31 May 2020 is World Health Organization (WHO) World No Tobacco Day. The theme this year is “Protecting youth from industrial manipulation and preventing tobacco and nicotine use” [1]. WHO wants this year’s campaign to serve the following purposes: 1) dispel myths and expose manipulation tactics used by the tobacco and nicotine industry, in particular youth marketing tactics, including the introduction of new and new products, flavors and other attractive features; 2) equip young people with knowledge of the tobacco and nicotine industries’ intentions and tactics to hook current and future generations to tobacco and nicotine products; and 3) empower empowerers (in pop culture, on social media, in the home or in the classroom) to protect and defend the youth and catalyze change by involving them in the fight against Big Tobacco.

The theme is chosen for good reasons. For decades, the tobacco industry has spent a large portion of its marketing budget on youth-targeted advertising. [2]. In 2016, the tobacco industry spent $ 26 million on marketing every day [3], and we know from insight into the industry’s own documents that marketing to children and young adults has always been a priority [4]. As recently as in 2006, a U.S. judge found that there was overwhelming evidence that tobacco companies encourage youth to smoke, track youth’s behaviors and preferences, market to youth based on that detection, and make substantial contributions. to the onset of smoking in young people. The tobacco companies polished the image of their youth brands to convey robust independence, rebellion, love of life, adventurousness, self-confidence, self-assurance and belonging to the “in” crowd. [5].

Some of the tobacco industry’s tactics from the past seem almost absurd today; Camel’s “Old Joe” character was clearly invented to attract children and in 1991 this brand logo was so well recognized by 3-6 year olds such as the Disney Channel logo [6]. Advertising like this has long been banned in most European countries, but the tobacco industry knows how to bypass it. As an example, RJ Reynolds has connected with thousands of consumers through their Camel branding website to design new cigarette packs [7], and Big Tobacco’s Instagram hashtags associated with companies’ tobacco products have been viewed a staggering 25 billion times; a very effective way of circumventing existing laws to restrict advertising to young people. Furthermore, the tobacco industry has recently made major investments in alternative nicotine delivery systems, such as smokeless tobacco, heated tobacco and e-cigarettes, the best known of which are Juul.

E-cigarettes and other alternative nicotine delivery devices are smartly marketed among teens; not surprisingly, the tobacco industry transferred their marketing skills to the new industry and applied the same marketing approach. E-cigarette advertising spending has increased dramatically, and social media is widely used. The median number of followers summarized across brands reaches more than 5 million on Facebook and Instagram alone [8]. At the same time, the tobacco companies are trying to rediscover themselves as concerned and ethical corporations, with initiatives such as the daring Philip Morris Institute for a Tobacco Free World, and the “Foundation for a Smoke-Free World”, also funded by Philip Morris International. What is really needed is an “Institute for a Philip Morris Free World”.

The new nicotine-containing products are attractive because they taste like candy, fruit, cake or one of at least 15,000 flavors, and the youth have the misperception that flavored e-cigarettes are less harmful [9]. The tactics used to smuggle these wares included statements that it was safer than tobacco and statements about their benefits as agents to promote smoking cessation.

First, safety and damage. For children who do not smoke, this is a non-issue as it is irrelevant whether these products are safer than smoking or not. Their risk will increase, not decrease, if they use it. All products contain nicotine and are highly addictive. Nicotine is not harmless. Symptoms of mild acute toxicity may include nausea and vomiting, diarrhea, increased salivation, increased respiratory secretions and bradycardia. Severe poisoning can further progress to seizures and respiratory depression. The human oral lethal dose is generally reported to be between 50 and 60 mg for adults, with the lethal dose for adolescents expected to be lower [10].

The evidence is sufficient to conclude that nicotine activates several biological pathways through which smoking increases the risk of disease. The respiratory and neurological health effects of nicotine have been clearly documented. In addition, nicotine appears to increase the risk of diabetes [11] and exposure to nicotine in the fetal life can have several adverse effects [10]. Adolescents’ brains are particularly vulnerable to the detrimental effects of nicotine. Based on existing knowledge of adolescent brain development, and the results of animal and human studies, it is likely that nicotine exposure during adolescence adversely affects cognitive function and development. Therefore, the potential long-term cognitive effects of nicotine exposure in adolescents are of great concern [10].

