We read with great interest the research conducted by Dubé et al1 that explores the perception that teenage students have of vaping and the role that it plays in their lives. Currently, it is estimated that 14.1% of U.S. high schoolers vaped at least once in the past 30 days,2 and vaping is more common than smoking any tobacco product.3 According to NYTS data, exclusive use of tobacco cigarettes declined substantially from 2.6% to 0.8% between 2018 and 2019.4 Record-low levels of tobacco smoking prevalence based on the NHIS have been observed also among young adults from 18 to 24 years old.5 The prevalence of cigarette smoking in 2014 was 16.6%, but by 2019, it had decreased to 7.7%. This decline in smoking prevalence was even greater among high schoolers, falling from 9.2% in 2014, to 5.8% in 2019. This plummeting smoking rates among adolescents provide evidence that vaping does not act as a gateway to cigarette smoking.
As highlighted by the authors a limitation of the study is the sample size. General recommendation for in-depth interviews suggests having a sample size of 20 to 30 participants.6 The aim of a qualitative study is to ensure a large enough sample size to uncover a variety of perspectives, up to the saturation point. The authors must demonstrate that a study sample of 11 subjects is large enough to sufficiently describe the phenomenon of interest, addressing even more deeply the topic of research (in line with the principle of saturation in qualitative research).
Considering the stage of development, it is not possible to ignore a large part of the young population that wish live new experiences, in light of the fact that the growing anxiety of these individuals is frequently attenuated only or also by smoking. The key question is whether these participants have received clear information about the effects of nicotine/vaping or have been exposed solely to misinformation. This aspect is essential, because this alone may restrict the information acquired in a qualitative study of a small population of adolescent vapers recruited from just an U.S single high school with responses not generalizable to the whole population of US high school students with related false saturation effect. Consequently, any further discussion about students’ answers is potentially pretty useless.
The emphasis on the psychosocial aspects that induce vaping behavior is particularly interesting in the manuscript. The strength of the peer group and family emerges very strongly in the choices of adolescents and underlines, in line with the research of Dubé et al,1 the need to know deeply these dynamics in the world of youth. In light of these considerations, future research should examine the causal relationship between vaping and traditional smoking, in order to investigate whether adolescents would have smoked even in the absence of vaping tools. Future research also should investigate whether vaping systematically leads to the use of more harmful smoke tools or whether it remains a separate practice – preferred for example for the less perceived risks, or perhaps for the taste.1
Finally, another aspect that could be further explored is whether European adolescents also use vaping devices as a tool to manage anxiety.
Declaration of Conflicting Interests:
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: R.P. is a full tenured professor of Internal Medicine at the University of Catania (Italy) and Medical Director of the Institute for Internal Medicine and Clinical Immunology at the same University. He has received grants from U-BIOPRED and AIR-PROM, Integral Rheumatology & Immunology Specialists Network (IRIS), Foundation for a Smoke Free World, Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A/S, Sandoz, Merk Sharp & Dohme, Boehringer Ingelheim, Novartis, Arbi Group Srl., Duska Therapeutics, Forest Laboratories, Ministero dell Universita’ e della Ricerca (MUR) Bando PNRR 3277/2021 (CUP E63C22000900006) and 341/2022 (CUP E63C22002080006), funded by NextGenerationEU of the European Union (EU), and the ministerial grant PON REACT-EU 2021 GREEN- Bando 3411/2021 by Ministero dell Universita’’ e (MUR) – —PNRR EU Community. He is the founder of the Center for Tobacco Prevention and Treatment (CPCT) at the University of Catania and of the Center of Excellence for the Acceleration of Harm Reduction at the same university. He receives consultancy fees from Pfizer, Boehringer Ingel- heim, Duska Therapeutics, Forest Laboratories, CV Therapeutics, Sermo Inc., GRG Health, Clarivate Analytics, Guidepoint Expert Network, and GLG Group. He receives textbooks royalties from Elsevier. He is also involved in a patent application for ECLAT Srl. He is a pro bono scientific advisor for Lega Italiana Anti Fumo (LIAF) and the International Network of Nicotine Consumers Organizations (INNCO); and he is Chair of the European Technical Committee for Standardization on “Requirements and test methods for emissions of electronic cigarettes” (CEN/TC 437; WG4). P.C. has been affiliated to the CoEHAR since December 2019 in a pro bono role. He is co-author of 2 papers supported by an Investigator-Initiated Study award program established by Philip Morris International in 2017 and 1 paper supported by grant WS53232647 from GRAND (Global Research Award for Nicotine Dependence), an independently reviewed competitive grants program funded by Pfizer Inc (USA). All other authors have no conflict of interest to declare.