength to mix their own liquid.[23] Experienced e-cigarette users even ranked the ability to customize as the most important characteristic.[23] Users ranked nicotine strength as an important factor for choosing among various e-cigarettes, though such preference could vary by smoking status, e-cigarette use history, and gender.[23] Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes.[23] There is an abundance of colors, designs, carrying cases, and accessories to accommodate the diversity in personal preferences.[105]

Motivation

Reasons for initialing or continuing use

E-cigarettes can have a high-tech look[109]
E-liquid comes in candy, fruit and coffee flavors, etc[110]

There are varied reasons for e-cigarette use.[9] Most users' motivation is related to trying to quit smoking, but a large proportion of use is recreational.[9] Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking cessation, as a safer alternative to traditional cigarettes, and as a way to conveniently get around smoke-free laws.[22] The majority of e-cigarette users state that flavor is a major reason in starting their use and ongoing use.[111] Some users vape for the enjoyment of the activity.[25] Many e-cigarette users use them because they believe they are safer than traditional cigarettes.[52] People who think they pose less risk than cigarette smoking are more likely to vape.[112]

A 2017 report found that smokers who previously vaped and quit though continued smoking, 51.5% believed that vaping is less risky than smoking.[113] In contrast, 90% of former-smokers who vape believed vaping as less risky than cigarettes.[113] A 2017 report found that a minority of the respondents believed that replacing cigarettes with e-cigarettes would be helpful for their health.[114] Many users vape because they believe it is healthier than smoking for themselves or bystanders.[25] Usually, only a small proportion of users are concerned about the potential adverse health effects.[25]

Some people say they want to quit smoking by vaping, but others vape to circumvent smoke-free laws and policies, or to cut back on cigarette smoking.[18] 56% of respondents in a US 2013 survey had tried vaping to quit or reduce their smoking.[115] In the same survey, 26% of respondents would use them in areas where smoking was banned.[115] Continuing dual use among smokers is correlated with trying to cut down on smoking and to get around smoking bans, increased desire to quit smoking, and a decreased smoking dependence.[116] Seniors seem to vape to quit smoking or to get around smoke‐free policies.[26] Concerns over avoiding stains on teeth or odor from smoke on clothes in some cases prompted interest in or use of e-cigarettes.[25] Some e-cigarettes appeal considerably to people curious in technology who want to customize their devices.[117] There appears to be a hereditary component to tobacco use, which probably plays a part in transitioning of e-cigarette use from experimentation to routine use.[27]

It is conceivable that former smokers may be tempted to use nicotine again as a result of e-cigarettes, and possibly start smoking again.[75] E-liquid flavors are enticing to a range of smokers and non-smokers.[72] Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given one.[31] College students often vape for experimentation.[118]

Reasons for initiating e-cigarette use in the European Union according to a Eurobarometer poll (2018)[119]

The belief that e-cigarettes are safer than traditional cigarettes could widen their use among pregnant women.[28] If tobacco businesses persuade women that e-cigarettes are a small risk, non-smoking women of reproductive age might start using them and women smoking during pregnancy might switch to their use or use these devices to reduce smoking, instead of quitting smoking altogether.[120] Traditional cigarette users who have not used e-cigarettes had mixed ideas about their possible satisfaction and around a third thought that e-cigarettes might taste bad.[25] Among current e-cigarette users, e-liquid flavor availability is very appealing.[76] The attraction of flavored e-cigarette products for pregnant women is likely due to alterations in taste, cravings, and nausea as well as a high sensitivity to bitter tastes which commonly occur during pregnancy.[54] Candy-, fruit- and menthol-flavored e-cigarettes appeal to adolescents more as compared to tobacco-flavored traditional cigarettes [121] Ice hybrid flavors or synthetic coolants (e.g., WS-23 and WS-3) used in e-liquids can be enticing.[122] They feel or taste similar to traditional cigarettes, and vapers disagreed about whether this was a benefit or a drawback.[25] Some users liked that e-cigarettes resembled traditional cigarettes, but others did not.[25] E-cigarettes users' views about saving money from using e-cigarettes compared to traditional cigarettes are inconsistent.[25] The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes.[25]

Reasons for circumventing smoking bans

E-cigarette users have contradictory views about using them to get around smoking bans.[25] Some surveys found that a small percentage of users' motives were to avoid smoking bans, but other surveys found that over 40% of users said they used the device for this reason.[25] The extent to which traditional cigarette users vape to avoid smoking bans is unclear.[25]

Reasons for discounting use

Some users stopped vaping due to issues with the devices.[25] Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use.[123] Commonly reported issues with using e-cigarettes were that the devices were hard to refill, the cartridges might leak and that altering the dose was hard.[124] Smokers mainly quit vaping because it did not feel similar to traditional cigarettes, did not aid with cravings, and because they wanted to use them only to know what they were like.[116] A small number of US surveys showed that smokers’ chief reasons for stopping vaping were that they did not feel similar to smoking cigarettes, were too costly, or were only experimenting.[116] A 2016 US survey reported that 77% of current smokers stated e-cigarettes were not as satisfying as traditional cigarettes and quit vaping.[125] E-cigarette do not provide nicotine to the blood as fast as cigarettes and fall short of the throat-hit that cigarettes give, causing some to turn back to traditional cigarettes.[126] In the small number of published studies on reasons for discontinuation of e-cigarette use in young users, adolescent and young adult smokers have cited lack of satisfaction and e-cigarettes' poor taste and cost as reasons for discontinuing.[80] Additional reasons have included negative physical effects (e.g., feeling lightheaded) and loss of interest.[80] In one study of young adults aged 18–35, former and never smokers of traditional cigarettes also cited the idea that e-cigarettes were "bad for their health" as a reason for discontinuation.[80]

Reasons among youth and children for initialing or continuing use

Companies sell an array of flavors like bubblegum, fruit, and chocolate, potentially to entice young people to vape.[127] Adolescent experimenting with e-cigarettes may be related to sensation seeking behavior, and is not likely to be associated with tobacco reduction or quitting smoking.[28] Youth may view e-cigarettes as a symbol of rebellion.[48] Children and adolescents may be tempted by flavored e-cigarettes.[2] Vaping may entice adolescents for many reasons which include the perceived absence of harmful adverse effects.[128] The main reasons youth experimented with e-cigarettes were due to curiosity, flavors, and peer influences.[129]

A 2016 study using longitudinal surveys from middle and high school students found flavoring is the second most important factor determining whether students try e-cigarettes, after curiosity and a 2015 study also reported the same finding.[23] E-cigarettes may appeal to youth because of their high-tech design, large assortment of flavors, and easy accessibility online.[109] Tempting candy and fruit flavors e-cigarettes are designed to appeal to youth.[130] The colors, flavors, and scents of e-liquids attract children.[125] E-liquids are sold in a myriad of candy and fruit flavors, such as bubble gum, cherry and chocolate, which may appeal to youth and children.[131]

