The Next Nicotine Epidemic May Not Look Like Smoking

For half a century, tobacco control has been built around one product and one behaviour: the cigarette, and the person who smokes it. That model was a public health success. Smoking has fallen across much of Europe, and the European Commission credits its regulatory framework with contributing to that decline. But nicotine no longer travels only in smoke. E-cigarettes, pouches and newer formulations deliver it in forms that are cheaper to make, easier to conceal and, in some cases, outside the legal categories written for tobacco. The question is no longer only how many people smoke. It is who is starting nicotine, through which products, and whether rules designed for cigarettes can follow them. Answering it well means separating two groups that the public conversation keeps merging: adults who smoke and might benefit from switching completely, and young people who have never smoked and might otherwise not have used nicotine.

Two different public health questions

Debates about vaping tend to ask a single question, whether it is good or bad, and then argue over the answer as if it applied to everyone. The evidence reads better as an answer to two separate questions about two different groups of people.

The first concerns adults who already smoke. For them, the risk that matters is continued smoking. The U.S. Centers for Disease Control and Prevention (CDC) states that e-cigarette aerosol generally contains fewer harmful chemicals than cigarette smoke, and that e-cigarettes may benefit adults who are not pregnant if used as a complete substitute for all smoked tobacco. The Cochrane living review of randomised trials, discussed below, adds that nicotine e-cigarettes can help people stop smoking. For this group, a regulated product that moves a person fully away from combustion can be a reasonable harm-reduction tool rather than a new risk added to an existing one.

The second concerns people who do not use nicotine, adolescents above all. Here there is no smoking to displace. Any use is added exposure to a drug that, according to both CDC and WHO/Europe, can affect a brain that keeps developing until the mid-20s. WHO/Europe notes that nicotine exposure during this period can alter neural pathways linked to attention, learning and impulse control. A benefit that is real for an adult who switches completely does not transfer to a 14-year-old who starts. A 2025 systematic review in Addiction likewise finds a consistent individual-level association between youth vaping and later cigarette initiation, while judging the certainty of that evidence very low and concluding that it remains unclear whether the behaviours are causally linked.

Read together, the two questions explain why the debate so often talks past itself. One side points to adults who quit; the other points to adolescents who start; and each is describing something true. The practical implication is that a policy has to pass two tests at once: does it help adults leave combustion, and does it keep young people who do not use nicotine from beginning? Measures that satisfy only one of those tests are not yet a public health strategy.

The product is changing, not only the habit

For most of the twentieth century, nicotine meant tobacco leaf. WHO/Europe’s 2026 World No Tobacco Day material describes a shift away from that assumption. Over roughly the past five years, the industry has relied increasingly on laboratory-synthesised nicotine and chemical analogues, which WHO experts say have become as cost-efficient as nicotine extracted from the plant. The implication they draw is that a new generation of products may contain little or no tobacco-derived nicotine while still acting on the same brain receptors that produce dependence.

The same WHO/Europe campaign names synthetic nicotine, nicotine salts and analogues as ingredients designed to increase addiction potential while being marketed as innovative or even less harmful. This does not mean that every vaping product or pouch is engineered the same way. It means that product design is now part of the epidemiology: two items labelled “nicotine” can differ considerably in how easily they are started, how discreet they are, and how readily they sustain use. WHO’s concern is that these features lower the barrier to initiation and reduce the perception of risk, particularly among adolescents and young adults.

The market data point the same way. The Commission’s April 2026 evaluation reports that between 2012 and 2023 the sales value of the EU e-cigarette market grew by 450%, and that sales value of nicotine pouches rose by 1,697% between 2018 and 2023. Over 2012–2023, the sales value of traditional tobacco products, excluding heated tobacco, fell by 8.5%, yet the sales value of all tobacco and related products rose by almost 3%. These are market figures, not exposure figures, and they say nothing by themselves about who is using what. What they do show is that the nicotine market has not shrunk with smoking. It has changed form.

