Background  

Since 2020, e-cigarette use among adolescents and young adults has skyrocketed, raising serious public health concerns. The tobacco-filled clouds that used to fill every public space have been replaced by a concoction of sweet-smelling vaping mist. E-cigarettes were first introduced in the early 2000s, advocated as a harm-reduction alternative for people who smoked tobacco products [1]. However, in the non-tobacco smoking group, there has been a higher uptake of e-cigarettes in adolescents who did not previously smoke tobacco [2], owing to the fear that the introduction of these nicotine-delivery devices may cause more harm than good in the adolescent population. 

The prevalence of adolescent tobacco cigarette smoking in England and the United States is currently at an unprecedented low [3]. However, could the increase in adolescent e-cigarette use potentially trigger a rise in tobacco cigarette smoking? A systematic review involving 17,389 adolescents and young adults, aged 14-30, concluded that there is an increased risk of subsequent cigarette smoking in those who use e-cigarettes [4]. E-cigarettes are fuelling nicotine addiction in young people and could be providing a gateway to explore other smoking options. This causes the risk of both e-cigarette and tobacco cigarette usage to increase exponentially. 

Figure 1 – Created by Harry Tattan-Birch, this graph shows the rise in e-cigarette prevalence among ages 18-45 between January 2021 and January 2022 [5]. 

 Figure 2 – Created by Harry Tattan-Birch, this graph shows the percentage of current e-cigarette users who use disposables between January 2021 and March 2022 [5]. 

Figures 1 and 2 are from a cross-sectional survey of adults aged 18 and over, between January 2021 and March 2022, where 36,876 participants were asked if they had used e-cigarettes. Figure 1 shows a rapid increase in e-cigarette prevalence in the younger participants, whereas in the age 45 and over category, it remained stable. Figure 2 shows that out of everyone who said yes to e-cigarette use in the study, the 18-year-old group had the most prolific increase in disposable vape use, with a rise from 0.4% to 54.8%. This study shows that in 2022, most of Britain’s e-cigarette users chose disposable products compared to the alternatives [5]. This means that disposable vapes are more appealing to the younger population, possibly due to their ease of use and accessibility. It is important to identify disposable vapes as the most popular form of e-cigarette, to create specific targeted prevention policies towards their use in adolescents.

The rise in adolescent e-cigarette use  

There are a multitude of reasons why e-cigarettes are appealing to the younger population. They have a fun and colourful appearance, and the variety of flavours available creates an excitement to try new ones. Moreover, the innocuous packaging allows a low-risk perception of e-cigarettes, unlike tobacco cigarette boxes, which commonly show pictures of decaying teeth or tar-stained lungs. E-cigarettes do not require a lighter and do not leave a lingering smell, making them easier to use and more commonly used inside the house [6].

The most notable rise in e-cigarette use has been found in people aged 16-24, and studies correlate this to social media, namely TikTok, which promotes the product by making it seem trendy, stylish and like a new lifestyle accessory [7]. This age group makes up the largest proportion of social media users. Adolescents are impressionable; their repetitive exposure to the positive media surrounding e-cigarettes is a significant driver in the rising vaping trends.

The research gap on e-cigarettes  

Given the very recent surge in e-cigarette popularity, data on its long-term health effects remains scarce. It is particularly difficult to predict what the repercussions of e-cigarette use will be for adolescents, as there has been insufficient time to assess the impact on their health as they age. Compiling the current data available on the acute health implications of e-cigarettes will allow educated predictions on what might happen over the next 50 years. 

Perhaps the tobacco epidemic is a foreshadowing of the health consequences of vaping in the adolescent age group. Tobacco cigarette smoking was abundant throughout the 1900s, with many choosing to smoke tobacco when there was limited evidence on the impacts on health. There has now been over a century’s worth of medical research studies associating tobacco smoking with a multitude of cancers, and it is listed as a modifiable risk factor in almost every disease [8]. Some may worry that over a century later, during a period of prolific tobacco smoking-related diseases, e-cigarettes may be recreating this picture. 

Current evidence for the health consequences of e-cigarettes

There is a misconception among the general population about what the inhaled e-cigarette vapour contains. Most people believe the vapour is steam from heated water with added flavourings. Few people realise that e-cigarettes heat a toxic e-liquid to form an aerosol for inhalation [9]. This e-liquid formula contains the chemicals propylene glycol and glycerine [10], which generate pulmonary toxins and the carcinogenic compounds acetaldehyde, acrolein and formaldehyde when heated [11]. These carcinogenic compounds are also found in tobacco cigarettes and have been shown to cause cardiovascular disease and non-cancerous lung diseases. Since these harmful compounds have been proven damaging to our health through research on tobacco cigarettes, it could be concluded that e-cigarettes also produce similar negative outcomes [12].

The biopsychosocial model allows a comprehensive approach to better understand the wide range of health consequences of adolescent e-cigarette use. The biological consequences of nicotine exposure include pulmonary inflammation, cardiovascular tachycardia and hypertension [13]. The psychological effects include increased suicidal ideation, impaired cognition and memory. The social implications of early nicotine exposure can include poor learning and higher stress levels. [14]

Nicotine and the adolescent brain  

After decades of research, studies have underpinned the complex mechanism of nicotine addiction. It is particularly interesting how it alters brain chemistry and elicits withdrawal symptoms in adolescents. The nicotine binds to the ubiquitous nicotinic acetylcholine receptors found throughout the body’s central nervous system, peripheral nervous system and the non-neuronal tissues. This causes the activation of different neural pathways in the ventral tegmental area, including dopamine, GABA and glutamate neurons [15]. These neurons stimulate reward systems in the brain, which alter neural pathways through positive reinforcement, making people want to continue vaping to retain that pleasurable feeling. After prolonged nicotine exposure to the receptor, it becomes desensitised, which means that higher doses of nicotine are required to diminish the nicotine cravings and to prevent the withdrawal symptoms of irritability, depressed mood, and restlessness [16]. 

