New tobacco and nicotine products reshape smoking habits in Lebanon

Two years ago, Ramzi, 23, swapped his three daily packs of cigarettes for 30 heated tobacco sticks a day. “It’s less harmful,” he says, convinced he has escaped the dangers of conventional smoking. Like many young people, he views e-cigarettes and heated tobacco products (HTPs) as a “safer” alternative to traditional cigarettes – a perception that remains widespread despite growing evidence that these newer tobacco/nicotine products carry health risks comparable to those associated with conventional tobacco use.

“Over the past decade, the nicotine landscape has evolved dramatically, particularly among younger generations, as smoking rates have surged worldwide following the arrival of these new products,” explains Dr. Mirna Waked, pulmonologist and chair of the Department of Internal Medicine at Saint George University Medical Center. “What is even more concerning is that these products have become a gateway to conventional smoking,” she adds.

Recent scientific research increasingly supports those concerns. Two systematic reviews examining data from Europe and North America found that young people who experiment with alternative nicotine delivery systems are roughly three to four times more likely to later begin smoking conventional cigarettes than non-users. The studies were published in BMC Public Health (O’Brien et al., 2021) and the International Journal of Environmental Research and Public Health (Dautzenberg et al., 2023).

Smoking rate doubles in seven years

Lebanon is no exception to the trend. According to the World Health Organization’s 2024 STEPS survey on noncommunicable diseases, smoking rates among adults aged 18 to 69 doubled in just seven years, rising from 38 percent in 2017 to 52.1 percent in 2024. The average age at which smokers began using tobacco was 20.2 years. More strikingly, half of smokers (50.5 percent) reported using two or more tobacco products. Manufactured cigarettes remained the most commonly used product, consumed by 60.7 percent of smokers, followed by shisha at 43.6 percent. HTPs accounted for 12 percent of use, while 1.3 percent of respondents said they actively used e-cigarettes.

The figures are particularly alarming given that the health risks remain substantial. “The main difference between conventional tobacco products and newer alternatives lies in their chemical composition, as some toxic substances are removed from the newer products,” Waked stresses.

Conventional cigarettes burn tobacco leaves at extremely high temperatures – typically between 800°C and 900°C. HTPs, by contrast, rely on electronic devices that warm real tobacco at lower temperatures, generally between 300°C and 350°C. E-cigarettes/vapes operate differently still, containing no actual tobacco. Instead, they heat a liquid solution that contains nicotine and sometimes other products and flavors to produce an inhalable vapor or aerosol at temperatures ranging from around 200°C to 250°C.

Despite these differences in mechanism, all three products contain – to varying degrees – highly toxic chemical byproducts generated during the manufacturing and processing of tobacco and nicotine liquids. These include heavy metals such as nickel and lead, found mainly in e-cigarettes and heated tobacco products, as well as formaldehyde, acetate compounds, glycerol and propylene glycol. “Glycerol has a higher viscosity than propylene glycol, which causes less irritation in the throat, hence the false perception that it is safer,” Waked notes.

High risks to health

“In the end, nothing fundamentally new has been invented. We have changed the products, but the health risks remain essentially the same,” she stresses, warning against what she describes as “misleading” studies concerning HTPs, particularly since much of the existing research on these products has been conducted by the very industries that manufacture them.

Citing a global umbrella review by Golder et al. on the health risks of vaping among young people, Waked explains that it found a 20 to 36 percent increase in the risk of developing asthma compared with non-vapers. Published in 2025 in Tobacco Control, the study also showed that “regular use of e-cigarettes is strongly associated with a higher prevalence of bronchitis and pneumonia.” It further noted that exposure to chemical substances – including flavoring agents, formaldehyde, and heavy metals released by device components – can induce oxidative stress and DNA damage.

The review also highlighted a consistent and concerning statistical association between adolescent vaping and mental health disorders, including increased suicidal thoughts and behaviors, as well as frequent headaches, migraines, and dizziness.

Aggressive marketing

A range of alarming risks that also raise questions about the enforcement of Law 174, Lebanon’s tobacco control legislation. Enacted in 2012, it prohibits the promotion, indirect advertising, and sponsorship of events by tobacco companies. Yet this trend, in turn, has been fueled in large part by the tobacco industry’s “aggressive marketing” strategies. Sweet, candy-like flavors designed to appeal to younger consumers, along with messaging portraying these products as a “safer” alternative, have helped normalize their use among adolescents and young adults.

The promotion extends well beyond traditional advertising: cafés and bars increasingly provide charging stations for HTP devices, while supermarkets and large shopping centers prominently display these products and e-cigarettes in dedicated kiosks. It also reaches users more directly, particularly through promotional emails sent by heated tobacco companies when consumers subscribe to a popular delivery app, all of this unfolding as authorities responsible for enforcing the law remain largely absent.