Nicotine pouches illustrate the same point more sharply. They deliver nicotine through the mouth without combustion and without aerosol, so they do not belong on the same risk ladder as cigarettes — and they should not be treated as identical to e-cigarettes either. A separate Cochrane living review of oral nicotine pouches finds the evidence on smoking cessation very uncertain and limited to small, short trials, with little to say yet about long-term health effects — a far thinner base than the high-certainty cessation evidence for nicotine e-cigarettes. At the same time, rising sales, discreet use and marketing aimed at a lifestyle rather than at tobacco make youth uptake a legitimate concern, especially where pouches sit outside the main EU tobacco rules. In short: not smoke, not proven as a cessation tool on the same footing as regulated nicotine e-cigarettes, and not a product whose public-health profile can be borrowed wholesale from either cigarettes or vaping.

That matters because tobacco control has traditionally regulated products one category at a time. A system built that way will always trail a market that can reformulate faster than legislation can be amended. The more durable question for policy is not “is this a cigarette?” but “what does this product do to the person using it, and who is it built to attract?”

What young people in Europe report

Two sources describe youth e-cigarette use in Europe, and they should be kept apart. The first is WHO/Europe’s 2026 analysis of adolescents aged 13–15 in the WHO European Region. It reports that 14.3% of this age group use e-cigarettes, the highest regional prevalence worldwide and about twice the 7.2% found elsewhere. In absolute terms, about 4.2 million adolescents in the Region use e-cigarettes, compared with about 4 million who use tobacco.

The second is ESPAD 2024, the European School Survey Project on Alcohol and Other Drugs, which surveyed students aged 15–16 in 37 countries and is reported by the EU drugs agency (EUDA). Among them, 44% had used an e-cigarette at least once and 22% had done so in the past 30 days. Girls reported more current use than boys (25% versus 19%). Among the 32 countries with comparable data for both rounds, current use rose from 14% in 2019 to 22% in 2024. And 60% of students said that obtaining e-cigarettes would be fairly or very easy.

Portugal 6.4%, ESPAD average 22%, Poland 36% of students aged 15–16 reported using e-cigarettes in the past 30 days in 2024.

Portugal

6.4%

ESPAD average

22%

Poland

36%

Source: EUDA, Key findings from the 2024 European School Survey Project on Alcohol and Other Drugs (ESPAD); students aged 15–16 in 37 countries. National values shown are the lowest reported (Portugal, 6.4%) and highest reported (Poland, 36%).

Several cautions apply before reading these numbers side by side. The WHO figure covers younger adolescents (13–15) in the 53-country WHO European Region; the ESPAD figures cover 15–16-year-olds in 37 countries; the survey instruments and definitions differ. A 14.3% prevalence in one and a 22% prevalence in the other should therefore not be treated as the same quantity, and neither should be taken to “correct” the other. What matters is that both independent sources describe a high level of use among European adolescents, and ESPAD adds a trend that is moving upward.

The spread between countries is also informative. Current use runs from 6.4% in Portugal to 36% in Poland, a difference of more than five-fold within one survey. A gap of that size is difficult to attribute to adolescent biology, which does not vary this much across a continent. The survey itself cannot say which factors explain it, but it suggests that national context, including availability, marketing and regulation, plays a part. For a public health reader, that is encouraging in one sense: if some countries sit at a fraction of the level of others, the pattern is unlikely to be fixed.

Less harmful is not the same as harmless

The most common error in this debate is to collapse a continuum into a binary. At one end is combustible tobacco, whose harms are established beyond serious dispute. At the other is no nicotine use at all. E-cigarettes sit between the two, and where they sit depends on who is using them and what they are replacing.

CDC puts both halves of the message in the same place. Its January 2025 guidance states that e-cigarette aerosol generally contains fewer harmful chemicals than cigarette smoke, and in the same passage states that this does not make e-cigarettes safe. The aerosol can contain nicotine, cancer-causing chemicals, heavy metals and fine particles that reach deep into the lungs, and the long-term effects are still being studied. CDC also advises that dual use, meaning the use of both cigarettes and e-cigarettes, is not an effective way to protect health. A person who cuts down on cigarettes while vaping has not necessarily moved along the continuum in the way the harm-reduction argument assumes.

The Cochrane living review is equally careful. Its authors found no clear evidence of short-term serious harms from nicotine e-cigarettes in the trial period, but they stress that long-term safety data are still needed. Absence of detected harm in trials lasting months is not evidence of absence over decades, and the review says so.