Infants and toddlers could ingest the e-liquid from an e-cigarette device out of curiosity.[132] Flavored tobacco has been shown to have a large market share among youth aged 12 to 17 years, confirming the attractiveness of these products to new and young smokers and their likely contribution to smoking initiation.[133] Infants and children liked sweet and salty flavors more than adults.[134] The bright packaging of e-cigarette products play a part in their allure to young children.[15] The vivid colors, strongly aromatic, and scented flavors for e-liquid bottles are particularly enticing to young children.[135]

Among US student respondents to the National Youth Tobacco Survey reporting ever using e-cigarettes in 2016, the most commonly selected reasons for use were used by "friend or family member" (39%), availability of "flavors such as mint, candy, fruit, or chocolate" (31%), and the belief that "they are less harmful than other forms of tobacco such as cigarettes" (17%).[136] The least commonly selected reasons were "they are easier to get than other tobacco products, such as cigarettes" (5%), "they cost less than other tobacco products such as cigarettes" (3%), and "famous people on TV or in movies use them" (2%).[136] A 2016 study of Finnish adolescents found that e-liquids with nicotine were more popular with ever smokers while e-liquids without nicotine were more popular with never smokers.[23]

Parents actively shape adolescent behavior with regard to e-cigarette use.[54] Social factors including peer or familial attitudes have a great influence on susceptibility to becoming smokers or vapers.[54] Youth with vaping parents are significantly more likely to start vaping than others.[54] The determinants of this association may be mimicry of parental habits and low awareness of parental disapproval among children and adolescents.[54] Generally, a higher frequency of e-cigarette use has been described among fathers, but the role of maternal use in inducing adolescent vaping seems to be more influential.[54] Parents who smoke or vape, especially mothers, are more tolerant toward their children vaping than non-smoking/vaper mothers.[54] A positive association between maternal and adolescence vaping was shown by Sabbagh et al. in 2020.[54] Patel et al. in 2019 demonstrated that a significant percentage of parents of middle- and high-school children have poor knowledge about the variety of nicotine vaping devices available and significantly underestimates their own children's vaping risk.[54] The likelihood of their intervention in preventing or stopping vaping-risk behaviors is dramatically low.[54]

Teen Beliefs

Youth tobacco use in any form, including e-cigarettes, is unsafe. A recent national survey showed that about 10% of U.S. youth believe e-cigarettes cause no harm, 62% believe they cause little or some harm, and 28% believe they cause a lot of harm when they are used some days but not every day. In 2014, nearly 20% of young adults believe e-cigarettes cause no harm, more than half believe that they are moderately harmful, and 26.8% believe they are very harmful.

Young people who believe e-cigarettes cause no harm are more likely to use e-cigarettes than those who believe e-cigarettes cause a lot of harm.

Content from the 2019 US Surgeon General's report entitled Teen Beliefs[137]

Impact of marketing

Marketing has certainly played a major role in vaping prevalence inflection among children and adolescents.[81] E-cigarettes can be purchased in vape shops, tobacco vendors, gas stations, groceries, pharmacies and even online.[81] The manufacturing companies, often owned by tobacco firms, address their products to youth by promoting appealing flavors 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 events.[81]

Various factors contribute to the escalating trend of e-cigarette use among young people.[138] One such factor is the widespread perception of e-cigarettes as a less hazardous alternative to traditional tobacco products.[138] Advertisements for e-cigarettes commonly portray them as an effective means to quit smoking or as a healthier option than regular cigarettes.[138]

E-cigarette advertisements seen by youth could increase the likelihood among youths to experiment with vaping.[139] A 2016 review found "The reasons for the increasing use of e-cigarettes by minors (persons between 12 and 17 years of age) may include robust marketing and advertising campaigns that showcase celebrities, popular activities, evocative images, and appealing flavors, such as cotton candy."[140] Millions of dollars spent on marketing aimed at smokers suggests e-cigarettes are "newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use".[141] Marketing messages echo well-established cigarette themes, including freedom, good taste, romance, sexuality, and sociability as well as messages stating that e-cigarettes are healthy, are useful for smoking cessation, and can be used in smoke free environments.[22] These messages are mirrored in the reasons that adults and youth cite for using e-cigarettes.[22]

Exposure to e-cigarette advertising influences people to try them.[92] Targeted advertising strategies by the tobacco industry has led to an increase in e-cigarette use among youths, people of color, and people of the LGBTQ+ community.[11] The growing prevalence of e-cigarette use may be due to heavy promotion in youth-driven media channels, their low cost, and the misbelief that e-cigarettes are safer than traditional cigarettes, according to a 2016 review.[12] E-cigarette marketing with themes of health and lifestyle may encourage youth who do not smoke to try e-cigarettes, as they may believe that e-cigarettes are less harmful and more socially acceptable.[110] This belief may decrease ones concerns relating to nicotine addiction.[110] E-cigarette marketing may entice adults and children.[142] E-cigarette websites regularly contain marketing statements that might appeal to a younger audience.[110]

Marketing tactics employed by e-cigarette companies, such as social media marketing, sponsorships, and celebrity endorsements, have significantly contributed to the increase in e-cigarette use among adolescents.[138] These strategies are often designed to target young people, normalize e-cigarette use, and increase the appeal of these products.[138] For instance, social media platforms such as Instagram and Twitter promote images and messages that associate e-cigarette use with social status, attractiveness, and popularity.[138] Similarly, sponsorships and celebrity endorsements help create a positive image of e-cigarettes and make them seem more glamorous and desirable to young people.[138]

As a result, the impact of e-cigarette marketing on adolescents cannot be overstated, as it influences their perceptions and attitudes toward these products.[138] The use of social media influencers, who are often popular among adolescents, to endorse e-cigarette brands can be particularly influential in shaping young people's opinions.[138] In addition, promoting flavored e-cigarettes that appeal to young people and using bright, colorful packaging also significantly attract adolescents to e-cigarettes.[138]

In 2016, 78.2% of middle and high school students have been exposed to e-cigarette advertisements from at least one source and increasing exposure seemed associated with higher odds of use.[81]

Impact of regulations

In countries where there is not regulation on e-cigarettes, vaping is common in areas where smoking is not permitted.[143] Flavor restrictions, sales licenses, warning labels, and imposing taxes can decrease the prevalence of youth e-cigarette use or intent to begin using e-cigarettes.[144]

