We must address the dangers of e-cigarettes and dual use

As we mark 60 years since the U.S. Surgeon General’s report Smoking and Health and the significant strides public health policies have made against tobacco-related diseases, it’s crucial to recognize that the battle is far from over.

The narrative surrounding e-cigarette use has focused solely on harm reduction without adequately considering the risks posed by dual use and the potential for new health complications. As smoking rates decline and e-cigarette use rises, it has become imperative to address this knowledge gap, especially since a systematic review published in the Lancet noted high rates of dual use (simultaneous use of tobacco and vaping) among adolescents.

Nicotine and tobacco use pose significant health risks to adolescents. Nicotine, a key driver for tobacco addiction, adversely affects adolescent lung development, the immune system, cognitive and mental health, and the brain. Adolescents exposed to tobacco are also at increased risk of becoming long-term users, facing a lifetime of higher risk of non-communicable diseases such as cardiovascular disease, cancers and chronic respiratory conditions.

A recent National Academies of Science, Engineering and Medicine (NASEM) study emphasizes the need for research on both the patterns and varying contexts of dual use to inform public policy on youth cigarette smoking and e-cigarette use.

A recent analysis investigating dual and poly-nicotine and tobacco product use among U.S. adolescents revealed a concerning increase between 2011 and 2022. The most common combination was the concurrent use of smoking and novel products including vaping. A report from the Centres for Disease Control and Prevention found that among current users in middle and high school, 31 per cent have used multiple nicotine and tobacco products over the past 30 days.

A 2021 Lancet report notes that in Canada, the use of electronic nicotine and non-nicotine delivery systems increased from 8 per cent in 2013-14 for high school students (aged 12 to 18 years) to 26 per cent in 2018-19, with older male students reporting the highest use.

A recent Japan-Ireland collaborative study published in Nature found that flavoured vapes, which are often targeted to younger users, can release more than 100 harmful chemicals upon heating, posing immediate health risks. Using artificial intelligence, researchers analyzed 180 vape flavours and found that chemicals from e-liquids generate numerous toxins and irritants when inhaled. The study identified approximately 127 acute toxins, 153 health hazards, and 225 irritants in these vaping products.

Given that using vaping provides no health benefits and may even pose risks to non-smoking youth, strategies to prevent their dual use by this group are crucial.

Research suggests that high-frequency dual cigarette and e-cigarette users are more likely to be nicotine dependent, and high-frequency electronic cigarettes/dual users had lower intention to quit.

Measures such as aggressive preventative education, warning labels, advertising restrictions and product bans should be recalibrated to encompass the nuances of e-cigarette use and its impact on population health. There is an urgent need for targeted control strategies, particularly to counteract the tobacco industry’s aggressive marketing targeting youth demographics and to tackle multiple product use as well as nicotine addiction among adolescents.

Furthermore, a recent meta-analysis by the New England Journal of Medicine (NEJM) underscores the importance of continued research into the long-term effects of e-cigarettes. While e-cigarettes offer some harm reduction benefits for certain individuals, we cannot ignore the potential health consequences, particularly in the context of dual use. By investing in rigorous scientific inquiry, policymakers can make more informed decisions that prioritize public health and safety.

It is unsafe for young individuals to use any form of tobacco.

The findings from the NEJM meta-analysis serve as a wake-up call for policymakers and public health experts. It’s time to move beyond oversimplified narratives and confront the complex realities of e-cigarette use. By re-evaluating our public health policies considering this evidence, we can better protect the health and well-being of current and future generations.

A recent systematic review analyzing nine studies involving 984,764 patients found that e-cigarette users had increased odds of experiencing a myocardial infarction (MI) compared to non-users. Dual use poses a greater risk of MI than e-cigarettes alone. Unfortunately, dual use is the most common pattern among e-cigarette users.

Considering the well-established risks associated with tobacco products, it is unsafe for young individuals to use any form of tobacco. The U.S. Preventive Services Task Force advises clinicians to offer prevention counselling to all adolescent patients.

Clinicians play a vital role in prioritizing e-cigarette cessation for adolescents across all settings. Thus, it is crucial for clinical settings to provide adolescents e-cigarette and tobacco dual use prevention services for adolescents not only for effective cessation support.

In our July 2023 Lancet article, we highlighted the essential role pediatricians and primary care physicians play in preventing adolescent e-cigarette use.