14.3% of adolescents aged 13–15 in the WHO European Region use e-cigarettes, the highest regional prevalence globally, compared with 7.2% elsewhere.

14.3% vs 7.2%

of adolescents aged 13–15 use e-cigarettes in the WHO European Region (highest globally), compared with the rest of the world.

Source: WHO/Europe, World No Tobacco Day 2026 materials (adolescents aged 13–15).

The continuum has a different meaning for an adolescent. For a person who smokes, the relevant comparison is cigarettes, and “fewer harmful chemicals” is a genuine improvement. For a 13-year-old, the relevant comparison is not using nicotine at all, and an e-cigarette sits at a worse place on that scale, whatever its position relative to a cigarette. The phrase “safer than smoking” is accurate for one audience and misleading for the other. Public health communication that does not distinguish them risks sending the first group’s reassurance to the second.

Flavour, design and the lifestyle pitch

If the product is changing, so is the way it is presented. WHO/Europe’s 2026 material describes bright packaging, fruit flavours, influencer promotion and discreet device design as mechanisms that normalise nicotine use and accelerate addiction among younger people, rather than as incidental features. The WHO campaign adds that products are designed to make initiation easier, to reinforce repeated use and to reduce perceived risk. These are statements about intent and design, and the evidence for any single feature varies. But they describe a pattern that is hard to reconcile with a market aimed only at adults who already smoke.

Digital channels amplify this. The Commission’s evaluation notes that novel tobacco and nicotine products are increasingly promoted through social media and influencers, and that some of this promotion falls outside the scope of the existing advertising rules. A young person encountering a product through a creator they follow is not meeting a regulated tobacco advertisement; the legal category, the audience and the intent are all blurred.

Flavours are where the trade-off is hardest, and it is better named than avoided. They are central to the appeal for young people, which is why WHO calls for flavour bans. Whether and how adults who are trying to switch away from cigarettes should keep access to some flavours is a regulatory question on which reasonable people differ, and this article does not claim the evidence settles it. The point is narrower. Flavour, packaging and promotion are design choices, and design choices can be regulated without any new scientific discovery.

There is a deeper issue in the “lifestyle” framing. The WHO campaign notes that new products are marketed as innovative or even less harmful. For an adult smoker, “less harmful” can be a fair description. Delivered to someone who has never smoked, the same words become an invitation. This is why the audience matters as much as the claim: identical language can inform in one setting and recruit in another.

What the evidence supports for adults who smoke

None of this argues against harm reduction for adults, and the strongest evidence for it deserves a fair hearing. The Cochrane living systematic review, with searches up to 1 January 2026, finds high-certainty evidence that nicotine e-cigarettes increase the likelihood of quitting smoking compared with nicotine replacement therapy (risk ratio around 1.6). In plain language, Cochrane illustrates the absolute rates as roughly 8 to 10 quitters per 100 with nicotine e-cigarettes versus about 6 per 100 with nicotine replacement therapy. Separately, it estimates the average benefit of that comparison at about four additional quitters per 100 (with a confidence interval around that estimate). Those figures should not be read as simple subtraction of the rounded ranges — 8–10 minus 6 is not meant to “equal” exactly four. Evidence versus non-nicotine e-cigarettes is of moderate certainty and also favours nicotine products.

About 8 to 10 in 100 people using nicotine e-cigarettes stopped smoking, compared with about 6 in 100 using nicotine replacement therapy.

8–10 vs ~6

per 100 people who smoked stopped, with nicotine e-cigarettes versus nicotine replacement therapy (high-certainty evidence). Cochrane’s pooled absolute benefit is about four additional quitters per 100 — not a literal subtraction of the rounded ranges above.

Source: Cochrane Database of Systematic Reviews, “Electronic cigarettes for smoking cessation” (CD010216), living review, searches to 1 January 2026.

The size of that effect deserves honest framing. An average gain of about four quitters per 100 is modest for any individual, since most people in both groups did not quit. It is, however, meaningful when applied across the very large number of people who smoke, and it is comparable to or better than what other cessation tools offer. That is why e-cigarettes belong in the conversation about helping adults, not on the list of products to be eliminated regardless of evidence.