After the implementation of the EU Tobacco Products Directive regulations, e-cigarette use among young people in European nations, including the UK, is slowing down.[42] However, unlike other countries, England still shows an increase in past and current e-cigarette use from 2014 to 2016.[42]

International

International

Among current and former smokers who have vaped at least once were reported in Canada, the UK, France, Belgium, Austria, Germany, the Netherlands, Luxemburg, Greece (22.4% in 2012), Malta (16.7% in 2012), Portugal (17.0% in 2012), Slovenia (20.3% in 2012), Spain (10.9% in 2012), Cyprus (23.6% in 2012), Denmark (36.3% in 2012), Slovakia (7.9% in 2012), the Czech Republic (34.3% in 2012), Ireland (12.1% in 2012), Latvia (23.9% in 2012), Lithuania (11.8% in 2012), Finland (20.5% in 2012), Sweden (12.4% in 2012), Estonia (22.3% in 2012), Hungary (22.3% in 2012), Bulgaria (31.1% in 2012), Romania (22.2% in 2012), Australia (2.0–20.0% in 2010–2013), Italy (5.6% in 2013), Poland (31.0% in 2012), Malaysia (19% in 2011), Brazil (8% in 2013), Mexico (4% in 2011), South Korea (11% in 2010), Brazil (8% in 2013), and China (2% in 2009).[145]

International youth

Figure shows history of ever use of e-cigarettes in teenagers by country and period. History of ever use of e-cigarettes in Canada, the US, Great Britain, and the rest of Europe between 2015–2017 and 2018–2019. If countries reported history of past use within any of these time periods, they were included. Please note that the 2015–2017 prevalence of ever use is for the following European countries: Belgium, Finland, Germany, Ireland, Italy, the Netherlands, and Portugal28. The 2018–2019 report in Europe collected data from Central and Eastern Europe, including the following countries: Poland, Lithuania, Belarus, Slovakia, and Russia. It should be noted that while a 2019 report indicated a prevalence of ever use in the United Kingdom of 32.7% (2018), the Action on Smoking and Health report in England produced a significantly lower prevalence of 16.4% for the same period in Great Britain. It could be that Northern Ireland has a higher prevalence of ever use and was omitted from the report.
Figure shows history of ever use of e-cigarettes in teenagers by country and period.[146] History of ever use of e-cigarettes in Canada, the US, Great Britain, and the rest of Europe between 2015–2017 and 2018–2019.[146] If countries reported history of past use within any of these time periods, they were included.[146] Please note that the 2015–2017 prevalence of ever use is for the following European countries: Belgium, Finland, Germany, Ireland, Italy, the Netherlands, and Portugal28.[146] The 2018–2019 report in Europe collected data from Central and Eastern Europe, including the following countries: Poland, Lithuania, Belarus, Slovakia, and Russia.[146] It should be noted that while a 2019 report indicated a prevalence of ever use in the United Kingdom of 32.7% (2018), the Action on Smoking and Health report in England produced a significantly lower prevalence of 16.4% for the same period in Great Britain.[146] It could be that Northern Ireland has a higher prevalence of ever use and was omitted from the report.[146]

According to a 2021 systematic review and meta-analysis, vaping among non-smoking youth is increasing in many countries.[66] Citing studies ranging from 2011 to 2020, the international average of lifetime e-cigarette use under the random effect model was 15.3% among young people.[42] The international pooled prevalence of young people's (ranging from 9 to 25 years old) current e-cigarette use was 7.7% and dual use was 4.0%.[42]

While the highest lifetime, current, and dual prevalence among young people were found in Sweden, Canada, and the UK, the lowest prevalence was found in Germany, followed by South Korea and Sweden.[42] Some protective and risk factors include perceived cost and danger of vaping, parental monitoring, internal developmental assets, cigarette use, family and peer smoking, exposure to online advertisements, and the presence of nearby retail stores.[42]

By country, the average lifetime e-cigarette use among young people was 23.5% in the US, 6.7% in South Korea, 23.7% in Sweden, 21.3% in Poland, 34% in European countries, 20% in New Zealand, 17.3% in Scotland, 12.6% in Finland, 12.3% in Greece, 9.5% in Mexico, 7.6% in Argentina, 7% in Thailand, and 4.7% in Germany.[42] The highest lifetime e-cigarette use among young people was in Sweden and the lowest was in Germany.[42]

For current e-cigarette use among young people, the average rate was 8.04% in the US, 31.4% in Canada, 17.1% in Poland, 1.7% in South Korea, 13.3% in the UK, 10.9% in Mexico, 9% in Malaysia, 6.7% in Thailand, 5.1% in Ireland, 4.2% in Sweden, 2.7% in European countries, and 2.8% in Greece.[42] The highest current e-cigarette use among young people was in Canada and the lowest was in South Korea.[42]

Current dual use among young people, were om the average 5.4% for the US and 3.3% for South Korea, 11% for the UK, 9.3% for Ireland, and 1.7% for Sweden.[42] The highest dual use among young people was in the UK and the lowest was in Sweden.[42]

In Asia, the rate of young Korean who had ever used e-cigarettes rose from 0.5% in 2008 to 42% in 2017.[42] Similarly, the current e-cigarette use of young Taiwanese men grew from 2.5% in 2014 to 6.4% in 2017.[42] In European countries, the prevalence of having ever used e-cigarettes varied by 17 to 62%.[42] Vapers in many European countries were previously cigarette users or started smoking at a young age, and some of these nations even reported a higher prevalence of e-cigarette use than traditional cigarette use (e.g., Iceland, Monaco, Lithuania, Poland, Ireland, Germany, Czechia, Hungary, France, and Norway.[42]

Arab countries

Arab countries

E-cigarette use has exponentially increased in the 2010 decade in Arab countries.[147] Prevalence of using e-cigarettes was particularly high (above 25%) among smokers in countries such as Jordan, Lebanon, Egypt, and Saudi Arabia.[147]

Dual users n Arab countries were reported in many of the studies cited in a 2023 review.[147] The use of e-cigarettes with other types of tobacco was more common than the use of e-cigarettes alone.[147] In many cases, smokers might switch to e-cigarettes and quit traditional cigarettes, but they might fail in that and become dual users.[147]

Saudi Arabia

In Saudi Arabia, the use of e-cigarettes among the general population was 2.2% and among the smoking population was 9.6%, which gave it the third smoking method in the country after cigarettes and hookah.[147] The prevalence of e-cigarette use has been steadily increasing in the past few years leading up to 2023, especially among young males.[147] In addition, e-cigarette use was reported in most studies among females and people aged less than 18 years.[147]

