Early and electronic. We could describe in this way, in two words, the relationship between smoking and adolescents, given that 43.4% of them already in middle school have tried their first cigarette, 4.1% have already done so in elementary school, and that the 20% of very young people access the vice by passing through the electronic ones. The alarm, given the age group involved and the percentages, comes from the recent congress of the Italian Society of Childhood Respiratory Diseases (Simri). According to a survey by the Istituto Superiore di Sanità of May 2021, 37.5% of Italian 14-17 year olds have already had contact with tobacco smoke and 41.5% with electronic cigarettes: 20.1% have begun to smoke with e-cig and 2.3% with heated tobacco devices.
“The use of electronic cigarettes is associated with a greater risk of becoming consumers of traditional cigarettes too (a phenomenon called gateway effect, doorway, access in English), so much so that young people who have never used traditional cigarettes, but they have tried the electronic ones at least once, they run a 3-4 times greater risk of starting to smoke traditional cigarettes – he says Maria Elisa Di Cicco, pediatrician and Councilor of the Italian Society of Respiratory Diseases – It is therefore not surprising that young people are the main target of the advertising campaigns of e-cig brands, most of which are among other things owned by the big tobacco industries ” . As if to say that they are always the same, or almost always, to produce both traditional and latest generation smoke. And that the latest generation sooner or later ends up favoring access to traditional smoking.
Among American teenagers in 2014 the prevalence of nicotine vaping surpassed the use of combustible tobacco. And from 2017 to 2018 among US high school students, vaping increased by 78%. A very rapid epidemic from which even our very young Italians do not escape. From a study conducted on 170,000 Italian students between the ages of 15 and 19, it appears that more than half have smoked at least one cigarette, however, while the prevalence of those who have smoked tobacco at least once in their life has decreased by 4 percentage points between in 2012 and 2018, going from 60.9% to 56.9%, the share of those who used an e-cig at least once in the same period of time went from 32.9% to 52%.
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Still, it’s not that electronic smoking doesn’t hurt. “The long-term damage is many, not only due to nicotine but also to other substances released by these devices: ethanol, aldehydes, ultra-fine particles, flavors and others – he says. Fabio Midulla, associate professor of Pediatrics at Sapienza University, head of the pediatric first aid and admission department of the Policlinico Umberto I in Rome and president of Simri. “The smoking of e-cigarettes predisposes to the risk of lung cancer, COPD, chronic obstructive pulmonary disease, emphysema, interstitial pneumonia, cardio-coronary problems. There are the neurological effects due to nicotine: we are talking about hyperactivity, loss of the ability to concentrate. Furthermore, the use of e-cig during pregnancy, which affects between 0.6 and 15% of women, can cause premature birth, low birth weight of the newborn ”.
Certain damage still to be investigated
“The immediate damage of e-cigs are in the respiratory tract, such as susceptibility to asthma and obliterative bronchiolitis – he adds Massimo Landi pediatrician of the Asl Città di Torino and vice-president Simri – We know that tobacco smoke favors lung adenocarcinoma and could also be the same for electronic smoking. For those who smoke tobacco, switching to electronic smoking may not involve greater risks than those of the traditional cigarette, but for those who have never smoked the door opens to exposure to toxic substances that will certainly cause damage, but which still are today. to investigate. We must pay attention, especially for the adolescent range “.
And yes, because, the experts recall, the earlier you start smoking or vaping, the harder it is to quit, because the adolescent brain is more sensitive to the pharmacological properties of nicotine, and therefore children develop addiction more easily than adults. Not surprisingly, the earlier the tobacco consumption, the lower the smoking cessation success rates.
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The evolution of e-cig
But why are electronic devices so successful? “The reasons are different – is the reflection of Midulla – there is the ability of adolescents to communicate on social networks which therefore act as amplifiers for each experience which increases curiosity and therefore the spread of the phenomenon. Then there is the question of aromas: electronic cigarettes give the possibility to vape with the flavor of cinnamon, fruit … a fact that is attractive for very young people not yet accustomed to smoking. There is also an attractive aesthetic, which could play a role: the latest generation e-cigs, the pod-mods, look like USB sticks, they are colorful, easy to handle, thin. And then there is the widespread idea that there is no nicotine in these devices, in reality this is not the case. In pod-mods, for example, there are 20 milligrams of nicotine per milliliter of inhaled liquid, the equivalent of a pack of cigarettes ”. Just about the pod-mods in June of last year it was published on Jama Pediatrics a systematic review of 35 scientific articles on the evolution of e-cigs conducted by researchers from Harvard University, Seoul and the Dana-Farber Cancer Institute in Boston. According to that work, pod-mod e-cigarettes have a greater potential to generate addiction and again according to the authors, the use by young people and young adults of these devices can be attributed to social acceptability, to the comfortable functionalities of the product. and aggressive social media marketing.
