Our cross-sectional survey, based on a large representative sample of Italian adults, found that the prevalence of regular e-cigarette and HTP users rose following imposition of the first lockdown, by roughly 20% and 40%, respectively. A non-negligible number of Italian adults started using these novel (tobacco) products during the stay-at-home order. These were more frequently young adults, men, and those with certain addictive behaviours and mental health symptoms before lockdown.

Our findings are in line with another Italian survey among 1825 adults, which showed a slight increase in daily consumption among vapers during the lockdown¹¹, although it should be borne in mind that the survey, which did not claim to be representative, was presented on the website of an organisation that has long promoted e-cigarettes, while one of the authors has close links to the tobacco industry¹⁷. Our findings are also consistent with evidence on adults from other countries—mainly from the USA and the UK. In general, the majority of adolescents or young adults reported less e-cigarette use during the stay-at-home order ^9,18–20 whereas the majority of older adults reported moderate to large increases^8,10,21,22.

Whereas the number of regular users largely increased, the prevalence of occasional users did not substantially change. This is likely due to the fewer opportunities during the pandemic to be involved in social events that might favour a sporadic use of these products. New e-cigarette users were not more frequently smokers of conventional cigarettes, and new HTP users were even more often never than current smokers. Once addicted to nicotine, these subjects often switch to conventional cigarette smoking, as shown in the few available longitudinal studies^23,24.

Conversely, new users were more frequently people—mostly young men—with specific addictive behaviours that were inaccessible in Italy during the strictest phases of the lockdown, such as some types of gambling²⁵, or that were unlikely to be acceptable to family members at home, such as cannabis use. This suggests that young adults, unable to satisfy certain addictions during the lockdown, might have attempted to compensate with these novel (tobacco) products. Our findings also point to the worrying link between cannabis and e-cigarette use reported in at least one study on US adolescents²⁶.

New users were also more likely to report anxiety symptoms, and might have been encouraged to engage in e-cigarette use by stress and tension accentuated by the pandemic and lockdown⁴. In fact, an observational study showed that Twitter users who tweeted about e-cigarettes had more concerns than others about the pandemic²⁷.

This first representative survey shows in only two to three months a substantial increase in the prevalence of use of e-cigarettes and HTPs likely due to the lockdown in Italy. According to the last report on global tobacco epidemic of the WHO, the observed trends are worrying from a public health perspective²⁸. However, it is unclear whether the changes and trends observed in terms of novel (tobacco) product use will persist over time or they represent only the result of an extraordinary event. Therefore, future longitudinal studies are required to elucidate the issue. We found that in Italy, novel (tobacco) products rather than acting as smoking cessation tools for hardcore smokers, served more as socially acceptable opportunities for young never smokers and, in general, for people already dependent to other less socially acceptable addictive behaviors, who found themselves unable to engage in those habits during the stay-at-home order. Data show that addictive behaviors are closely related and therefore all the supporting programs for people with selected addictions should take into account the inter-relationship between such addictions and act in a joint way to avoid poly-dependence. In addition, in this critical period, psychological support is needed, not only for the mental well-being of people, but to avoid the onset of new addictive behaviors.