Eleven studies were conducted among university students in Saudi Arabia, where the average age of the participants was under 26 years.[147] The findings of these studies indicated that most participants had heard about e-cigarettes, and 5.7–51.4% of them were e-cigarette users.[147] In addition, between 31.0 and 42.7% of the participants reported that they used e-cigarettes to help in quitting smoking.[147] Although the participants in these studies had reported that e-cigarettes were harmful, they also reported that e-cigarettes were 'less dangerous' than traditional tobacco smoking.[147] Generally, male students were more likely to use e-cigarettes than females, including medical students.[147]

Jordan

The prevalence of e-cigarette use ranged between 11.7% and 39.2% in three studies.[147] In addition, the prevalence of e-cigarette use was more among males than females.[147] The general opinions of the participants were that e-cigarettes might have the same or some harmful effects as traditional cigarettes and e-cigarettes could lead to nicotine addiction in the future.[147]

United Arab Emirates

The prevalence of e-cigarette use among the general population in the United Arab Emirates (UAE) was 3.8% in 2020.[147] The prevalence was higher (8.8%) among university students, including dual users, and males were more common users of e-cigarettes than females.[147] In another study conducted among current and former e-cigarette users, more than a quarter of participants were dual users.[147]

Egypt

In a study conducted between 2015 and 2017 among young adults who had a history of waterpipe use in Egypt, e-cigarettes were used by 10.4% of the participants.[147] In addition, young female waterpipe smokers who also used nicotine-containing e-cigarettes were more than ten times the young males (51.2% vs 4.1%).[147] Another two studies conducted among university students reported that e-cigarette prevalence was between 10.6 and 16.5%.[147] At the same time, more than half of those who vaped also used other smoking products.[147]

Kuwait

The use of e-cigarettes was reported in two studies among the adolescent population aged 16–18 years in Kuwait.[147] In these two studies, more than a quarter of the participants were found to be e-cigarette users.[147] In addition, a high percentage of the smokers (84.8%) were dual users, and male adolescents were more likely to use e-cigarettes than females, despite the sales of e-cigarettes are banned in Kuwait.[147]

Lebanon

A 2020 study reported that the use of the e-cigarettes among participants was 11.5%, and most participants (above 80%) believed that using e-cigarettes is less harmful or not harmful compared with traditional cigarettes.[147] In addition, more than half of the participants also thought that e-cigarettes could help people cut down on cigarettes or quit smoking. [147] In another study, most participants believed that e-cigarettes were less harmful than traditional cigarettes, and in another study, 8% of the participants reported current use of e-cigarettes.[147]

Qatar

Although the personal use of e-cigarettes is not prohibited in Qatar, the sale, distribution and/or possession of e-cigarettes in large quantities are illegal.[147] In two studies about e-cigarette use among the general population in Qatar, the prevalence of e-cigarette users was almost similar at 1.6% and 2.0%, and the majority of those who vaped (above 82%) were dual users.[147] In the third study, among university students, the prevalence was higher (14.0% of the participants).[147] Furthermore, the overall prevalence of using e-cigarettes was higher among males than females.[147] As per the published articles in Qatar, e-cigarette users perceived e-cigarettes to be less harmful than other tobacco smoking.[147] In addition, e-cigarette users believed that e-cigarettes could help reduce smoking, and quitting smoking was a reason to use e-cigarettes by the participants.[147] Moreover, the availability of various flavors and the lack of restrictions on using e-cigarettes in public places were reported in a study as factors that may increase the use of this type of product among the population.[147]

Tunisia

There were two published conference abstracts on the use of e-cigarettes in Tunisia, as of 2023.[147] In the first abstract in 2020, among healthcare workers, 4.8% of the participants were e-cigarette users.[147] Their reasons to use e-cigarettes were for pleasure and to reduce smoking or quit smoking.[147] Furthermore, a 2021 study demonstrated that 20.5% of high school students (aged 15–20 years) were e-cigarette users.[147]

Asia

China

Of the participants 15 to 65 in Hong Kong in 2014, 2.3% stated to have ever tried an e-cigarette.[148]

Japan

Of the participants 15 years of age and up in Japan in 2015, 6.6% stated to have ever tried an e-cigarette and a heated tobacco product while 1.1% had used both in the last 30 days.[149] The participants were 4.4% current smokers, 1.7% former smokers and 0.3% who have never smoked.[149]

South Korea

Of the adult participants in South Korea in 2013, 6.6% stated to have ever tried an e-cigarette while 1.1% were current e-cigarette users.[148]

Southeast Asia

Country policy responses in Southeast Asia vary considerably, from strict bans to no or partial regulation.[150] In countries with weak e-cigarette regulations, the usage may be pervasive, especially among young people.[150]

Unlike in high income countries, several countries in Southeast Asia observed increasing use of e-cigarettes later (since 2015).[150] Reports indicated that the prevalence of e-cigarette use among Malaysian adolescents increased by more than 700% from 1.2% to 9.8%.[150] According to the Global Youth Tobacco Survey, 3.3% of adolescents currently use e-cigarettes in Thailand, while 14.1% of adolescents currently use e-cigarettes in Philippines.[150] Overall, the highest prevalence of current e-cigarette use was reported in Indonesia (11.8%), while the lowest prevalence was reported in Thailand (3.3%).[150]

Taiwan

Of the participants 15 years old and higher in Taiwan in 2015, 2.7% stated to have ever tried an e-cigarette.[148]

Oceania

Australia

Vaping in Australia has risen quickly even with legal barriers to trade of nicotine for non-therapeutic uses.[151] As of 2016, it is unclear whether comparable rises in e-cigarette use as seen in the US are to be anticipated in Australia.[152] In New South Wales in 2014, the prevalence of regular e-cigarettes users was 1.3%, with 8.4% had tried them.[152] Around 78,000 people were regular e-cigarettes users in New South Wales; this is generally low than in some other countries, such as the US and the UK.[152]

A 2015 online survey found that 97% of participants stated they were daily smokers before trying an e-cigarette.[151] Regular e-cigarette use among Australian adults increased from 1.2% in 2016 to 2.5% in 2019.[153] In Australia, 20% of non-smoking young adults aged 18 to 24 yeas old reported vaping in 2019.[66] In Australia, people who do not smoke aged 14 years or older who had vaped at least once went up from 4.9% in 2016 to 6.9% in 2019.[66] A 2013 national Australian survey showed that 15.4% of smokers that were 14 years old or higher had vaped at least one time in the prior 12 months, even though selling nicotine liquid is not legal there.[154]

In Australia, young adults aged 18 to 24 are the group with the highest rates of ever use or experimentation with e‐cigarettes, with 63.9% of smokers and 19.6% of non‐smokers reporting having ever used an e‐cigarette.[155] Between 2016 and 2019, the proportion of young adults who were current e‐cigarette users (including daily, weekly, monthly or less than monthly) almost doubled from 2.8% to 5.3%.[155]

