Violence is a significant global public health concern due to its detrimental effects on both physical and mental development. During the pandemic, several countries including China, England, the United States of America, France and Brazil reported an increase in domestic and gender-based violence, especially toward women, children and adolescents (1). In five Latin American countries, including Mexico, an increase in domestic physical altercations was reported (2). Adolescents who experience violence encounter a multitude of challenges in their personal development, as well as in their interpersonal and social relationships.

Exposure to violence within the family has been demonstrated to influence in nicotine product use among adolescents (3, 4). Physical, psychological and sexual violence in the family have been associated with an elevated risk of consuming cigarettes, alcohol (5), and other psychoactive substances (6). Additional studies have found youth who experience various forms of neglect and digital violence are also more likely to use cigarettes and e-cigarettes than youth who do not have these experiences (7, 8). To date, however, no studies have identified the specific types of violence associated with e-cigarette use or “dual use” of both cigarettes and e-cigarettes.

In many countries, smoking among adolescents has declined while e-cigarette use has increased (9). The rise of youth e-cigarette poses significant public health concerns because they can adversely impact the developing brain during adolescence, a period when risk-taking behaviors are prevalent (10). Research has identified a number of risk factors for adolescent e-cigarette use, such as being male, older, belonging to a sexual or gender minority, traumatic childhood experiences, peer influence, and alcohol and other substance use (11–13). A comprehensive understanding of the risk factors for e-cigarette use can help identify targets for prevention strategies.

Of the 3,046 participants (Table 1), more than half were female (57.4%), most identified as heterosexual (64.5%), and the majority were aged between12 and 14 years (78.0%). About half (51.3%) of participants resided with both parents, 29.5% were employed, and 34.6% had low FAS. Almost half of the adolescents surveyed reported having been the target of physical violence (46.9%), with 42.6% reporting psychological violence, 34.9% neglect, 12.3% digital violence and 5.2% sexual violence (Figure 1).

This study found that experiences of violence were positively associated with exclusive use of combustible cigarettes, e-cigarettes, and dual use of both product among middle and high school students, during the COVID-19 pandemic. Experiences of physical (46.9%), psychological (42.7%), and sexual violence (5.2%) were higher than in another study of Mexican adolescents (20.3, 35.0, and 2.6%, respectively) in 2021 (32), though these differences may be due to contrasting age ranges of students (12–19 vs. 15–18) or question wording. By contrast, digital violence was higher in that other study (34.4% vs. 12.3%), perhaps because their data were collected earlier in the pandemic when students were taking classes virtually that may, in turn, have increased opportunities for exposure to online bullying (33). While previous studies have linked violence with smoking an e-cigarette use (7, 8, 34), to our knowledge, only one study in Mexico (24) has identified neglect and sexual violence associated with combustible cigarettes use, with no data e-cigarettes or dual use.

Our results indicate that adolescents who experience household physical violence were more likely to smoke, either exclusively or concomitantly with e-cigarettes (i.e., dual use). Having experienced psychological and digital violence were more strongly associated with exclusive e-cigarettes use. Additionally, dual use of combustible and e-cigarette was more prevalent among adolescents who reported experiencing four out of five types of violence: physical, neglect, digital and sexual. These finding underscore the importance of understand – and developing strategies to prevent – violent experiences, including within the family environment, as they represent stressful or traumatic precursors that seem to increase the likelihood of tobacco use (7).

Our results are generally consistent with studies of the associations between Adverse Childhood Experiences (ACEs) and cigarette use, e-cigarette use, and dual use of both products (7, 8). ACEs include physical violence, psychological violence, forms of sexual abuse and neglect, as well as living with people who have a mental illness, who suffer from substance abuse, or who are violent toward other family members (35). ACEs are also a significant factor in tobacco use-related disparities faced by sexual minority groups (34). Similarly, we found that adolescents who do not consider themselves, heterosexual are more likely to be e-cigarette and dual smokers, though not from combustion cigarettes. However, the last result may be the product of an insufficient sampling frame to identify a significant association. Future research with larger sample sizes are needed to determine whether the strength of association between experienced violence and substance use vary by sexual orientation.

Our results show that adolescents who report having suffered neglect and sexual violence are more likely to be dual users. This is consistent with a study (24) of high school students from four Mexican states that showed that males, though not females, who had suffered neglect were more likely to smoke cigarettes than those who did not. The study also measured sexual violence, finding that cigarette use is higher among adolescents who have experienced sexual violence compared to those who have not. However, the year in which this other study was conducted, e-cigarettes were not yet commercially available. To prevent substance abuse and mitigate adverse health consequences, child abuse and stress in the home likely need to be addressed.

Our results show that adolescents who are victims of digital violence – or cyberbullying – are more likely to use e-cigarettes. This may be related to the greater social media use during the pandemic. A longitudinal study (36) shows that using video calls and online shopping is related to a higher risk of starting to use e-cigarettes among adolescents, as is technophilia, whose measurement includes assessment of time spent online (21).

In Mexico, it is illegal to sell or market e-cigarettes, but it is not illegal to use them (37). Our survey revealed that a higher percentage of adolescents use e-cigarettes (8.5%) than those who smoke combustible cigarettes (3.8%). Systematic reviews and meta-analysis find that adolescents who start using e-cigarettes are four times more likely to go on to use combustible cigarettes compared to those who have not used e-cigarettes (38), although the only longitudinal study of this issue in Mexico found weaker associations than studies in other countries (39). Furthermore, Mexican adolescents who used e-cigarettes as their first nicotine product appeared to be relatively low-risk compared to those who first used cigarettes (40). This suggests that e-cigarettes help recruit people to use cigarettes (41). The government must enforce the law for tobacco control, prohibiting the sale, distribution and consumption of tobacco products, and even move toward the eliminating of flavorings in tobacco products.

Family as one of the main factors that influence health-related behaviors, such as diet, physical exercise, tobacco, and alcohol consumption (42–44). The family is also a key factor in the development of psycho-emotional protective factors. Our results show that having household rules restricting adolescent media use may protect against cigarette use, consistent with prior research on parental monitoring of adolescent behaviors (30). However, these associations were not found for adolescents who use e-cigarettes or use both products. Interpretation of these results is unclear, but it may be that specific parental rules around e-cigarettes are needed.

Our research confirms what other studies have found (21, 40, 45): adolescents from wealthier families are more likely to use e-cigarettes. This is probably because they have more access to them or the expendable income to buy them. The low cost and easy availability of cigarettes, including single cigarettes, explains the lack of association between family affluence and cigarette use.

As adolescents move through life, their decisions about smoking and using e-cigarettes are influenced more by their peers than by their parents. Our findings regarding the correlation between social and family influences among current e-cigarette users are consistent with those of previous studies (46). Current e-cigarette users and dual users are associated with having parents or friends who use e-cigarettes. However, having at least one friend who smokes increases this risk (47). Hispanic adolescents in the United States (48), have reported that e-cigarette use among their peer networks strongly influences their own decisions.

Our results suggest a need for intersectoral interventions that likely require involvement from family, school, and the community. ACEs – which include violence of all types – are undeniably associated with addictive behaviors. Friends and parents have a significant influence, and adolescents smoking is influenced by their financial resources. This knowledge must inform the development of effective tobacco prevention strategies and legislation.

In the school context, prevention and awareness strategies must involve the active participation of parents. It is vital to emphasize their importance as role models and the behaviors they could show toward tobacco in front of their children. Prevention activities and programs may need to begin in primary education, given the relatively early age at which adolescents begin to experiment with both cigarettes and e-cigarettes.