Monday, September 09, 2013

Electronic Cigarette Experimentation Increases Among Youth, But Use Among Nonsmokers Remains Low and Regular Use Rates are Still Unknown

The Centers for Disease Control and Prevention (CDC) reported last week that the prevalence of youth in grades 6-12 who have experimented with electronic cigarettes in the past month increased from 1.1% in 2011 to 2.1% in 2012. Among middle school students, the prevalence of past month use increased from 0.6% to 1.1%.  Among high school students, past-month use increased from 1.5% to 2.8%.

Based on these results, CDC Director Dr. Thomas Frieden proclaimed: "The increased use of e-cigarettes by teens is deeply troubling....Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

In response to the CDC report, Connecticut Attorney General Richard Blumenthal stated as follows: "“Electronic cigarettes as marketed today – with flavors like bubblegum and strawberry – are targeted at young people with the very clear intent of creating a new generation of smokers. Without question, tobacco companies are using the same despicable tactics with e-cigarettes that they used in previous decades with traditional cigarettes to lure youth down a path of nicotine addiction and eventual death."

Senator Markey responded: "“These e-cigarettes are a gateway to tobacco use by children and teens and should not be marketed to youth."

The Rest of the Story

The alarm calls being made by public health officials and politicians are premature. And their conclusions are unsupported by these data.

In no way do these data support the hypothesis that electronic cigarettes are a "gateway to tobacco use" by children and teens as Senator Markey claims. And there is no evidence provided that electronic cigarettes are being "targeted at young people with the very clear intent of creating a new generation of smokers" as Attorney General Blumenthal claims.

It is not at all surprising that youth smokers might experiment with electronic cigarettes. To the extent that these youth are able to switch over to electronic cigarettes, they are most likely reducing their long-term prospects of becoming cigarette smoking addicts. The danger is if nonsmoking youth start using these products and then end up becoming addicted to nicotine, causing them to transition to cigarette smoking.

But what do the CDC data tell us about whether the kids experimenting with e-cigarettes are smokers or nonsmokers?

Among youth who experimented with electronic cigarettes in 2012, the overwhelming majority - 90.6% - were smokers.Only about one in ten of the youths who experimented with electronic cigarettes were never smokers. And among the high school students who tried electronic cigarettes, only 7.2% were never smokers. Thus, it is quite clear that the overwhelming majority of the experimentation that is occurring among youth is happening among youth who already smoke cigarettes. This is not necessarily a bad thing, on its own, if it can reduce the chances of these youths becoming lifelong cigarette addicts.

The proportion of nonsmoking youth who experimented with e-cigarettes in the past 30 days remains small:
  • Overall, only 0.5% of youth were nonsmokers using e-cigarettes in the past 30 days;
  • Among middle school students, only 0.4% were nonsmokers using e-cigarettes in the past 30 days; and
  • Among high school students, only 0.5% were nonsmokers using e-cigarettes in the past 30 days.
There are three other important points that make up the rest of the story.

1. The survey measured experimentation, but not regular e-cigarette use.

It is not surprising that about 2% of youth would try electronic cigarettes. But the important issue is what percentage of these youth enjoy them enough to become regular users? The CDC survey measured past month use (which is essentially experimentation), but it did not assess daily use, or anything close to regular use. So what we end up with is a measure of experimentation, but no idea of whether youth are actually taking up this behavior and becoming regular vapers.

2. The survey found no evidence that e-cigarettes are a gateway to smoking.

In contrast to the alarming statements of the politicians and the CDC director (who was talking more like a politician), the survey provided no evidence whatsoever that electronic cigarettes are serving as a gateway to cigarette use. Not a single case was documented in which a nonsmoking youth began using electronic cigarettes, became addicted to nicotine, and then went on to become a regular cigarette smoker. So we're still in the realm of unsubstantiated claims.

3. The low rates of youth nonsmoker use of e-cigarettes in light of the high rates of experimentation with e-cigarettes among youth suggest that e-cigarettes are not currently a major problem that is creating a gateway to increased cigarette addiction.

Given that the rate of experimentation with electronic cigarettes is as high as 10% among high school students, the finding that only 0.5% of high school students are nonsmoking, current electronic cigarette users is actually somewhat reassuring. It suggests that this behavior has not caught on among nonsmokers -- at least not yet.

4. Neither this study, nor other evidence, supports the assertion that electronic cigarettes are being marketed with the intention of recruiting youth and/or creating new cigarette smokers from those youth.

It is difficult to refute a statement for which there is no evidence presented in support. Attorney General Blumenthal claims that electronic cigarettes "are targeted at young people with the very clear intent of creating a new generation of smokers." However, he provides not a shred of evidence to support this outcontention. Perhaps in political circles, that flies. But in science, it does not. I cannot make a statement like that with providing at least some supporting evidence.

In fact, the existing evidence refutes Blumenthal's contention, because the clear intention of electronic cigarette marketers is to sell as many electronic cigarettes as they can, not as many cigarettes as they can. In fact, of the more than 250 companies now on the general market, only one even sells cigarettes in the first place. Blumenthal's assertion, therefore, is not only unsubstantiated, but preposterous.

Summary

The rest of the story is that both health leaders and politicians (perhaps being one in the same) are using these data to make false and exaggerated claims that have no basis in science. There is no evidence that regular electronic cigarette use is becoming a substantial problem among youth nonsmokers and there remains no evidence that electronic cigarettes have become a gateway to cigarette addiction. These is also no evidence that these products are being marketed with the intention of turning youth into new cigarette smokers.

Nevertheless, I am in no way arguing here that regulation is not needed. Just the opposite. The FDA needs to step in and do everything it reasonably can to ensure that electronic cigarettes do not become popular among youth, and especially that they do not become a gateway to nicotine addiction and cigarette use.

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