New Zealand

Of the participants 15 years old and higher in New Zealand in 2014, 13.1% stated to have ever tried an e-cigarette while 0.8% were current e-cigarette users.[149]

Europe

European Union

In 2016 in Europe, there were 7.5 million e-cigarette users.[56] In 2018, regular e-cigarette use in the UK was greater than in other countries in the EU.[156] 1.2% of people who have not used cigarettes stated they have tried an e-cigarette in the EU, which totals about 29.3 million adults.[157]

European Union youth

Those from 11 to 16, one-time e-cigarette use varied from 7-18% of the respondents among the 2015-2016 EU surveys.[158] Regular vaping in young people who have not tried smoking, varied from 0.1% to 0.5% in all EU surveys.[158] The popularity of vaping is greater among the youth from Central and Eastern Europe than other places in Europe.[127]

Denmark

In 2012, prevalence of e-cigarette use in Denmark was 4.2%.[157]

France

In France, a 2014 survey estimated between 7.7 and 9.2 million people had tried e-cigarettes and 1.1 to 1.9 million use them on a daily basis.[159] The same survey also found 67% of smokers used e-cigarettes to reduce or quit smoking.[159] Of respondents who indicated they tried e-cigarettes, 9% said they had never smoked tobacco.[159] Of the 1.2% who had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited e-cigarettes as essential in quitting.[159] Approximately greater than 90% of French smokers have vaped.[77] In 2014 in France, 83% e-cigarette users continued to smoke cigarettes.[22]

A 2016 French cross-sectional study found 23.0% of French college students tried an e-cigarette and 5.7% were current users.[157] The same study found dual use of traditional cigarettes and e-cigarette was 14.5%.[157]

Germany

In recent years leading up to 2021, there has been a rise in vaping among people aged 12 to 25 in Germany.[160] A 2019 survey found 2% of respondents were regular e-cigarette users in Germany.[161] A 2019 federal government drug report found 14 to 17-year-olds make up fewer than 1% of e-cigarette users in Germany.[161]

Italy

In 2018 in Italy, there were about 1.3 million e-cigarette users, and 67.8% were also smoking.[162] 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%).[81] According to forecasts, e-cigarettes sales will surpass those of traditional tobacco by 2023.[81]

In Italy, e-cigarette use increased by 12.1% and almost 2% of non-users started vaping during the COVID-19 lockdown, especially vulnerable categories such as youngsters, drug-addicted (of less available substances) or people experiencing anxiety symptoms (worsened by the pandemic background).[81]

Lithuania

In 2012, prevalence of-cigarette use in Lithuania was 0.6%.[157]

Portugal

In 2012, prevalence of-cigarette use in Portugal was 0.6%.[157]

United Kingdom

The top two most popular non-reusable vape brands in 2022 in the UK were Elf Bar and Geek Bar.[163] The number of vapers was 3.6 million in 2019, which dropped to 3.2 million in 2020, while rising back to 3.6 million in 2021 in the UK.[164] Regarding the 3.6 million vapers in 2021 in the UK, slightly below 2.4 million were former smokers; 1.1 million were current smokers; and slightly below 200,000 had never smoked.[164] As of 2020, 58.9% of UK adult e-cigarette users are former smokers, 38.3% currently use both combustible tobacco and e-cigarettes, and 2.9% of never smokers are e-cigarette users.[8] As of 2020, 4.3% of British young adults aged between 18 and 24 were using e-cigarettes and 3.2 million adult users were recorded.[165] In the UK, current e-cigarette use increased from 1.7% of adults in 2012 to 7.1% in 2019 and then decreased to 6.3% in 2020.[8] There were an estimated 3.6 million adult users in the UK in 2019.[166]

Regular e-cigarette use in the UK in 2018 was about 2%.[156] In the UK in 2018, e-cigarette use among adults was about 6%.[107] In the UK in 2017, around 2.9 million adults use e-cigarettes.[167] In the UK, user numbers increased from 700,000 in 2012 to 2.6 million in 2015, but use by current smokers remained flat at 17.6% from 2014 into 2015 (in 2010, it was 2.7%).[168] About one in 20 adults in the UK uses e-cigarettes.[169] In the UK in 2015, 18% of regular smokers said they used e-cigarettes and 59% said they had used them in the past.[168] Among those who had never smoked, 1.1% said they had tried them and 0.2% still use them.[168] In 2014 in the UK, 60% e-cigarette users continued to smoke cigarettes.[22] About 60% of all users are smokers and most of the rest are ex-smokers, with negligible numbers of never-smokers.[170] In 2015 figures showed around 2% monthly EC-usage among under-18s, and 0.5% weekly, and despite experimentation, "nearly all those using EC regularly were cigarette smokers".[171] Non-smokers in the UK who vaped are more likely to have smoked later on than people who did not vape.[172] The number of vapers was about 700,000 in 2012 in the UK.[164]

United Kingdom youth

In May 2023, there was a 50% rise in minors trying e-cigarettes in the UK.[173] Elf Bars and Geek Bars were the most prevalent disposable vaping products used among children in the UK in 2022.[174] Public Health England reported that 1.7% of those aged 11–18 years in England had regularly used e-cigarettes in 2018.[175] Regular use in 2018 was low in this age group in England among those who had never smoked.[175] A 2017 study found that 37% of students ages 15 to 16 in Wales, UK, had ever used e-cigarettes versus 26% of students who used conventional cigarettes.[176]

In 2016 in the UK, those between 11 and 18 in the UK, 10% reported they have used e-cigarettes at least once or twice.[177] In 2016 in the UK, 2% reported they have vaped more than once a month, including 1% stated they used them every week.[177] A 2016 study found 11–16-year-olds English children exposed to e-cigarette advertisements highlighting flavored, in contrast to flavor-free products, did bring about more appeal to e-cigarettes.[24]

In Fife, Scotland in 2013, 19% of 15-year-olds and 10% of 13-year-olds reported they tried e-cigarettes.[178] Both were 3% above that of the typical figures in Scotland for this age group.[178] 10–11-year-olds Welsh never-smokers are more likely to use e-cigarettes if a parent used e-cigarettes.[179] In 2014, 77 out of 1467 (5.2488%) of respondents among 10–11-year-olds in Wales had tried an e-cigarette.[17] In 2014, 12.3% of 11–16 year olds of respondents in Wales had tried an e-cigarette, while 1.5% of them were current e-cigarette users.[145]