The conditions attached to that evidence matter as much as the headline. The trials tested regulated, specified products in people who smoked and were trying to quit, and Cochrane’s conclusions apply to that use. They do not describe what happens when disposable, high-nicotine, flavour-led products are sold widely to anyone. CDC’s limits on the benefit are consistent: it applies to non-pregnant adults who use e-cigarettes as a complete substitute, and not to youth, and not to dual use. The evidence supports a pathway out of smoking. It does not support a way into nicotine.

A regulatory framework written for another market

The European Commission’s April 2026 evaluation of the Tobacco Products Directive and the Tobacco Advertising Directive is candid about this. It concludes that the EU framework contributed to the decline in smoking but has been outpaced by novel products. Nicotine pouches fall outside the Tobacco Products Directive, leaving national rules fragmented, and the evaluation identifies gaps in advertising rules, including promotion on digital channels. It also records that daily e-cigarette use in the EU rose from 1% in 2020 to 1.7% in 2023. These are small absolute numbers, but they are moving in one direction, and the products involved were largely absent when the framework was drafted.

The WHO data illustrate the same gap at a different geographical scale. In the WHO European Region, which is wider than the EU, only seven countries ban all e-cigarette flavours, according to 2024 data cited by WHO/Europe in 2026. Those two sets of figures should not be merged, since the EU and the WHO European Region are different jurisdictions with different legal powers. But they converge on the same conclusion: the rules in place were largely designed for a market that has since moved on.

The implication is less about any single measure than about the logic of regulation. A framework that defines products by what they are made of can be sidestepped by changing what they are made of. One that defines them by what they do, including how addictive they are, how appealing they are to young people and how they are marketed, is harder to outrun. It can also keep regulated access for adults who need it, which is what the trial evidence assumes. Policy makers face a design problem more than a moral one: how to keep the benefit for adults who switch without leaving the door open for young people who begin.

Controlling nicotine without losing sight of smoke

It would be a mistake to read all of this as a story in which cigarettes have become a solved problem. In the WHO European Region, tobacco still kills 1.2 million people every year, and 202,000 of those deaths result from exposure to second-hand smoke. Those figures are what the whole tobacco control effort was built to reduce, and they remain far larger than anything yet attributable to non-combustible products. Keeping both facts in view is the discipline this topic demands: nicotine delivery is changing, and combustion is still where most of the damage lies.

This is also why the opening question about two groups matters so much. Public health earned its credibility on tobacco by being clear about the harm of smoking and consistent about who it was trying to protect. The same clarity applies here. For adults who smoke, a regulated route away from combustion has real, trial-backed support. For young people who do not use nicotine, there is nothing to reduce, and the rise in use that WHO/Europe and ESPAD describe is a signal that prevention has not kept pace with the market. Neither fact cancels the other.

The harder part is the communication. A simple message, whether a ban or a defence, would be easier to deliver. The evidence offers a more demanding one: less harmful than smoking, not harmless; useful for some adults, unnecessary and risky for young people; promising in trials, still uncertain in the long run; and shaped far more by how products are designed, sold and regulated than by the label on the device. If tobacco control’s first century was about learning to see the cigarette, its next task is to see nicotine in all its forms, and to hold on to the smoke while doing so.

Sources & further reading

1. WHO/Europe — World No Tobacco Day 2026: the next nicotine revolution is already here (27 May 2026)
2. EUDA — Key findings from the 2024 European School Survey Project on Alcohol and Other Drugs (ESPAD)
3. Cochrane — Can electronic cigarettes help people stop smoking, and do they have any unwanted effects when used? (CD010216; living review, searches to 1 January 2026)
4. Begh R, Conde M, et al. — Electronic cigarettes and subsequent cigarette smoking in young people: A systematic review, Addiction (2025)
5. Cochrane — Oral nicotine pouches for cessation or reduction of other tobacco or nicotine use (CD016220; living review)
6. U.S. Centers for Disease Control and Prevention — Health Effects of Vaping (January 2025)
7. European Commission — Executive summary of the evaluation of the Tobacco Products Directive, the Tobacco Advertising Directive and related policies (SWD(2026) 112, April 2026)
8. WHO/Europe — World No Tobacco Day 2026: unmasking the appeal, countering nicotine and tobacco addiction (31 May 2026)