Table 1. The Five Steps to Help Adolescents and Young Patients Quit Smoking and vaping
Ask: Inquire if patients use tobacco products.
Advise: Encourage them to quit.
Assess: Determine their readiness to quit.
Assist: Provide support in quitting, such as prescribing medication and referral to behavioral counseling and related community resources such as Quitline/self-help groups.
Arrange: Set up follow-up sessions for continued support.


Their involvement is essential for several reasons:

Trust and Relationship Building: Adolescents often have established relationships with their pediatricians and primary care physicians, which fosters trust and open communication. This rapport allows physicians to have meaningful conversations about the risks associated with e-cigarette use.

Early Identification and Intervention: Primary care visits provide an opportunity for early detection of e-cigarette use. Physicians can use screenings and discussions during routine appointments to identify risk factors and intervene before habits become deeply ingrained.

Health Education and Guidance: Physicians are well-positioned to provide evidence-based information about the dangers of e-cigarettes and offer guidance on healthier lifestyle choices. They can also provide resources and referrals for additional support if needed.

Family Involvement: Pediatricians and primary care physicians often interact with families, which can facilitate broader conversations about e-cigarette and dual use and its impact. Involving parents and guardians in prevention efforts can enhance the overall effectiveness of interventions.

Comprehensive Care Approach: As pediatricians and primary care providers, physicians can integrate e-cigarette prevention into a broader approach to adolescent health. This holistic perspective ensures that interventions are tailored to particular needs.

Advocacy and Support: Physicians should advocate for policy changes at the community and legislative levels to curb adolescent access to e-cigarettes and combustible tobacco. They can also offer ongoing support to adolescents and families navigating the challenges of nicotine addiction.

By leveraging their expertise and the trust they’ve built with patients and families, pediatricians and primary care physicians can play a pivotal role in preventing e-cigarette use and e cigarette use in combination with combustible tobacco among adolescents. Clinical care community proactive involvement can lead to more effective interventions and better health outcomes for this vulnerable population.

Table 2. Addressing dual use of e-cigarettes and combustible tobacco
Preventative Education: Provide clear information about the risks of using both e-cigarettes and traditional tobacco products simultaneously.

Evidence Based Health Literacy: Ensure patients understand the potential harm and implications of dual use.

Behavioural Counseling:

Motivational Interviewing. Use evidence-based counseling techniques to explore patients’ motivations, barriers, and readiness to quit.

Individualized Plans. Tailor cessation plans based on patients’ preferences, readiness and lifestyle.

Setting Goals. Collaboratively set achievable goals for reducing or quitting tobacco use.


Nicotine Replacement Therapy (NRT). Consider NRT options (such as nicotine gum, patches, or lozenges) to address nicotine dependence.

Prescription Medications. Evaluate the appropriateness of prescription medications (e.g., varenicline or bupropion) for smoking cessation.

E-Cigarette Use Reduction:

Gradual Transition. Encourage patients to gradually reduce e-cigarette use while working toward complete cessation.

Switching Strategies. Explore switching from high-nicotine e-cigarettes to lower-nicotine options.

Behavioural Substitution:

Replace Habits. Help patients identify alternative behaviours to replace smoking or vaping.

Healthy Coping Mechanisms. Teach stress management techniques, physical activity or mindfulness practices.

Peer Support and Resources:

Support Groups. Connect patients with local or online support groups for encouragement and shared experiences.

Quitlines. Refer patients to tobacco quitlines for personalized counseling and resources.

Monitoring and Follow-Up:

Regular Check-Ins. Schedule follow-up visits to monitor progress, address challenges and adjust treatment plans.

Celebrate Successes. Acknowledge and celebrate any reduction in dual use or successful quit attempts.




Table 3. Quitting is a process. These resources offer vital support and motivation
Stanford Tobacco Prevention Toolkit: Classroom materials for preventing adolescent vaping

National Cancer Institute: SmokefreeTXT for Teens

CATCH My Breath E-Cigarette Educational Program: An evidence-based program for schools

Canadian Cancer Society: Quitting Is Possible

Government of Canada: Tools for a smoke free life

Lung Health Foundation: A logical plan for quitting

Ontario Tobacco Research Unit: Stop Vaping Challenge App



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Nilanga Aki Bandara


Nilanga Aki Bandara is Founding Chair, Global coalition to empower adolescents and youth on harmful therapeutic interventions to prevent combustible tobacco use.

Peter Tiu


Peter Tiu is a university outreach coordinator, Global coalition to empower adolescents and youth on harmful therapeutic interventions to prevent combustible tobacco use.

Sandhita Saha


Dr. Sandhita Saha is a community GP interested in adolescent and youths’ tobacco free lifestyles strategies.

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