In 2014, using an e-cigarette at least once was 22% among youth, whereas using a traditional cigarette at least once was 18% among youth in England.[180] E-cigarette use among non-smoking youth was 11% in England in 2014.[181] Current e-cigarette use among mostly 11–15-year-olds was 9% in 2021, compared to 6% in England in 2018.[182] About 21% of 15-year-olds girls were currently using e-cigarettes in 2021, compared to 10% in England in 2018.[182]

The Americas

Canada youth and young adults

Figure shows prevalence of e-cigarette use (past 30 days) in teenagers in North America over a five-year period (between 2015 and 2020). Past 30-day prevalence of e-cigarette use from 2015 to 2020 in North America (comparisons between Canada and the United States) in teenagers (grades 7 through 12). Reported prevalence declined in 2020 during the COVID-19 pandemic. The Canadian Tobacco and Nicotine Surveys were used for 2015, 2019, and 2020 surveys, respectively. The 2018–2019 surveys for Canada were obtained from the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey, in a 2019 survey. The National Youth Tobacco Survey (in the Surgeon's Report on E-Cigarette Usage), CDC, and US FDA data from reports, between 2015 and 2020 were also used. It should be noted that there is a slight discrepancy in reported past 30-day prevalence of use in Canada between a Canadian report in 2017 and the ITC survey report (6.6% versus 8.4%) as well as between the US FDA report and the ITC in 2019 (20.8 versus 16.2%).
Figure shows prevalence of e-cigarette use (past 30 days) in teenagers in North America over a five-year period (between 2015 and 2020).[146] Past 30-day prevalence of e-cigarette use from 2015 to 2020 in North America (comparisons between Canada and the United States) in teenagers (grades 7 through 12).[146] Reported prevalence declined in 2020 during the COVID-19 pandemic.[146] The Canadian Tobacco and Nicotine Surveys were used for 2015, 2019, and 2020 surveys, respectively.[146] The 2018–2019 surveys for Canada were obtained from the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey, in a 2019 survey.[146] The National Youth Tobacco Survey (in the Surgeon's Report on E-Cigarette Usage), CDC, and US FDA data from reports, between 2015 and 2020 were also used.[146] It should be noted that there is a slight discrepancy in reported past 30-day prevalence of use in Canada between a Canadian report in 2017 and the ITC survey report (6.6% versus 8.4%) as well as between the US FDA report and the ITC in 2019 (20.8 versus 16.2%).[146]

Current use among 16–25-year-olds is 41% in 2020 among a sample size of 137 responders.[42] A second study found that the current use among 14–18-year-olds is 22% in 2020 among a sample size of 60,601 responders.[42] For current e-cigarette use, the average rate was 31.4% in Canada (out of two studies).[42] Among adolescents in Canada, lifetime, past-12 month, and 30-day prevalence of cannabis vaping increased by two- to seven-fold, from 2013 to 2020.[183]

In 2017, only 3% of Canadian youth in grades 7 to 12 are current smokers, and 20% are current e-cigarettes users, suggesting that upwards of 17% of e-cigarette users were originally non-smokers.[184]

United States

In the US, vaping is normally the highest among young adults and adolescents.[185] E-cigarette use in the US is three times higher among young adults than older individuals and has been linked to smaller discreet devices which have entered the marketplace.[165]

Worldwide evidence of e-cigarette use shows a 46.6% increase in e-cigarette use in the US from 2020 to 2022.[186] In 2019, e-cigarette use was highest among adults aged 18–24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes.[187] The prevalence of adult e-cigarette use in the US increased from 2.8% in 2017 to 3.2% in 2018.[6] In 2016 in the US, there were greater than 2.5 million e-cigarette users.[56] Among current e-cigarette users aged 45 years and older in 2015, most were either current or former regular cigarette smokers, and 1.3% had never been cigarette smokers.[188] In contrast, among current e-cigarette users aged 18–24 years, 40.0% had never been regular cigarette smokers.[188]

A 2018 review suggested that e-cigarettes are contributing to the tobacco epidemic by attracting smokers who are interested in quitting but reducing the likelihood of those smokers to quit successfully.[22] This effect may be reflected in the fact that in 2015 the number of cigarettes consumed in the US was higher than in 2014, the first time cigarette consumption increased since 1973.[22] In the US, as of 2014, 12.6% of adults had used an e-cigarette at least once and about 3.7% were still using them.[189] In 2014, about 3.8% employed adults were e-cigarette users.[190] As of mid-2015 around 10% of American adults have used an e-cigarette.[191] In 2014, 1.1% of adults were daily users.[192] In 2014 in the US, 93% of e-cigarette users continued to smoke cigarettes.[22]

Non-smokers and former smokers who had quit more than four years earlier were extremely unlikely to be current users.[192] Former smokers who had recently quit were more than four times as likely to be daily users as current smokers.[192] Experimentation was more common among younger adults, but daily users were more likely to be older adults.[192] Cigarettes and e-cigarettes are most commonly used together for adults and youth utilizing more than one tobacco product.[72] 15% of individuals with mental illness have tried vaping.[193] Their use is prevalent among former cancer patients in the US.[194]

United States youth

Estimates of current tobacco use among youth in the US in 2023
Estimates of current tobacco use among youth in the US in 2023[195]

The recent decline in smoking has accompanied a rapid growth in the use of alternative nicotine products among youth and young adults.[196] E-cigarettes are the most frequently used tobacco product among US youths.[197] In the US, youth are more likely than adults to use e-cigarettes.[188] In the US among youth, vaping is the most in boys, non-Hispanic white youth and Hispanic youth.[185] E-cigarette use among adolescents and never-smokers is increasingly prevalent, with reports indicating that use has more than doubled between 2017 and 2019 in Americans aged 16–19.[87] A considerable increase in e-cigarette use among US youths, coupled with no change in use of other tobacco products during 2017–2018, has erased recent progress in reducing overall tobacco product use among youths.[198]

Since their entrance into the US in 2007, teen use has increased, even after a short drop during the peak of the COVID-19 crisis.[199] In 2023, about one out of every 22 middle school students (4.6%) reported that they had used e-cigarettes in the past 30 days.[195] In 2023, one of every 10 high school students (10.0%) reported that they had used e-cigarettes in the past 30 days.[195] Among middle and high school current e-cigarette users in the US, use of disposable e-cigarette devices increased significantly between 2019 and 2020 and was the most commonly used device type reported in 2021.[108] In 2020 and 2021, approximately eight in 10 middle and high school students who used e-cigarettes reported using flavored e-cigarettes.[108] Among current youth e-cigarette users overall in the US in 2022, 84.9% used flavored e-cigarettes; of these, the reported flavor types, in descending order of use, were fruit (69.1%); candy, desserts, or other sweets (38.3%); mint (29.4%); and menthol (26.6%).[108] In 2020, 19.6% of US high school students (3.02 million) and 4.7% of US middle school students (550,000) reported current e-cigarette use.[7] Following an outbreak connected to vaping-induced lung illnesses in 2019, vaping among middle and high school students in the US dropped significantly in 2020.[200]

