India stands at a critical demographic crossroads. With the largest youth population in the world, the nation’s strength lies in the health and productivity of its young citizens. Yet, this very asset is increasingly at risk. Over the past decade, there has been a troubling rise in nicotine use among adolescents and young adults, driven not only by conventional tobacco products such as cigarettes and smokeless tobacco but also by newer and misleadingly marketed products like e-cigarettes and vaping devices.
The recent clarification by AIIMS New Delhi against deceptive e-cigarette marketing comes at a crucial juncture when the tobacco industry’s latest strategy attempts to undermine decades of tobacco control progress in India. As mounting scientific evidence exposes the severe health risks of Electronic Nicotine Delivery Systems (ENDS), India must not only maintain but significantly strengthen enforcement of the Prohibition of Electronic Cigarettes Act (PECA) 2019.
The science is clear: ENDS are not safe
A comprehensive 2025 systematic review analysing 40 clinical trials on heated tobacco products — closely related to e-cigarettes — revealed damning evidence against industry safety claims, refuting the “95 per cent safer” myth propagated by tobacco companies.
Even more alarming is breakthrough cancer research published in the Journal of Cancer Biology that conclusively establishes that e-cigarettes cause DNA damage, inhibit repair mechanisms, and promote cancer development.
The youth epidemic India avoided
India’s prescient ban in 2019 protected the world’s largest youth population from a devastating epidemic of nicotine addiction. Brazil, a fellow BRICS country, banned ENDS in 2009. Research published in 2024 involving 39,214 young people aged 16-19 years across Canada, England, and the US found clear associations between vaping and respiratory symptoms. Alarmingly, adolescents globally are more than twice as likely as adults to use these products.
The tobacco industry’s deception runs deeper. STOP, a global tobacco watchdog, revealed that only 10 of 49 clinical trials on these products were truly independent. The industry has systematically manipulated science, with some companies specifically targeting non-smokers during festivals, events, sports tournaments, social media and publications popular with young people, despite public claims of targeting adult smokers only.
The engineered addiction
Modern e-cigarettes deliver addiction more efficiently than traditional cigarettes. Nicotine salts allow higher concentrations with reduced throat irritation, enabling deeper inhalation and faster brain delivery. US data shows disposable e-cigarettes now contain nine times more nicotine than pre-filled cartridges, while prices have dropped dramatically, a deliberate strategy to hook young users.
Further, certain flavours — particularly fruit and “multiple” flavours — were found to be significantly associated with adverse health outcomes. The tobacco and vaping industry has weaponised both chemistry and marketing to engineer what can only be described as “super-addiction” among adolescents. Nicotine also serves as a gateway to other forms of substance dependence.
Cardiovascular catastrophe in waiting
For India, already battling a heavy burden of cardiovascular disease, widespread nicotine exposure would be catastrophic. Evidence shows that e-cigarette use is directly linked to heightened cardiovascular risks, including a 56 per cent increase in heart attack risk and a 30 per cent increase in stroke risk. Nicotine accelerates cardiovascular damage by raising heart rate and blood pressure, triggering arrhythmias, inducing oxidative stress, causing rapid endothelial dysfunction, increasing inflammation, and accelerating atherosclerosis— effects that manifest within weeks, not years.
With India’s rising prevalence of diabetes and hypertension, the introduction of population-level nicotine exposure through e-cigarettes would exponentially compound existing health challenges.
Environmental crisis and public safety threats
ENDS also pose severe environmental and safety challenges. The number of devices discarded in 2022 raised critical alerts in the UK and other European countries, with several countries now considering bans on single-use disposable devices. These products generate tons of electronic waste containing lithium and copper from batteries, while residual e-liquids constitute toxic waste requiring specialised disposal.
The environmental hazards extend beyond waste management. Incidents related to the explosion of ENDS devices have been reported globally. The combination of lithium batteries, heating elements, and chemical liquids creates inherent risks of device malfunction, fire, and explosion — dangers that multiply when these products become widely available to inexperienced users.
For India, already grappling with electronic waste management challenges and environmental sustainability goals, the introduction of millions of disposable vaping devices would create an additional environmental burden with no corresponding public-health benefit. The toxic waste generated by e-liquid residuals poses particular risks to India’s water systems and soil quality, while improper battery disposal contributes to heavy metal contamination.
Government clarity, industry resistance
Official communications from the Ministry of Health and Family Welfare in May 2019 and December 2023 explicitly prohibited healthcare professionals from conducting unauthorised research on ENDS or publishing supportive statements. The National Medical Commission reinforced these directives, emphasising that any research requires prior approval from the Directorate General of Health Services.
Yet, industry influence and campaigns continue to persist. A systematic review revealed how tobacco companies fund seemingly independent research, create front organisations, and co-opt respected institutions to legitimise their products. Recent calls for policy reconsideration exemplify these sophisticated influence operations.
Enforcement failures and solutions
Despite PECA’s comprehensive framework, e-cigarettes remain readily available through online platforms and local vendors. Young Indians continue accessing these products with alarming ease, undermining the law’s protective intent.
India must implement a multi-pronged enforcement strategy. First, expand ENDS definitions to include emerging products like synthetic nicotine devices attempting regulatory circumvention. Second, mandate internet service providers and financial institutions to flag e-cigarette transactions. Third, establish specialised enforcement units with dedicated funding and technical expertise.
International cooperation is crucial. E-cigarette manufacturers operate through complex global supply chains designed to evade national regulations. India should leverage its diplomatic influence to strengthen international treaties governing cross-border tobacco trafficking.
Defending public health
Countries with permissive e-cigarette policies now face youth epidemics far exceeding any theoretical adult smoking cessation benefits. The US Surgeon General has declared youth vaping an epidemic, while the UK, despite harm reduction rhetoric, struggles with rising adolescent usage.
India’s youth — over 600 million people under 25 — represents the world’s largest population vulnerable to nicotine addiction. The ENDS industry frequently points to countries where e-cigarettes are legally available, using them as false models to pressurise India and nations like Brazil into reversing their bans. Yet, in many of those countries — including the United States, United Kingdom, Australia, France, and New Zealand — legislation is being revisited and tightened due to the dramatic surge in vaping among youth, adolescents, and even schoolchildren.
The stakes are nothing short of generational. India has, through PECA 2019, shielded the world’s largest youth population from a new wave of nicotine addiction. Strengthening enforcement of PECA 2019 is, therefore, not merely a matter of regulatory compliance — it is a moral imperative.
Countries across the world have shown that with sustained policy, education, and community action, nicotine addiction can be curtailed. India can lead this transformation. Let us pledge that the young Indians will not be defined by the chains of addiction but by the strength of health and wellness – a vision for our Viksit Bharat.
Singh is director, National Institute of Cancer Prevention and Research (ICMR), Noida. Srinivas is director, All India Institute of Medical Sciences (AIIMS), New Delhi and Kashyap is a cardiologist, formerly at Army Hospital Research and Referral, New Delhi
For India, already battling a heavy burden of cardiovascular disease, widespread nicotine exposure would be catastrophic. Evidence shows that e-cigarette use is directly linked to heightened cardiovascular risks, including a 56 per cent increase in heart attack risk and a 30 per cent increase in stroke risk. 
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