Nicotine product use in a sample of schoolchildren in Poland

INTRODUCTION

Tobacco smoking remains the leading preventable risk factor for morbidity and mortality in Europe and beyond. Over the past few decades, there have been signi­ficant changes in the prevalence and patterns of tobacco use and tobacco control measures in many countries [1], including in Poland [2-4].
Tobacco consumption in Poland peaked in the 1980s, when prevalence of cigarette smoking was among the highest in the world [2]. However, beginning in the 1990s, a comprehensive tobacco control regime led to a steady decline in smoking rates and Poland became a model for other countries [5]. Cigarette sales in Poland decreased significantly from 100 billion sticks in the mid-1990s to 41 billion in 2015 [2], with a corresponding decline in per capita adult cigarette consumption from approximately 2,850 per year in 1999 to under 1,300 in 2015 (a drop of more than 50%) [3]. As a consequence, standardized death rates due to lung cancer among young and middle- aged men (aged 20-64 years) fell, from 62/100,000 to 38/100,000 between 2001 and 2015 [6].
However, in recent years this trend has stalled and seen new challenges. Unfortunately, since 2015, tobacco control efforts in Poland have weakened, leading to in­creasing cigarette sales. The Polish law on the protection of health against the effects of using tobacco and tobacco products, implemented in 1995, included an article requiring the development of a National Anti-tobacco Programme with annual reports to be made by the Council of Ministers and accepted by the Sejm1. Tobacco control was then one of the duties of the Chief Sanitary Inspectorate involving thousands of employees of the sanitary and epidemiological inspection. Another important article, introduced by amendment in 1999, established a fund for the implementation of the Anti-tobacco Programme in the amount of 0.5% of the excise tax collected from the sale of tobacco products. Unfortunately, realization of these all articles has been ceased [3].
Tobacco use among children and adolescents has experienced changing trends. Among 15-year-olds, daily smoking increased between 1990 and 1998 and then began to decrease, first among girls followed by boys [7]. Between 2004 and 2014, the proportion of daily smokers in all age groups decreased by half. In 2014, the proportion of daily smokers among 15-year-old children was around 10% in both genders [8]. By 2018 daily cigarette smoking among 15-year-olds further decreased to 6.5% in boys and 4.8% in girls [9]. The historical gender differences in smoking prevalence (higher among males than females) Poland have gradually diminished since the 1990s. In 2018, there was no longer any noticeable gender difference in daily smoking.
At the same time, this substantial decrease in smoking rates in children and adolescents has been accompanied by the introduction, aggressive marketing and growing popularity of electronic nicotine delivery devices (ENDS) in Poland [10, 11]. According to HBSC surveys, the proportion of current ENDS users among 15-year-olds increased from less than 20% (19.5 boys and 18.2% girls) in 2018 [9] to 31% in 2021-2022 [12].
Growing interest in ENDS has become a public health concern globally. Overall, current and ever use of ENDS has increased over the past decade but varies between countries [13]. Yoong et al. [14] showed that the pre­valence of ever use of ENDS and non-nicotine delivery devices in children and adolescents exceeded 40% in some countries, such as France, Spain, Guam, Italy, Poland and the U.S., and the prevalence of current use was over 20% in Guam, Poland, and the USA [14]. In the U.S., current e-cigarette use among youth aged 16-18 years peaked in 2019 at 30%, though it has decreased since then. In 2024, 3.5% of U.S. middle school students and 7.8% of high school students were currently using ENDS [15].
ENDS are, in various forms, non-combustible devices designed to deliver nicotine to the human body. They are distributed under various names, such as electronic cigarettes (e-cigarettes) or vaporizers. They may look like regular cigarettes, cigars or pipes, and some resemble pens or computer USB sticks. These products usually use liquids (containing nicotine, but also a flavouring composition, propylene glycol, and other ingredients) that are heated and create an aerosol for inhalation [16, 17]. Research confirms that flavour is the main reason why young people try ENDs and other nicotine and tobacco products [18, 19]. The vast majority of ENDS users, particularly among youth, use flavoured products [20, 21]. Additionally, flavourings keep young people addicted. A study by Leventhal et al. [22] showed that teen users of non-standard flavour ENDS were more likely to continue vaping and take more puffs with each ENDS use 6 months later, compared with those who used only tobacco-, mint-, menthol-, or unflavoured ENDS. Additionally, in a study of U.S. teens, 70% of participants reported that they would quit ENDS if these products were only available in tobacco flavours [23].
The category of disposable ENDS, present on the Polish market since 2018, seems to pose particular risk in Poland. According to a report by the Institute of Forecasts and Market Analysis, disposable ENDS were the fastest growing nicotine product category on the Polish market in the years 2022-2023. According to the report, real sales of disposable, flavoured ENDS in 2022 amounted to approximately 32.3 million units and tripled to approximately 99.7 million units in 2023. An attractive price (below PLN 30), a large selection of flavours (approximately 770 variants) and wide, un­controlled availability make these products easily accessible to children and adolescents [24].
Another group of nicotine products are heated tobacco products (HTPs). They are less popular than ENDS among children and adolescents and are more likely to be used by young and middle-aged adults. In the Natio­nal Youth Tobacco Survey, an annual nationally- representative, cross-sectional survey of U.S. middle and high school students, around 2% of adolescents reported current use of HTPs [25]. Even though HTPs are less commonly used compared with e-cigarettes, interest in trying these products is very high among teen smokers and is also present among teen non-smokers. A study showed that among youth never-smokers and never- vapers across multiple countries (Canada, England and the U.S.) susceptibility to trying IQOS (25.1%) was higher than for tobacco cigarettes (19.3%), but lower than for e-cigarettes (29.1%) [26].
The nicotine product market has been very dynamic in recent years and has become extremely attractive to young people, which has a decisive influence on changes in behaviours and patterns of use. Therefore, it is important to monitor patterns of use of various forms of nicotine products, particularly among youth, as well as their impact on adolescent health and brain development. Previous surveys in Poland, including the Global Youth Tobacco Survey, have not collected information across the diverse spectrum of tobacco and nicotine products (such as nicotine pouches) or detailed information on risk perceptions in relation to specific product types. The aim of this study was to assess the use and perceptions of different forms of nicotine products among adolescents aged 14-18 years in Poland.

