Greece is one of the few countries in Europe where a significant increase in traditional smoking and e-cigarettes (vaping) among adolescents has been recorded in recent years.
Although available data for our country show that smoking among adults is decreasing – although it remains at 30% – among adolescents, alarming levels of both conventional and e-cigarette use are recorded. The proportion of 16-year-olds in Greece who say they have smoked conventional or e-cigarettes has increased significantly, from 43% in 2019 to 54% in 2024 according to the results of the latest two cycles of the European School Survey Project on Alcohol and Other Drugs (ESPAD).
But how do we explain this “apparent” contradiction of smoking decreasing in adults and increasing with all forms of smoking in adolescents?
Dr João Breda, Head of the WHO Office for Quality of Care and Patient Safety in Athens, Special Envoy of the WHO Regional Director for Europe and Head of the WHO Office in Greece explains to APE-MPA that policies were designed for yesterday’s products.
“Taxation, anti-smoking laws, warnings on packaging and restrictions on advertising were initially designed with conventional cigarettes and other smokable products in mind. Modern products – especially e-cigarettes and nicotine sachets – with sweet flavours, attractive designs and aggressive online marketing often exploit loopholes in the legal framework and poor enforcement of rules to protect minors,” Dr João Breda tells APE-MPA. Another reason, he points out, is the fact that the tobacco industry’s product promotion is systematically directed towards young people. “Across the European Region, the WHO and independent researchers document a clear pattern: sweet flavours, partnerships with popular content creators on social media, sponsorships linked to music and digital games, and devices that look more like electronic devices than tobacco products. These practices are not aimed at a 55-year-old chronic smoker, but at a 15-year-old,” he says.
He also points out that enforcement of the regulations has slackened and is weaker precisely at the points where teens are procuring the products. Even where age restrictions on sales are provided for, enforcement often proves inadequate in places such as kiosks, small shops and online sales, and through informal networks such as friends or older siblings. “Thus, although the legal framework may appear strict, in practice there remain loopholes that are exploited, resulting in a teenager being able to obtain tobacco and nicotine products relatively easily,”
In our country, the phenomenon is clearly alarming, points out Zenia Saridaki, a pathologist-oncologist and active member of the “Women in Oncology” (w4o) network. As she explains to Michalis Kefalogiannis, this “is mainly due to the fact that the new nicotine products were not presented to teenagers as something dangerous, but as something modern, ‘innocent’, easy to use and socially acceptable. Furthermore, normalisation through social media, influencers, appealing flavours, algorithmically targeted content and aggressive marketing has created an environment where addiction often masquerades as a trend. Today, young people don’t just see relevant messages. They encounter them over and over again in a digital environment that constantly replicates what seems ‘popular’, ‘harmless’ or ‘cool’ making nicotine seem part of their everyday culture.”
At the same time, access remains very easy. In Greece, more than 50% of students have already tried e-cigarettes, which shows that the use has now penetrated very strongly among school-age children.
The World Health Organization (WHO) is deeply concerned about the rapid increase in the use of e-cigarettes (nicotine or other substances) and heated tobacco products, particularly among children and adolescents. “There is already sufficient evidence to say clearly that these products are not harmless. First of all, they contain nicotine, a highly addictive substance which is of particular concern in children and adolescents because it affects the developing brain and sets the stage for addiction at a very early age. In addition to nicotine, however, in vaping products the aerosol contains other chemicals that can be toxic to health, while heavy metals, aldehydes, volatile organic compounds, nitrosamines, polycyclic aromatic hydrocarbons and other substances have been described in liquids and aerosols. The relevant literature also points out that these substances are associated with oxidative stress and an inflammatory response in the respiratory and cardiovascular systems, and some of them are proven carcinogens,” J. Breda stresses, speaking to APE-MPA.
Ms Saridaki, for her part, points out that today science can clearly say that these products have already been associated with lung damage and a risk of addiction. “But it has not yet fully captured all their long-term effects, as has happened with traditional smoking after decades of study. This is because the products, devices and their chemical compositions are constantly changing, so long-term monitoring is more difficult. At the same time, we know that many decades of follow-up are needed to fully capture their possible association with cancer, as carcinogenesis is a process that evolves over time,” he explains.