Even though the rate of smokers has declined in the US for decades, as of 2023, the resulting health advantage is partially offset by the rising number of e-cigarette users and the rising number of young e-cigarette users.
Even though the rate of smokers has declined in the US for decades, as of 2023, the resulting health advantage is partially offset by the rising number of e-cigarette users and the rising number of young e-cigarette users.[201]

Among both US high school and middle school students, current use of e-cigarettes increased considerably between 2017 and 2018, reaching epidemic proportions, according to the US Surgeon General; approximately 1.5 million more youths currently used e-cigarettes in 2018 (3.6 million) compared with 2017 (2.1 million).[198] However, no significant change in current use of combustible tobacco products, such as cigarettes and cigars, was observed in recent years or during 2017–2018.[198] This recent increase in e-cigarette use among youths is consistent with observed increases in sales of the e-cigarette Juul, a USB-shaped e-cigarette device with a high nicotine content that can be used discreetly and is available in flavors that can appeal to youths.[198] This indicates that e-cigarettes were the driver of the observed increase in any tobacco product use.[198] In 2018, e-cigarette use is highest for boys, whites, and high school students.[202] A 2017 policy review on bans on the sale of e-cigarettes to minors across the US found that e-cigarette use decreased along with smoking traditional cigarettes.[146]

Among American youth who had tried a vaporizer at least once, 65-66% most recently tried flavoring in 12th, in 10th, and in 8th grade in 2017.[203] Vaping with nicotine was approximately 20% in 12th and 10th grade and for 8th graders 13%, according to data from the Monitoring the Future in 2017.[203] Close to 80% of respondents in a 2017 Truth Initiative study aged 15–24 reported using Juul also used the device in the last 30 days.[204] E-cigarettes were the most commonly used tobacco product among US middle school and high school students in 2016.[136] In 2016, more than 2 million US middle and high school students used e-cigarettes in the past 30 days, including 4.3% of middle school students and 11.3% of high school students.[188] In 2015, 58.8% of high school students who were current users of combustible tobacco products were also current users of e-cigarettes.[205] 1 in 6 high school students used an e-cigarette in the past 30 days in 2015.[206] Between 2011 and 2015, vaping among minors increased 900 percent.[207] In the US, vaping among youth exceeded smoking in 2014.[90] As of 2014, up to 13% of American high school students had used them at least once in the last month.[208]

Youth are attracted by e-cigarettes’ novelty, the perception that they are harmless or less harmful than cigarettes, and the thousands of flavors (e.g., fruit, chocolate, peanut butter, bubble gum, gummy bear, among others).[22] As a result, youth e-cigarette use in the US doubled or tripled every year between 2011 and 2014.[22] At the same time that e-cigarette use was increasing, cigarette smoking among youth declined, leading some to suggest that e-cigarettes were replacing traditional cigarettes among youth and are contributing to declines in youth smoking.[22] At least through 2014, however, e-cigarettes had no detectable effect on the decline in cigarette smoking among US adolescent.[22]

Between 2013 and 2014, vaping among students tripled.[209] In 2013 the Centers for Disease Control and Prevention (CDC) estimated that around 160,000 students between 2011 and 2012 who had tried vaping had never smoked cigarettes.[196] E-cigarette use among never-smoking youth in the US correlates with elevated desires to use traditional cigarettes.[28] Teenagers who had used an e-cigarette were more inclined to become smokers than those who had not.[92] In the 2015 Monitoring the Future survey, a majority of students who used e-cigarettes reported using liquid without nicotine the last time they vaped.[210] Vaping among minors in US is linked to a desire to smoke and without an interest in stop smoking.[44] The majority of youth who vape also smoke.[211]

A long-term survey of high school students in Hawaii reported that shifting from never-use to smoking was associated with vaping.[212] A 2010–2011 survey of students at two US high schools found that vapers were more likely to use hookah and blunts than smokers.[31] Among grade 6 to 12 students in the US, the proportion who have tried them rose from 3.3% in 2011 to 6.8% in 2012.[45] Those still vaping over the last month rose from 1.1% to 2.1% and dual use rose from 0.8% to 1.6%.[45] Over the same period, the proportion of grade-6-to-12 students who regularly smoke tobacco fell from 7.5% to 6.7%.[213] The evidence indicates that vaping may promote, instead of impede, the use of traditional cigarettes among US adolescents.[214] Among adolescents in the US, lifetime, past-12 month, and 30-day prevalence of cannabis vaping increased by two- to seven-fold, from 2013 to 2020.[183]

Gateway theory

In the context of drugs, the gateway hypothesis predicts that the use of less deleterious drugs can lead to a future risk of using more dangerous hard drugs or crime.[215] There is wide concern that vaping may be a "gateway" to smoking.[30] Vaping may also act as a gateway to illicit drug use (recreational use of illegal drugs), is an area of concern.[31] Studies indicate vaping serves as a gateway to traditional cigarettes and cannabis use.[69] Nicotine is a gateway to opioid addiction, as nicotine lowers the threshold for addiction to other agents.[216] A 2015 review concluded that "Nicotine acts as a gateway drug on the brain, and this effect is likely to occur whether the exposure is from smoking tobacco, passive tobacco smoke or e-cigarettes."[217] Vaping without nicotine seems to act as a gateway device.[44]

Under the common liability model, some have suggested that any favorable relation between vaping and starting smoking is a result of common risk factors.[218] This includes impulsive and sensation seeking personality types or exposure to people who are sympathetic with smoking and relatives.[218] A 2014 review using animal models found that nicotine exposure may increase the likelihood to using other drugs, independent of factors associated with a common liability.[note 2][220] The gateway theory, in relation to using nicotine, has also been used as a way to propose that using tobacco-free nicotine is probably going to lead to using nicotine via tobacco smoking, and therefore that vaping by non-smokers, and especially by children, may result in smoking independent of other factors associated with starting smoking.[220] Some see the gateway model as a way to illustrate the potential risk-heightening effect of vaping and going on to use combusted tobacco products.[221]

The "catalyst model" suggests that vaping may proliferate smoking in minors by sensitizing minors to nicotine with the use of a type of nicotine that is more pleasing and without the negative attributes of regular cigarettes.[222] A 2016 review, based on the catalyst model, suggests "that the perceived health risks, specific product characteristics (such as taste, price and inconspicuous use), and higher levels of acceptance among peers and others potentially make e-cigarettes initially more attractive to adolescents than tobacco cigarettes. Later, increasing familiarity with nicotine could lead to the reevaluation of both electronic and tobacco cigarettes and subsequently to a potential transition to tobacco smoking."[13]

