Trends in waterpipe and e-cigarette use among young people in the European Union, 2012–2023: a repeated cross-sectional study

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Background: Alternative tobacco and nicotine-containing products can challenge progress in tobacco control. Waterpipes and e-cigarettes gained popularity among youth at different times, driven by flavours, social influence, and perceived reduced harm. This study examined trends in waterpipe and e-cigarette use among youth in the European Union (EU) from 2012 to 2023. Methods: We analysed data from five waves (2012-2023) of the Special Eurobarometer surveys in 26 EU Member States (N = 20,466; ages 15-30). Multilevel Poisson models assessed trends by sociodemographic subgroups, adjusting for country-level factors. Adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) are reported. Findings: From 2012 to 2023, ever waterpipe use fell from 31.2% (95% CI: 29.1-33.3%) to 14.9% (13.2-16.8%), and current use (since 2017) from 2.5% (1.8-3.5%) to 1.8% (1.2-2.7%). Ever e-cigarette use rose from 12.2% (10.8-13.8%) to 25.8% (23.7-28.2%), and current use from 1.6% (1.1-2.3%) to 5.3% (4.0-6.8%), with cross-country variation. Compared with 2017, ever waterpipe use was lower in 2023 (aPR: 0.52, 95%CI: 0.42-0.66). Ever e-cigarette use was lower in 2012 (0.47; 0.40-0.54) and 2014 (0.75; 0.67-0.84). Current waterpipe use increased in 2020 (1.96; 1.16-3.28) then declined, while current e-cigarette use rose in 2020 (1.64; 1.15-2.34) and 2023 (4.27; 2.73-6.67). By 2023, ever waterpipe use was lower across all subgroups despite earlier heterogeneity, whereas ever e-cigarette use was higher among women (1.41; 1.18-1.69), urban residents (1.27; 1.11-1.46), and those without financial difficulties (1.38; 1.20-1.60). Current e-cigarette use was also higher across all groups. Interpretation: Declining waterpipe use and rising e-cigarette use among young Europeans show divergent patterns and differences across sociodemographic groups, particularly among women and socioeconomically disadvantaged groups. Continued surveillance and targeted interventions are needed to address emerging vulnerabilities in high-risk populations. Funding: European Union's Horizon 2020.

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