Therefore, the correct scientific message is not “we don’t know, so they may be safe”, but “we already know that they are associated with harms and risk of addiction, and for their full long-term consequences we await even more data,” he concludes.
The recommendation – he says – to everyone is clear: don’t start using these products and treat them as an innocent alternative. “For teenagers, the message should be absolute: no nicotine. For adult smokers who want to quit, the approach must be medical and organised, with medical advice and evidence-based cessation methods, not an arbitrary switch to vaping products. Based on the evidence and literature we have reviewed, vaping is not an evidence-based and reliable cessation method, and scientific bodies in the US and Europe do not recommend it as a smoking cessation tool.”
Really, how does the WHO deal with e-cigarette vaping (nicotine or other substances) and heated tobacco? Does it distinguish them from traditional smoking and what action is it taking or considering taking regarding their use, especially by young people?
“WHO recognises that these products work differently from conventional cigarettes, but the basic public health objective remains the same: to protect the health of the population and prevent addiction. Conventional cigarettes remain the most harmful, as the combustion of tobacco produces very high levels of toxic chemicals. Heated tobacco products heat the tobacco instead of burning it, but still expose users to nicotine and other harmful substances. Therefore, they are not harmless. E-cigarettes do not contain tobacco leaves, but many of them contain nicotine and other chemicals. The aerosol they produce is not just ‘water vapour’ and carries risks for both users and those in the same room,” says the WHO’s country head.
Does the WHO admit that there is a reduction in harm compared to traditional cigarettes? What are its official recommendations?
When it comes to so-called “harm reduction”, the WHO does not consider e-cigarettes or heated tobacco products to be safe alternatives, nor does it recommend them as smoking cessation tools, Mr. Breda and continues:
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“The safest option remains the complete cessation of all tobacco and nicotine products. Their use by children and adolescents, or in combination with other tobacco products, increases the risk, and the risks differ depending on the product and the user,” he explains, while referring to the WHO’s recommendations to governments, he says they are clear and inclusive: Preventing initiation of use by young people; restricting or banning flavours that appeal to children; banning advertising, promotion and sponsorship, including online marketing; strictly enforcing age limits and reducing affordability through tax and pricing measures; mandating strong health warnings; establishing product specifications and requiring disclosure of their composition and emissions; and including these products in smoke-free legislation; ostensibly
The WHO also calls on States to fully implement the WHO Framework Convention on Tobacco Control, including measures to protect public health policies from interference by the tobacco industry (Article 5.3).
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“This need becomes even more pressing when companies attempt to present new nicotine and tobacco products as “less harmful” and use this argument to influence both policymakers and public opinion. Public health policies must be based on independent scientific evidence and prioritise the prevention of youth use,”
What do the various identified data on tobacco product use among boys and girls show?
When it comes to the differences between boys and girls, caution is needed, Ms Saridaki says and explains: “We would not say that we have such simple and uniform data to speak with certainty specifically for Greece. Globally, the WHO shows that e-cigarette use among adolescents is higher among boys than girls (8.6% vs. 5.7%). But in Europe the picture is more complex: on e-cigarettes girls appear marginally higher than boys (15.% vs. 13.6%), while on conventional cigarettes the European region shows a slightly higher performance among girls (8.7% vs. 8.2%). So we are talking about a sensitive and complex issue, not a stereotype of ‘boyish’ behaviour.”
“If you were to ask us for a careful interpretation rather than an absolute scientific finding, we would say that aesthetic “normalization”, association with image, company and social identity may work more strongly in girls, while curiosity, imitation and risk testing often play a role in boys. But these are plausible social observations and not a conclusion that should be presented as an evidence-based finding specific to the Greek adolescent population,” Ms. Saridaki adds.
However, the WHO’s position is clear: legislation needs to be strengthened to protect public health – particularly of children and adolescents – and to ensure that modern products do not undermine the progress made in tobacco control.