There is also growing evidence that e-cigarettes cause harm [12–17], of cell models and animal research, as well as single exposure or short-term studies on humans. These studies have clearly shown that although there is overlapping toxicity, e-cigarettes are not merely a dehydrated version of tobacco but have their own unique toxicities, not least since nicotine is only one of many toxic substances in the new nicotine-containing products . Acute severe toxicity is well described (e-cigarette or vaping product use associated with lung injury, or EVALI); 80% are probably related to cannabinoids added to the fluids, but 20% are not. Furthermore, it may not make sense for Public Health to allow the circulation of hardware that can be used to deliver such a risky mix. Let us make it clear: the acute toxicity of e-cigarettes is significant. Furthermore, it took decades before the terrible long-term consequences of tobacco were appreciated; we can impossibly know about the long-term effects of e-cigarettes. Only a fool would be complacent, given the literally thousands of chemicals involved, the uncertainty about the content and toxicity of most of these compounds, and the absolute certainty that many know toxicities.

Second, what about quitting smoking? For non-smoking children, smoking cessation is not relevant; it’s a non-issue. As far as smoking cadets (and adults) are concerned, it is important to know that no e-cigarette brand has been approved as a smoking cessation tool, as there is a lack of evidence for its long-term effect. Furthermore, the data on “strike” simply means a switch from tobacco to e-cigarettes [18], with all the potential toxicities involved. While there may be hard smokers who can just quit e-cigarettes altogether, at least they are not approved by the National Institutes of Health and Care Excellence in the UK as an aid to quit smoking, and only the most gullible will think this is how they are marketed. When was the last time you saw nicotine patches marketed by being attached to an attractive young female’s naked arms? Those who advocate for e-cigarettes as agents of smoking cessation should have a coherent policy to protect children and young people from these devices.

Finally, are e-cigarettes a gateway to smoking? The answer is yes [19], but who cares? This is a total non-issue. They are a gateway to smoking as well as nicotine addiction, but whether the adolescents progress to smoking or not, we can not tolerate the appearance of a generation of addicted Darth Vapers as the e-cigarettes. in itself is harmful. The American Surgeon General has rightly stated that he will not tolerate sitting passively while recruiting a new generation of nicotine addicts [20].

Although the tobacco and vaping industry views the growth of e-cigarette sales as a triumph for public health (they would, would not they?), Falsely claim that more widespread use of e-cigarettes will reduce smoking and the harmful effects of smoking, the European Respiratory Society (ERS) has strongly denied this myth [21]. Nevertheless, the tobacco and vaping industry currently uses differences of opinion about the severity of harm among researchers to illustrate the uncertainty in anti-vaping advice; just as they used any uncertainty about health effects of smoking in the 1950s and 1960s to promote the feeling of little harm associated with smoking: “Doubt is our product”, as stated by one tobacco company [22]. This is another non-issue: is it safer to walk across a highway with your eyes closed, or a Formula 1 track during a race? Who in their right mind would do that too?

We need to fight the promotion of nicotine to youths. The tobacco industry would love to be a part of this effort, but as a Trojan horse, ensure they can continue to make money from addictive young people. The leopard cannot change its spots, but the industry is smarter than the leopard, and at least tries to reuse those spots. WHO emphasizes the involvement of influencers as a way to reinforce the anti-smoking messages to children and adolescents, using their experiences of a large and successful campaign in China [23]. Building on our experiences in the fight against cigarette smoking in adults, a wide range of activities, regulations and policies will be required if we are to counter the strong and ruthless industry behind all nicotine-containing products. It will have to be adapted for children and young people, the high priority prey for the tobacco industry, in the past, present and in the future. The ERS will be more than happy to contribute to this work. Doubt may be the product of Big Tobacco, but stone-cold certainty is that of the Society.