Unravelling the Persistence of Adolescent Smoking: The Paradox and the Philippine Distinction

Despite decades of health education campaigns, adolescent smoking and vaping persist worldwide, revealing a paradox in which awareness of harm does not reliably prevent use. Between 2021 and 2025, global surveys showed declining cigarette smoking but sustained or rising e-cigarette use, even among youth highly knowledgeable about nicotine’s risks. The tobacco landscape adolescents encounter is no longer limited to combustible cigarettes. Novel nicotine and tobacco products—most notably electronic nicotine delivery systems (ENDS) (e-cigarettes/vapes), heated tobacco products (HTPs), and nicotine pouches—have diversified points of access, product appeal, and perceived harm profiles, complicating prevention efforts and surveillance. This commentary examines the mechanisms underpinning the awareness–behaviour gap, highlighting adolescents’ developmental vulnerabilities, peer influence, industry marketing strategies, and weak policy enforcement. The paradox is especially visible in the Philippines, where adolescents demonstrate some of the highest levels of awareness internationally yet report strikingly high rates of experimentation and dual use. Factors unique to the Philippine context—including widespread household and school exposure, peer-driven norms, regulatory turbulence, and aggressive marketing—neutralise the protective effects of awareness. The enactment of the 2022 “Vape Law,” which reduced the minimum age of purchase from 21 to 18 and shifted regulatory oversight from the Food and Drug Administration to the Department of Trade and Industry, created an impression of leniency and weakened the deterrent effects of public health campaigns. Addressing this paradox requires moving beyond knowledge-based interventions to structural reforms such as age restrictions, flavour bans, and enforcement mechanisms that restrict access, reshape social environments, and disrupt tobacco industry strategies. Awareness is necessary, but without systemic change, it remains insufficient to reduce adolescent tobacco use.