As Mr Breda says: “A comprehensive legislative and regulatory approach is needed, focused on three key objectives: discouraging smoking initiation, reducing the attractiveness of products and limiting exposure. This includes strict restrictions on advertising, promotion and sponsorship – including online and social media promotion – restrictions on flavours and product features that appeal to young people, age limits on sales to be respected through effective enforcement and control on online sales, prominent health warnings on packaging and a ban on misleading claims, product specifications and mandatory disclosure of ingredients and He explains that pricing and taxation are equally important tools and calls on governments to work closely with the WHO.
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Many teenagers are no longer starting with traditional cigarettes, but with vaping, warns Ms Saridaki. “The data on which our campaign is based points out that many children are starting vaping without ever having smoked, and the age of first contact is decreasing alarmingly. Based on the available evidence, this behaviour does not appear to act as a safe ‘relief valve’, but often as a gateway to nicotine and then to conventional smoking. Based on what we currently know, adolescents who vape are about three times more likely to start conventional cigarettes as well. So, the dominant public message cannot be that “it is better to start by vape”. Quite the opposite: nicotine establishes dependence, changes behavior, and legitimizes a child’s relationship with an addictive product.”
Really, how can young people be convinced not to start this new habit? Is it appreciated that the best way is to talk to them in their own language?
“Yes, we strongly believe that to get the message to young people, it needs to be told in their own language, not by intimidation, not by moralising, not by didacticism. The W4O Hellas campaign itself was designed exactly on this logic: to move away from the traditional, strict, accusatory style and speak to teenagers in terms of identification, humour, image, modern cultural codes and authentic models. As we have mentioned in our campaign, it is not enough to say the right message, you have to say it in a way that is heard,” says Ms. Saridaki and continues:
“This is exactly what both of our campaign video spots serve. The first, ‘Vape is a little bit sand. You don’t!”, deconstructs the supposedly “cool” image of vaping with humor and satire. The second, “Vape is not cool. You are!”, shifts the message from satire to inspiration, with the participation of the world champions of the National Aquatics Team, so that young people can hear a message of life from people they can admire and trust. Our choice was clear: identification instead of distance, life role models instead of finger wagging, participation instead of teaching. And this is not an abstract communication idea.”
The goal, then, is not to scare children, it’s to empower them. To give them a reason to say “no”, not because someone forced it on them, but because they understand that true strength, freedom and confidence don’t need nicotine, he concludes.
What can parents, educators and society as a whole do today to protect children from this new form of addiction?
First of all, we need to understand that this new form of addiction cannot be addressed with bans alone or with informational slogans alone. We need a common attitude from parents, schools, the scientific community, the state and society as a whole,” she stresses. “Parents must talk to their children early, openly and without panic, not only when the problem appears. Teachers need to have the right tools to recognize the phenomenon and open a meaningful discussion in the school environment. We also believe that information should start as early as primary school, through activities and health education lessons that foster a solid culture of prevention in children. And society must stop treating vaping as something “small”, “harmless” or “trendy”
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Because prevention is not only a matter of individual responsibility, it is primarily a matter of public health.
From our side, at W4O Hellas, we believe that this effort must be continuous and consistent. Our campaign is not an isolated intervention, but the beginning of a broader prevention strategy that we want to develop with new awareness actions, interventions with young audiences, partnerships with scientific and social institutions and a stronger presence in places where attitudes and behaviours are formed.”
Regarding Greece and how the WHO head of office sees the actions being taken on this issue, he said: “The new package of digital tools to strengthen enforcement in Greece is of particular interest and, according to the WHO, offers significant potential for more effective implementation. The European Union has already presented an ‘age verification project’, while several Member States – including Greece – are testing digital age verification solutions linked to the future European Digital Identity Wallet. In some countries, digital age verification checks for distance sales of tobacco products and e-cigarettes are also envisaged.”
I would say, then, concludes J. Breda, that “Greece is moving in the right direction. The prospects are encouraging, but success will depend on the full and effective implementation of the measures, on how strictly infringements are dealt with and on whether it is integrated into a broader and coherent policy of tobacco and nicotine product control.”
