The epidemiological picture is striking. Recent national surveys among Italian adolescents aged 13 to 15 show that traditional cigarette smoking declined from 21 percent to 16 percent between 2010 and 2022, while e-cigarette use rose sharply. Roughly 20 percent of adolescents reported regular vaping, more frequently among girls, and one-third had tried the devices at least once. Similar trends have been documented across other high-income countries, where falling rates of combustible smoking have coincided with rising experimentation with vaping. Notably, despite legal bans on sales to minors, most Italian adolescents reported easy access to products through retail outlets, exposing a critical gap between legislation and enforcement.

What drives this uptake? The review identifies a familiar playbook. Marketing strategies used by e-cigarette companies closely mirror those historically employed by the tobacco industry, emphasizing independence, rebellion, and social sophistication. Sleek designs, user-friendly interfaces, and an enormous variety of flavors, from mint and fruit to confectionery aromas, make the devices particularly attractive to teenagers. Most adolescents continue to believe that vaping is a safer alternative to smoking, and up to 80 percent of those using nicotine-containing products believe they are using nicotine-free devices. Predictive factors for use include rule-breaking tendencies, poor academic performance, proximity of retailers to schools, and friends who smoke, while participation in team sports, parental monitoring, and strong academic aspirations appear protective.

The biological evidence is where the review turns most sobering. Vaping aerosols contain volatile organic compounds, aldehydes, and heavy metals capable of inducing oxidative stress, inflammation, and cellular injury. A recent Australian study found that exposure to heated tobacco products such as IQOS was as detrimental to human lung cells as traditional cigarettes and e-cigarettes, generating toxic compounds including formaldehyde, acrolein, and acetaldehyde. Children and adolescents who vape face increased risks of bronchitis, wheezing, asthma, shortness of breath, and chronic cough, even without ever touching a conventional cigarette. A meta-analysis of 15 studies confirmed a significant association between e-cigarette use and asthma, with a pooled odds ratio of 1.39.

Flavoring chemicals add their own dangers. Diacetyl, used in sweet flavors, has been linked to bronchiolitis obliterans, the severe and irreversible lung damage popularly known as popcorn lung. Cinnamaldehyde, a common additive in cinnamon-flavored liquids, impairs ciliary motion in human bronchial epithelial cells by disrupting mitochondrial function, compromising the mucociliary clearance that keeps airways clean. Second-hand exposure compounds the problem: passive nicotine exposure among adolescents has been associated with bronchial symptoms and shortness of breath, and a systematic review involving more than 900,000 participants reported that prenatal vaping exposure increases adverse neonatal outcomes by 53 percent, including low birth weight and preterm birth.

The most dramatic respiratory crisis came in 2019, when EVALI, or E-cigarette or Vaping Product Use-Associated Lung Injury, was first identified in the United States. Linked primarily to THC-containing products and vitamin E acetate, the condition produced cough, chest pain, and dyspnea, with 80 percent of cases requiring hospitalization. During the outbreak, 2,807 adolescents were hospitalized, 20 percent required intensive care, and approximately 70 deaths were reported. Most affected patients exhibited persistent lung abnormalities even six months after diagnosis, underscoring the long-term impact of vaping-related injury.

The cardiovascular story is equally troubling. Nicotine and other chemical components of vaporized e-liquids can impair endothelial function, increase arterial stiffness, and elevate blood pressure, all recognized early markers of cardiovascular disease. Studies comparing traditional cigarettes and e-cigarettes have shown that both acutely increase aortic stiffness, with electronic cigarettes producing comparable detrimental effects over longer durations. Experimental animal models of chronic vapor inhalation have yielded endothelial dysfunction and arterial stiffness similar to conventional cigarette smoke. Because the adolescent cardiovascular system is characterized by active vascular remodeling and an immature endothelium, early exposure may accelerate arterial aging and predispose young users to lifelong cardiovascular risk.

Perhaps the most consequential findings concern the developing brain. Adolescence is a critical period of neurobiological maturation, particularly within the prefrontal cortex and limbic regions that regulate cognition, emotion, and decision-making. Nicotine acts on nicotinic acetylcholine receptors, and chronic exposure leads to receptor desensitization and altered dopamine signaling within the brain’s reward pathway, heightening vulnerability to addiction. Reactive oxygen species contribute to neurotoxic effects, inducing epigenetic modifications such as DNA methylation that reinforce addictive behaviors. Epidemiological data from the 2017 and 2019 U.S. Youth Risk Behavior Surveys revealed that adolescents who used e-cigarettes were significantly more likely to report depression, suicidal thoughts, and suicide attempts compared with non-users, with associations stronger among female adolescents. Alarmingly, dependence can develop even at low levels of use, with withdrawal symptoms occurring after minimal exposure.

The review also documents the gateway effect and the dual-use phenomenon. Longitudinal evidence shows that adolescent e-cigarette use increases the likelihood of later combustible cigarette smoking, while the reverse relationship is not observed, suggesting nicotine primes the brain’s reward circuitry for other addictive behaviors. E-cigarette use correlates with higher rates of alcohol, marijuana, and amphetamine consumption, and e-liquids can even be used to aerosolize psychoactive substances including synthetic cannabinoids and methamphetamine. Meanwhile, between about 30 and 60 percent of e-cigarette users continue to smoke conventional cigarettes simultaneously. These dual users exhibit the highest prevalence of respiratory symptoms and marked endothelial dysfunction with reduced nitric oxide bioavailability, comparable to or exceeding levels observed in exclusive smokers, undermining the harm-reduction rationale entirely.

Prevention, the authors argue, requires a coordinated, multi-level approach. School-based interventions, media campaigns, and community programs are most effective when sustained over time and integrated with public education, family engagement, and policy enforcement. Cessation remains a major challenge: spontaneous quitting rates among those aged 15 to 21 are as low as 4.1 percent, though behavioral therapies grounded in cognitive-behavioral models show modest benefits, and SMS-based interventions increased continuous abstinence rates in a meta-analysis of more than 27,000 young people. Pharmacological options such as nicotine replacement therapies and varenicline have limited evidence in adolescents. Public health policy remains a cornerstone, with the World Health Organization’s 2025 World No Tobacco Day campaign calling for comprehensive regulations banning flavors and youth-oriented marketing. The authors conclude that e-cigarette use poses significant health threats to adolescents, undermining decades of tobacco control progress, and that coordinated interventions, regulatory enforcement, and continued research are essential to prevent nicotine dependence and protect the wellbeing of future generations.

Subject of Research: Systemic health effects of e-cigarette use among children and adolescents

Article Title: The new nicotine epidemic: understanding the systemic harms of e-cigarettes in the adolescent population

Article References: Fainardi, V., Barbetta, E., Petz, M., Rizzo, L., Ruberti, F., & Esposito, S. (2026). The new nicotine epidemic: understanding the systemic harms of e-cigarettes in the adolescent population. Frontiers in Adolescent Medicine, 4, Article 1723536. https://doi.org/10.3389/fradm.2026.1723536

Image Credits: AI Generated

DOI: 10.3389/fradm.2026.1723536

Keywords: e-cigarettes, vaping, adolescents, nicotine addiction, public health, EVALI, respiratory disease, cardiovascular risk, neurodevelopment, gateway effect, prevention, tobacco control