While the evidence is constrained by publication and attrition bias and adequately controling for possible confounding factors, there is a longitudinal relationship between teen vaping and trying smoking.[223] It is unclear to the degree that the relationship is a gateway effect or is the result of common liability.[223] Although the association between e-cigarette use among non-smokers and subsequent smoking appears strong, the available evidence is limited by the reliance on self-report measures of smoking history without biochemical verification.[224] None of the studies cited in a 2021 review included negative controls which would provide stronger evidence for whether the association may be causal.[224] A considerable amount of the evidence also failed to consider the nicotine content of e-liquids used by non-smokers, which means it is difficult to make conclusions about whether nicotine is the mechanism driving this association.[224]

The chances of smoking were six times higher in non-smoking teens who vaped in the UK.[180] A 2016 UK Royal College of Physicians report stated that the concerns regarding vaping leading to smoking in young people are unfounded.[225] They stated that it more likely occurs from a common liability to using both products.[225] They went on to state, "Renormalisation concerns, based on the premise that e-cigarette use encourages tobacco smoking among others, also have no basis in experience to date."[226] A 2015 Public Health England (PHE) report found no evidence e-cigarettes increase adult or youth smoking.[227] They stated that it is possible e-cigarettes has contributed to the drop in smoking.[227] In 2018, the Forum of International Respiratory Societies released a position statement, stating "While some publications from Great Britain have downplayed the use of electronic cigarettes and their link to combustible cigarette use in adolescents, numerous longitudinal studies have confirmed their role as a gateway to more conventional tobacco products."[228]

Other uses

An e-liquid containing a mixture of cannabinoid concentrates.
An e-liquid containing a mixture of cannabinoid concentrates[29]

The introduction of e-cigarettes has given cannabis smokers a different way of inhaling cannabinoids.[29] Powder or liquid vaping formulations that contained synthetic cannabinoids have been mislabeled as delta-9-Tetrahydrocannabinol or cannabidiol.[229] E-cigarettes are unlike traditional cannabis cigarettes in several respects.[29] Recreational cannabis users can individually "vape" deodorized or flavored cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as "stealth vaping".[29]

While cannabis is not readily soluble in the liquid used for e-cigarettes, recipes containing synthetic cannabinoids which are soluble are available online.[29] Companies also make synthetic cannabinoids liquid cartridges for use in e-cigarettes.[230] This is likely the result of companies capitalizing on the rise of e-cigarette use among young people.[230] E-cigarettes are being used to inhale MDMA, cocaine powder, crack cocaine, synthetic cathinones, mephedrone, α-PVP, synthetic cannabinoids, opioids, heroin, fentanyl, tryptamines, and ketamine.[231] It is common, in prison surroundings, to soak papers or tissues with synthetic cannabinoids, and then smoke them with tobacco or vape them using e-cigarettes.[232]

National Institute on Drug Abuse's animated infographic regarding the Monitoring the Future 2015 survey findings[233]

Concerns have been raised about e-cigarettes and their potential misuse for consuming cannabis and other psychoactive drugs by youth.[29] E-cigarette devices can be used to deliver other psychoactive drugs, including methamphetamine, cocaine, heroin, or cathinones.[29] E-cigarettes have been used to vape N-Ethylhexylone.[234] There is a link between teen e-cigarette use and using other chemicals, including alcohol, cannabis, and amphetamines, in addition to other hazardous behaviors like fighting and trying to commit suicide, which are highest among dual e-cigarette and traditional cigarette users.[235] An accidental 5F-ADB intoxication of a 16-year-old male after vaping was reported in 2021.[236]

Being exposed to nicotine early on can lead to greater risk of dependence later in life for nicotine and other drugs such as alcohol.[237] Nicotine obtained from vaping is frequently used in combination with alcohol.[238] E-cigarettes users are much more likely to misuse alcohol than non-e-cigarette users.[239] Nicotine and alcohol can have reinforce enhancing effects that may encourage co-use.[240] Vaping increases alcohol drinking among adolescents.[241]

Smoking blunt cigars is associated with vaping.[242] The very limited data found that from a small community of 55 users, suggest that cannabis vaping via e-cigarettes or e-vaporizers are infrequent behaviors among cannabis users, and mostly practiced by middle-aged men.[29] A 2015 study found that 5.4% of US middle and high school students were vaping cannabis using e-cigarettes and 18% of vapers had also tried vaping cannabis using their e-cigarette.[243] A 2015 Monitoring the Future survey findings on e-cigarette use highlights uncertainty about what teens are actually inhaling when using vaping devices, and at least 6% report they are using the vaporizers to inhale cannabis.[244] About 6% do not know what substance they last vaped.[244]

Some personal vaporizer devices can be used with cannabis plant material or a concentrated resin form of cannabis called "wax".[80] E-cigarettes can be altered to use hash oil, wax concentrated with tetrahydrocannabinol (THC), or dried cannabis leaves.[245] E-liquids may be filled with substances other than nicotine, thus serving as a way to deliver other psychoactive drugs, for example THC.[29] Cannabinoid-enriched e-liquids require lengthy, complex processing, some being readily available online despite lack of quality control, expiry date, conditions of preservation, or any toxicological and clinical assessment.[29] The health effects specific to vaping these cannabis preparations is largely unknown.[29] Dripping is the process of adding drops of e-liquid solution specifically onto the heating coil.[246] The prevalence of dripping with the use of e-cigarette devices is not known.[246]

Graphic from the 2019 US Surgeon General's report entitled Behavior Risks. The accompanied text states, "E-cigarette use among youth and young adults is strongly linked to the use of other tobacco products, such as regular cigarettes, cigars, hookah, and smokeless tobacco. Some evidence suggests that e-cigarette use is linked to alcohol use and other substance use, such as marijuana. And certain e-cigarette products can be used to deliver other drugs like marijuana."
Graphic from the 2019 US Surgeon General's report entitled Behavior Risks[247]

Gallery

Notes

  1. While the prevalence of young people's conventional cigarette use has decreased in many countries, the use of e-cigarettes has risen, as of 2022.[42]
  2. A 2012 review found "Whereas the "gateway" hypothesis does not specify mechanistic connections between "stages", and does not extend to the risks for addictions, the concept of common liability to addictions incorporates sequencing of drug use initiation as well as extends to related addictions and their severity, provides a parsimonious explanation of substance use and addiction co-occurrence, and establishes a theoretical and empirical foundation to research in etiology, quantitative risk and severity measurement, as well as targeted non-drug-specific prevention and early intervention."[219]

Bibliography

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