MATERIAL AND METHODS

Data were gathered within a cross-sectional study among 3,929 schoolchildren and young adults aged 13-24 in selected schools in Poland in June 2024 using the CAWI (computer assisted web interviewing) method (via an online questionnaire distributed with a link or a QR code). The questionnaire addressed items relating use of conventional cigarettes and other tobacco pro­ducts (cigars, shisha, etc.), novel nicotine products (ENDS, heated tobacco products, nicotine pouches), as well as electronic non-nicotine delivery systems (ENNDS).
The questionnaire contained 6 to 46 closed-ended questions. The first 5 questions gathered information about respondents’ basic demographics (sex, age, level of education, means of subsistence) and the existence of any experiences with a set of tobacco and nicotine products. The more products the respondent had indicated, the more subsequent questions the questionnaire presented. The last question posed to all the respondents, regardless of their experiences with tobacco and nicotine products, asked about their awareness of the harmfulness of the products using a 5-point Likert scale. Except for one, all questions were in a single-choice format. The exception was a question about experiences with eight types of products: traditional cigarettes, disposable e-cigarettes without nicotine, disposable e-cigarettes with nicotine, reusable e-cigarettes without nicotine, reusable e-cigarettes with nicotine, heated tobacco, nicotine pouches, and other products such as cigars, cigarillos, pipes, shisha, snuff, etc. In this case, the question was in a multiple-choice format – respondents could indicate any number of products they had tried, although selecting the last possible option, “I have not tried this type of product,” would have blocked the possibility of choosing any of the others.
The survey was completely anonymous, respondents were informed and asked for consent to participate in the study. The questionnaire could be filled out only once from a given device. Until the survey was completed and the decision was made to submit the questionnaire, respondents could have returned to previously completed pages, changed their answers, and even filled out the survey partially and returned to complete it later. The study used an opportunistic approach, not probabilistic techniques determining the sample, and the questionnaires were collected intentionally (non-randomly).
The analysis in this article includes adolescent respondents of secondary schools, aged 14-18 years (M = 15.63, SD = 1.35). Those below 14 and more than 18 years of age were excluded from the analysis. Half of the participants were female (50.6%), 42.9% were male, and 207 persons declared as non-binary or refused to answer for the question. The respondents attended either primary (29.4%) or secondary schools (70.0%), while 17 persons did not reveal information about their education level (Table 1). As expected, most participants were financially dependent on their parents or guardians, fully (85.6%) and partially (6.4%), whereas 39 persons claimed being financially self-sufficient, and 219 refused to reveal their means of subsistence. We used the categories “current user” to describe people who used the products at least once in the last 30 days, and “daily user” to describe people who used the products every day in last 30 days.
The study collected 3,210 questionnaires from the 14-18 years respondents, however 29 of them had been eliminated due to inconsistencies in respondents’ answers. Hence, eventually, the number of usable questionnaires dropped to 3,181. The distribution of variables concerning behaviours for girls and boys was delivered by frequencies and proportions with 95% confidence intervals calculated using the SPSS Statistics.

