Background:
Nicotine use represents an important modifiable cardiovascular risk factor. While the prevalence of conventional cigarette smoking among adolescents has declined in recent years, alternative nicotine products have gained increasing importance. E-cigarettes as well as oral nicotine and tobacco pouches are shaping contemporary patterns of nicotine use among young people. Despite regulatory restrictions, nicotine and tobacco pouches remain readily accessible and are increasingly used. Data on the prevalence of these products and the factors associated with their use among adolescents in Germany remain limited.
Methods:
As part of the prevention project SchoolVapeScience, a school-based cross-sectional study was conducted in 2026 at six secondary schools in the Lübeck region. A total of 958 adolescents aged 11 to 21 years participated in an anonymous digital survey. Data were collected on the use of different nicotine products, risk perception, social and familial influences, exposure to nicotine-related content on social media, and self-reported adverse effects. Group comparisons and hierarchical multivariable logistic regression analyses were performed to identify factors associated with product use.
Results:
Overall, 24.4% of adolescents reported lifetime use of e-cigarettes, 17.4% reported lifetime use of conventional cigarettes, and 9.4% reported lifetime use of nicotine and tobacco pouches. Male adolescents reported higher rates of regular nicotine and tobacco pouch use than female adolescents (p = 0.007), whereas female adolescents reported more frequent e-cigarette use (p = 0.028). Increasing age was significantly associated with higher odds of nicotine and tobacco pouch use (OR 1.66; 95% CI 1.32–2.10). The strongest association was observed for nicotine use within the social environment (OR 6.62; 95% CI 3.03–14.45). Adolescents who perceived nicotine and tobacco pouches as less harmful than cigarettes were more likely to report personal use (OR 2.17; 95% CI 1.04–4.55). Users also reported more frequent exposure to nicotine-related content on social media. Commonly reported adverse effects included oral burning sensations, dizziness, nausea, palpitations, and tachycardia.
Conclusions:
The findings indicate a shift in adolescent nicotine exposure towards alternative nicotine products. E-cigarettes have become the most commonly used nicotine product, while nearly one in ten adolescents had already experimented with nicotine and tobacco pouches despite regulatory restrictions. Social influences, reduced risk perception, and exposure to nicotine-related social media content appear to contribute substantially to the use of these products. Given the well-established cardiovascular effects of nicotine, these findings underscore the importance of early preventive interventions. Modern cardiovascular prevention strategies should address changing patterns of nicotine use among adolescents and extend beyond conventional cigarette smoking to include e-cigarettes and oral nicotine products.