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“The availability of numerous aromas represents the workhorse of the e-cig industry- resumes Di Cicco- It is well known, in fact, that a vast choice of aromas encourages the first use of tobacco in adolescents”, which is the reason for which the sale of traditional flavored cigarettes has been banned for some time, “that’s right, but the restrictions on the possibility of flavoring e-cigarette liquids are still widespread – resumes the pediatrician – leaving the industry free to leverage a a factor that is crucial for attracting young people, advertising ‘natural’ flavors, always new, which encourage experimentation and keep curiosity alive ”. Thanks to the aromas it is possible to reduce the sensation of harshness that would be experienced at the beginning with the only use of nicotine as well as accentuating the perception by adolescents that the electronic cigarette is less harmful than it actually is. “And this is precisely the message conveyed massively by advertising through the media and social networks – underlines Di Cicco – the electronic cigarette is proposed as a healthier, cheaper and cleaner alternative than traditional cigarettes and the message is so well conveyed that many teenagers are not even aware of the fact that e-cigarettes can contain nicotine ”.
The importance of health education
So: the numbers and long-term effects of e-smoking on health are there. The industry does its job, which is to make money: in the absence of effective stakes, strict and clear regulations, it tries to increase profits. Young people and the very young also do their job: they are curious and transgressive by nature, and therefore easy users of attractive, even if harmful, messages. So where is the solution? “In health education, which should be implemented. As Sapienza Maternal and Child Department we are thinking about a health education project for schools regarding smoking and other things. But it must be clear that school is not enough – Midulla underlines and concludes – the family is a crucial place, fundamental for educating and conveying health messages ”.
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Heated tobacco devices, an invitation to caution by toxicologists
2.3% of adolescents enter the world of smoking via heated tobacco devices, or Heated Tobacco Products HTP, a bit of a hybrid between electronic cigarettes and traditional cigarettes: like electronic cigarettes they have an electric device that heats and a product for generating a vapor containing nicotine, and like traditional cigarettes the heated product is tobacco and not a liquid. Precisely on HTP devices, a study was presented at the recent Sitox congress whose results are an invitation to caution. The study was conducted on rats exposed for 30 days to HTP vapors. At the time of analysis, the animals showed changes in the epithelium lining the trachea, damage to the pulmonary alveoli, inflammation, in some cases, DNA mutations and even potential liver damage. “Certainly tobacco heating products reduce the concentration of the major toxic substances present in cigarette smoke, but some typical effects of exposure to smoke remain. We still have to understand, then, if this reduction of toxic substances is sufficient and translates into an effective reduction of the health risk “, he said. Fabio Vivarelli, one of the researchers involved in the work. At first, toxicologists also wondered if these devices could represent alternatives at least for smokers addicted to 2 or 4 packs a day, says Sitox, but these studies call everything into question because the evidence to date shows that it is not It is true that HTP is less harmful than the traditional cigarette. “For now and until we have more solid data, as recommended by the WHO – continues Vivarelli – we cannot consider tobacco heating devices or electronic cigarettes a therapeutic method for quitting smoking. Much better to rely on traditional methods “.
How much confusion
“Tobacco heating products have been approved by the American FDA as a modified risk device for tobacco exposure – says Silvia Granata she, too, like Vivarelli involved in the research – but the study underlying this approval lacks a comparison between heated tobacco cigarette and liquid e-cigarette. There are also two types of modified risk – explains the researcher -: exposure risk and health risk. The FDA has approved these modified risk devices only for the first type of risk, therefore, in fact, we do not know if there is safety for health. All this generates confusion in people, who perceive this device as safe when in reality we do not yet know if it is “.