RESULTS

The study results showed that more than one-third of study participants (35.3%) experimented with pro­ducts containing nicotine: 30.7% with ENDS, 24.2% with traditional cigarettes, 15.0% with HTPs, and 10.8% with nicotine pouches. One-fourth of the studied group (24.7%) experimented with products without nicotine. Sixty percent of studied children and adolescents have never tried any of these products (Table 2).
In the study, 18.1% of participants reported current use (at least once in the past 30 days) of products with nicotine and 7.0% of non-nicotine products. Around 16% of students were current users of ENDS, 12% of traditional cigarettes, 4.9% HTPs, and 4.1% nicotine pouches. Among schoolchildren taking part in the study, 6.4% declared using ENDS daily, 5.1% admitted to daily use of traditional cigarettes, 0.8% nicotine pouches, and 0.6% HTPs. Less than 2% of participants used products without nicotine in a daily manner (Table 2).
Dual use of traditional cigarettes and ENDS was also prevalent among participants, with 9.7% reporting current dual use and 3.4% daily dual use (Table 2). Indeed, current dual use of ENDS and traditional cigarettes (9.7%) was more common than single use of either product type (1.4% only cigarettes; 3.2% only ENDS). Similarly, there were more dual daily users of ENDS and cigarettes (3.4%) than those using either category alone (only cigarettes 1.4% or only ENDS 2.4%) (Table 2). Almost half (41.3%) of students who had ever used tobacco products reported initiation under the age of 14 years and 27% of them reported at least one quit attempt.
Over 9 out of 10 current users (at least once in the last 30 days) of traditional cigarettes experimented with ENDS (92.4%), and 80.5% of daily users of ENDS expe­rimented with cigarette smoking. Current use of both traditional cigarettes and ENDS was higher among girls compared with boys (13.3% vs. 11.3% for cigarettes and 17.7% vs. 14.9% for ENDS). Use of both categories also increased steadily with age, with prevalence highest among those 18 years of age. Current ciga­rette use rose from 3.9% among 14-year-olds to 25.4% among 18-year-olds and ENDS use rose from 6.1% at 14 years to 30.4% at 18 years of age. Prevalence also varied with type of education, with both cigarette smoking and ENDS use being higher among vocational (25.5% cigarettes; 20.3% ENDS) and technical (16.7% cigarettes; 17.5% ENDS) school students compared with primary or secondary school students (Table 3).
Participants were asked about the harmfulness of different types of tobacco and nicotine products. Overall, traditional cigarettes were perceived as the most harmful while heated tobacco products were in the second position. E-cigarettes with nicotine and nicotine pouches were perceived as less harmful than conventional cigarettes and HTPs. E-cigarettes without nicotine were rated lower harm than those with nicotine. Overall, schoolchildren who had no experience with using nicotine products perceived them as more harmful compared with those who had experimented with or used them.