Exposure to nicotine during the developmental period can have detrimental effects on the brain, including problems with learning and memory, respiratory function and reward-related regulation. There is increased vulnerability during this time, due to the increase in neuroplasticity, making the brain more susceptible to changes from chemical alterations like nicotine exposure [17]. During the developmental period from childhood to adulthood, the brain is at higher risk of the maturational effects of nicotine. It has been found that both serotonin and dopaminergic pathways are distinctly more sensitive to nicotine in adolescents, compared to adults. Long-term nicotine exposure in adolescents diminishes neurophysiological function, leading to enhanced anxiety, impulsiveness and difficulty concentrating [18]. One study found that there is a significant correlation between e-cigarette use and mental health conditions like post-traumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD) and depression [19]. Possible links could include the use of e-cigarettes to help cope with the acute psychological symptoms someone with a mental health condition endures. However, the evidence for the direct effects of vaping on psychiatric disorders is very limited. 

E-cigarette cessation measures

Cessation of e-cigarette use in the younger population may be beneficial for adolescents both physically and emotionally. The adolescent population makes up the majority of disposable e-cigarette users, making it vital to specifically target the younger age groups in a way that will have the largest impact.

The Tobacco and Vapes bill of 2024-2025 aims to reduce tobacco cigarette and e-cigarette use in the UK. The government has planned to ban disposable vapes on 1^st June 2025, to benefit the environment and limit childhood exposure to e-cigarettes. This legislation aims to reduce youth vaping by restricting access, however, there are worries that this could urge disposable vape users to try other nicotine products, such as tobacco cigarettes, which are detrimental to health. This bill seeks to regulate the use of e-cigarettes in certain locations, designating many public places as smoke-free. Due to the social nature of vaping among adolescents, this policy could support a decline in vaping among younger adults and deter them from e-cigarette use [20].

The UK government has suggested several policies to aid e-cigarette cessation, and this has been followed up by an online survey in 2024 to understand the level of support each policy has. The policies with the most support targeted the appearance of the devices and product displays in shops. Four out of five people aged 16 and over agreed that child-friendly packaging on e-cigarettes should be banned and standardised to reduce the appeal of e-cigarettes for young people [20].

A study from 2022 shows how a three-tiered approach could best target the younger population to promote vaping cessation [21] (Figure 3). The first policy advocates limiting access to e-cigarettes and banning advertising of vapes and associated products. To limit access, perhaps the government should implement the same policy as tobacco cigarettes, making it illegal for anyone born after 1^st January 2009 to purchase e-cigarettes. This would add an additional barrier to the younger population, making it harder for them to access e-cigarettes, as they will never be able to purchase them with their valid identification. 

Figure 3 – Created by Lynnette Nathalie Lyzwinski shows a three-tiered approach aiming to aid the cessation of e-cigarettes in adolescents [21].

The second policy advocates raising awareness of the short-term and possible long-term health implications of e-cigarettes. This education could occur in schools during form time or in an assembly. It is vitally important that people are made aware of the possible effects of vaping. In recent years, the media have portrayed e-cigarettes as a positive accessory, with limited information on the effects of nicotine use. This may have promoted the rise in adolescent vaping, as this age group uses social media the most. It may be beneficial to use social media to raise awareness of the possible health risks associated with e-cigarettes. Social media platforms should make it a violation to produce any content promoting e-cigarette use in adolescents. They can also use moderators to help remove any inappropriate advertisements.

The third policy aims to create vaping cessation apps, which could provide a structured plan on how to cut down gradually, and give alternative nicotine replacement therapies (NRT), which do not cause lung irritation like e-cigarettes. There is a wide range of alternative therapies, including nicotine patches, chewing gum, sprays and lozenges, which can be purchased from pharmacies and supermarkets. NRTs are typically preferred over vaping as they do not require inhalation of an aerosol, they allow fast control over nicotine cravings and are thought to be safe to use. 

Over the past 5 years, the prevalence of vaping among adolescents has reached an all-time high. E-cigarettes were introduced as a safer alternative to tobacco cigarettes, but in the future, some may question whether the introduction of e-cigarettes was ever safe at all. This idea results from the adolescent population, who did not previously smoke tobacco cigarettes, abusing disposable vapes, as their purpose was not for this population. As time progresses, the health effects of e-cigarettes will emerge, allowing recognition of their impact on adolescent health. The exposure to nicotine from a younger age alters brain chemistry during a critical period of development, leading to possible cognitive impairment. It is critical to push for more powerful public health policies, to limit the unnecessary exposure of e-cigarettes and shield our generation of adolescents from a future of negative health implications. This topic should be the pinnacle of evidence-based research over the upcoming decades, to create better predictions and show the true effects that e-cigarettes can have on the human body. It will be valuable to monitor how nicotine exposure at a young age may affect the development of our younger population, owing to a rise in preventable disabilities in adulthood. It sparks curiosity over what outcomes the ban on disposable vapes on the 1st of June 2025 will have on the adolescent population. Whether it will reduce e-cigarette usage as intended or push the younger population to try alternative products like other types of e-cigarettes or tobacco cigarettes. Ultimately, protecting the future generations requires a multi-level strategy —through product regulation, limiting consumption and persistent scientific inquiry—before the damage becomes irreparable.

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