Over the past five decades, tobacco control has been one of the greatest public health success stories. The combined efforts of scientific research, regulation, fiscal policies, and healthcare professionals have led to a substantial decline in cigarette smoking and the burden of tobacco-related disease. However, this progress is now under threat.
The World Health Organization (WHO) has warned of the rising use of electronic cigarettes among adolescents and young adults in many countries, with prevalence already exceeding that of conventional cigarette smoking in some settings.1 The European School Survey Project on Alcohol and Other Drugs (ESPAD) identified e-cigarettes as the most frequently used nicotine product among 15–16-year-old students.2 In Spain, the 2023 ESTUDES survey confirms this trend: e-cigarettes represent the fastest-growing nicotine product among students aged 14–18 years, with a lifetime prevalence of 49.5% (50.5% among girls and 48.5% among boys).3 Notably, a substantial proportion of users had never smoked conventional cigarettes. These findings challenge the narrative that these products are intended solely for adult smokers and instead support the hypothesis that they are designed to recruit new nicotine users.
Throughout its history, the tobacco industry has repeatedly demonstrated an extraordinary capacity for reinvention. When conventional cigarettes became socially unacceptable, the industry simply changed the product. Electronic cigarettes, heated tobacco products, and nicotine pouches are the latest expression of a commercial strategy whose objectives remain unchanged: to normalize nicotine use, minimize perceptions of risk, and associate nicotine use with freedom, innovation, social acceptance, and personal success, thereby attracting a new generation of consumers.4,5
Today, however, digital technologies have transformed the industry's reach. The emergence of what might be termed digital capture represents the major strategic shift from the twentieth century. Algorithms on TikTok, Instagram, YouTube, and Twitch enable highly targeted promotional content to reach specific groups of adolescents through covert advertising, user-generated content, and influencer marketing.6–9 This form of promotion is considerably more difficult to identify and regulate than traditional advertising and plays a pivotal role in normalizing nicotine use among young people.
The available evidence indicates that these strategies are highly effective. Repeated exposure to pro-vaping messages significantly increases the likelihood of experimentation and initiation among adolescents.
It is often argued that these products are less harmful than conventional cigarettes. Absence of combustion does not equate to absence of harm. The aerosols generated by these devices contain nicotine together with multiple toxic constituents capable of inducing well-documented biological injury.10
Recent systematic reviews have shown that vaping produces acute hemodynamic changes, endothelial dysfunction, and increases in cardiovascular risk biomarkers closely associated with the development of cardiovascular disease.11 Likewise, multiple studies have documented impaired pulmonary function, increased respiratory symptoms, worsening asthma, and persistent inflammatory changes in the airways. The emergence of EVALI highlighted that these devices can cause severe lung injury under certain circumstances, although it likely represents only the most extreme manifestation of a broader spectrum of respiratory damage.12
The lack of studies with several decades of follow-up has become one of the tobacco industry's principal arguments—and that of its allies—for delaying stricter regulation. This reasoning closely mirrors the strategy employed throughout the second half of the twentieth century. For decades, scientific uncertainty was deliberately exploited to cast doubt on the causal relationship between smoking and disease, postponing effective public health action while millions developed preventable illnesses. History has shown that waiting for absolute certainty before taking action can have devastating consequences for public health. In this context, the precautionary principle is entirely justified, particularly when the target population consists of adolescents and young adults.
The marketing of novel nicotine products cannot be evaluated solely from a toxicological perspective. Their greatest threat lies in their capacity to renormalize nicotine use among a generation that had grown up viewing smoking as an increasingly unacceptable behavior. This renormalization is arguably the tobacco industry's greatest strategic achievement over the past two decades.
This is no longer merely a tobacco epidemic—it is a nicotine epidemic. The products have changed, but the biological target and the commercial objective remain the same: creating and sustaining nicotine dependence among a new generation of users.
It is therefore no coincidence that Article 5.3 of the WHO Framework Convention on Tobacco Control goes beyond regulating tobacco products and explicitly calls for protecting public health policies from tobacco industry interference.13 This recommendation remains as relevant today as ever. Tobacco companies are not merely marketing new products; they are also seeking to shape scientific debate, influence public perceptions of risk, and affect the development of regulatory policies. Ignoring this reality would mean repeating mistakes we already know too well.
Likewise, comprehensive regulation is urgently needed to place electronic cigarettes, heated tobacco products, and all other nicotine delivery devices on the same regulatory footing as conventional tobacco products. This should include comprehensive restrictions on advertising, promotion, and sponsorship; bans on youth-oriented flavors; expansion of smoke- and aerosol-free environments; equivalent taxation; stricter enforcement of age restrictions on sales; and robust surveillance systems capable of monitoring the evolution of these emerging forms of nicotine use. In Spain, a new draft tobacco control bill promoted by the Ministry of Health is currently under parliamentary consideration.
The history of tobacco control offers a lesson that should not be forgotten. The enormous human cost of conventional cigarettes resulted not only from their toxicity but also from the delay in implementing effective policies while the tobacco industry consolidated its market. Today, we understand the industry's strategies far better and possess sufficient scientific evidence to act before the damage becomes irreversible. We have both the opportunity—and the responsibility—to prevent a new generation of young people from becoming addicted to nicotine under the misleading guise of products presented as modern, technological, and harmless.6–9
The tobacco industry has changed its products, but not its strategy. Our response should remain equally consistent: protecting young people from nicotine addiction must continue to be an unwavering public health priority in the face of an emerging epidemic.14
Seventy years ago, the scientific community began to unravel the devastating consequences of conventional cigarette smoking. Today, we possess a historical perspective that our predecessors did not: we understand the tobacco industry's commercial strategies, the biological mechanisms underlying nicotine addiction, and the regulatory tools needed to protect public health. The question is no longer whether we should wait for more evidence, but whether we are willing to act before another generation pays the same price as the last.
Healthcare professionals have a responsibility that extends beyond the consulting room. In addition to treating patients with nicotine dependence, we must actively engage in health education, counter misinformation disseminated through social media, collaborate with the media, and advocate for evidence-based public health policies. Scientific societies should provide clear and independent leadership in confronting commercial messaging, particularly when it targets minors.15
Authors’ contributionsMBF designed and wrote the manuscript.
Artificial intelligence involvementThe author declares that no artificial intelligence was used in the drafting of this manuscript.
FundingThe author declares that no funding was received for this article.
Conflicts of interestThe author declares no conflicts of interest.
