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1. Introduction
Smoking continues to be a major cause of illness and death worldwide. In Europe it is one of the main public health problems, since Europe has some of the highest prevalence of tobacco use among adolescents compared to other World Health Organization regions [1]. For example, the average percentage of 15-16 years old European adolescents who have smoked in the last 30 days is 21%, and 10% smokes every day [2]. Because tobacco use mainly starts during adolescence, and because adolescents are extremely sensitive to the addictive substance nicotine [3], protecting youth against the dangers of tobacco use has high priority.
Alternative tobacco products, i.e., electronic cigarettes with nicotine, electronic cigarettes without nicotine (also known as ‘shisha-pens’) and water pipes (also known as ‘shisha’ or ‘hookah’), have become increasingly popular among adolescents. In fact there is an upward trend in adolescent use of e-cigarettes: rates of ever use have doubled or tripled in recent years [4]. For example, ever use of e-cigarettes use by Dutch adolescents aged 12-16 years is 34% (e-cigarettes with/without nicotine have not been measured separately), which is even higher than the ever use of conventional smoking, i.e., 23%. Use of a water pipe use is also popular, i.e., 23% of the adolescents have used water pipes [5].
There are several concerns related to the use of alternative tobacco products. First, these products could undermine years of efforts to ‘denormalize’ smoking [6]. Denormalization of smoking behavior is considered an important population strategy to make non-smoking the generally accepted norm and to prevent deviant behavior, i.e., smoking [7]. Second, there is strong evidence that smoking e-cigarettes/e-cigarettes without nicotine and water pipe act as a ‘stepping stone’ to smoking conventional cigarettes [8,9,10,11,12]. Third, although the level of toxicants is higher in conventional cigarettes, e-cigarette vapors contain toxic substances [13,14] and smoking just one puff of an e-cigarette without nicotine can cause irritation of the airways [15]. Also, water pipe smoking is associated with several negative health outcomes, e.g., increase of heart rate, blood pressure, or even lung cancer and carbon monoxide poisoning [16,17]. In view of these concerns, tobacco control policies aiming to prevent smoking onset should focus not only on conventional cigarettes, but also on alternative tobacco products.
A possible strategy...