DISCUSSION

This study provides information on patterns of use and risk perceptions across multiple categories of tobacco and nicotine products. Overall, the results indicate that experimentation and use of tobacco and nicotine products remains high among Polish youth, particularly for traditional cigarettes and ENDS. More than one-third of study participants experimented with products containing nicotine and 18.1% reported current use (at least once in the past 30 days). E-cigarettes were the most highly used product category, followed by traditional cigarettes. Dual use across product categories was also highly prevalent, and the majority of daily ENDS users (80.5%) had experimented with traditional cigarettes. Use also began early, with almost half (46%) of students reporting initiation before age 14 years. Female gender, increasing age, and being in a vocational or technical school program were associated with greater use of both traditional cigarettes and e-cigarettes.
These findings are largely consistent with results from other studies in Poland and other countries. Data from the 2022 Poland Global Youth Tobacco Survey (GYTS) reported similar values for current use of any tobacco product (17.1%) and traditional cigarettes (11.7%), but higher values for e-cigarettes (22.3%) and HTPs (10%). However, differences in the framing of questions and product descriptions as well as differences in ages of students included may have contributed to differing results. The GYTS also reported higher use of traditional cigarettes and e-cigarettes among girls compared with boys [27]. These results mark a change from an earlier 2016 GYTS survey, where current use overall was higher for both traditional cigarettes (20.5%) and e-cigarettes (26.9%) and prevalence was lower among girls compared with boys [10]. A review of ENDS use across 75 countries based on GYTS data from 2014 to 2019 placed Poland among the countries with the highest rates of ever and current e-cigarette use [28].
Dual use across product categories also represents a familiar pattern seen in other countries in Europe and beyond, where youth using e-cigarettes are more likely to also use traditional cigarettes and vice versa. This trend raises particular concern, as use of e-cigarettes and other novel tobacco and nicotine products may lead to greater uptake of traditional cigarettes among adolescents and young adults. Inconsistent regulatory policies across products categories also may contribute to greater experimentation with novel products and dual use [29, 30]. Use of HTPs and nicotine pouches tends to be lower, as shown in our results and other studies, but these products still raise concern as their use has increased over time and may also contribute to dual and multi-product use. Our findings also showed significant use for pro­ducts without nicotine. While products without nicotine do not directly pose a risk for dependence, their use may contribute to experimentation with other product categories. Additionally, these products remain poorly studied and largely unregulated, which raises the potential for other unknown health risks. GYTS and other surveys have so far lacked detail to track the full spectrum of novel product categories, especially new products are introduced. Such monitoring is important to inform public health measures.
The results of the present study showing the scale of nicotine product use in Polish youth are alarming in the context of research confirming the adverse effects of nicotine on the children’s developing brain. Even minor exposure to nicotine during the developing teenage brain can lead to long-term cognitive deficits and dysregulation of frontal cortex function [31]. Moreover, a significant association has been demonstrated between the use of nicotine vaping devices and depression [32-34], the number of suicide attempts [34], anxiety disorders and impulsive behaviors [33].
This study also assessed students’ harm perceptions of different tobacco and nicotine product types. Respondents rated traditional cigarettes and HTPs as imposing a higher level of risk compared with e-cigarettes and nicotine pouches. While e-cigarettes and other nicotine products may pose lower risk to users compared with traditional cigarettes, they are not free of risk, particularly to adolescent users, and perceptions that these products are low harm may influence patterns of use.
Notably, our findings suggest that students who are using nicotine products tend to have lower risk perceptions of these products compared with those who have not used them. Further good quality epidemiological studies of how risk perceptions impact behavior is needed here. Previous studies have demonstrated that product marketing and use of flavors, which is common in e-cigarettes and nicotine pouches, contribute to youth uptake of tobacco and nicotine products [35, 36].
One potentially encouraging finding was the high frequency of quit attempts, as almost half of respondents reported at least one prior quit attempt. This suggests that students may be open to campaigns and interventions that promote cessation. Text messaging programs targeted to adolescent e-cigarette users have shown promise for supporting cessation [37]. Additionally, a national prevention campaign was found to increase awareness and beliefs among U.S. youth about the harms of e-ciga­rette use, along with traditional cigarette smoking [38]. Understanding attitudes and perceptions of tobacco and nicotine products can inform targets and themes for prevention campaigns [39]. For example, a recent study of Polish adolescents found that a sense that health status is outside one’s control (that one’s own actions and behavior cannot impact health status) was associated with use of e-cigarettes [40]. That finding suggests that prevention and cessation campaigns could target attitudes about locus of control and health.
This study has some limitations to be noted. The schools selected for participation reflect a convenience sample and student participation in the survey was optional, so the study population is not necessarily representative of all Polish students. This survey reflects one point in time while the market for tobacco and nicotine products and related behaviors are changing over time. At the same time, however, smaller point estimate surveys can more readily respond to changing conditions in comparison with a national survey. This study provides important data points around patterns of use and risk perceptions of students across multiple tobacco and nico­tine product categories which can be further developed through future studies and larger surveys.

CONCLUSIONS

This study is innovative in providing data on patterns of use and risk perceptions of Polish students toward multiple types of tobacco and nicotine pro­ducts. The results demonstrate that use of traditional cigarettes and e-cigarettes, including dual use, continue to pose a public health threat to Polish youth, including both girls and boys. It is important to continue to monitor the spectrum of tobacco and nicotine products on the market and their use by adolescents and young adults, as well as to develop and implement interventions for prevention and cessation.

DISCLOSURE

The authors report no conflict of interest.

References