General discussion 403 12 the complexity of the world by looking at it in terms of wholes and relationships rather than splitting it down into parts”.37 Systems thinking is the logical next step in tobacco research, as concluded by the National Cancer Institute, as there is a growing macro-level focus moving from individual interventions to community level and more broad-based interventions.38 Systems thinking can contribute to better understanding and managing the complexity of tobacco use from both an epidemiological point of view as well a personal health issue. Vapes/e-cigarettes Major elephants in the room in this dissertation are vapes and/or e-cigarettes. Originally marketed as the solution to quit smoking, they are nowadays a gateway for youth to develop nicotine addiction and start smoking.39,40 In 2019, at the beginning of this dissertation, e-cigarettes seemed a relatively minor issue. As e-cigarettes do not have incomplete combustion, we could not detect changes in expired carbon monoxide among e-cigarette users and therefore excluded them from the PERSIST trial. Nowadays, with almost 22% of Dutch adolescents having tried cigarettes or vapes in the last year, vaping is a new major public health challenge.41 “Every time history repeats itself the price goes up” definitely goes for vapes. Nicotine concentrations are higher, children start younger, and we have little view on the illegal markets distributing these vapes through, for example, social media platforms. This asks for a thorough approach, such as proposed by the Nicotinee initiative, proposing to ban the sales of nicotine containing products to anyone born after January 1st 2012.42 Embedding a smoke-free generation in law is an important step for a tobacco-free future but several challenges lay ahead. While laws seem to be a way to ensure continuation, recent developments in New Zealand show that a change in governments can cause a major step back in tobacco control.43 Additionally, the UK law bans the sales of cigarettes but regarding vapes it needs to “consult on plans to reduce the appeal and availability of vapes to children”,44 despite vapes being a major issue among youth. If the tobacco industry keeps finding ways to circumvent tobacco legislation, it might be time for a nicotine free generation.
RkJQdWJsaXNoZXIy MTk4NDMw