New Study Refutes Claim that Electronic Cigarettes are a Gateway to Smoking

A new study published in the American Journal of Preventive Medicine refutes the claim that electronic cigarettes are a gateway to smoking.

(See: Meier EM, Tackett AP, Miller MB, Grant DM, Wagener TL. Which nicotine products are gateways to regular use? First-tried tobacco and current use in college students. American Journal of Preventive Medicine 2015; 48(S1):S86-S93.)

The paper reports the results of an online survey of 1,304 undergraduate students at a large university in Oklahoma. The mean age of respondents was 19.6 years. Students were asked to report:

(1) the first nicotine-containing product they used (cigarettes, smokeless tobacco, electronic cigarettes, hookah, or NRT); and

(2) all of the nicotine-containing products that they current use.

Thus, the study was able to ascertain the proportion of students who had initiated nicotine use with electronic cigarettes and went on to become smokers (and remained smokers at the time of the survey).

The two most important findings of the study were as follows:

(1) Of the 1,304 students, only 3 reported having first tried electronic cigarettes and currently being a smoker. There were 59 students who had initiated with electronic cigarettes, so the proportion of these students who progressed to smoking and were currently smoking was 5.1%. In contrast, 18.6% of students who initiated nicotine use with smokeless tobacco progressed to smoking and were currently smoking.

(2) Of the 59 students who initiated nicotine use with e-cigarettes, only 1 was currently using e-cigarettes, and this student reported only occasional use of these products.

The authors conclude that: "ETPs were the first product tried by some students (n=59), 78% of whom first tried e-cigarettes. Interestingly, only one of these students was still using an ETP at the time of the study, and this was reported as occasional use of e-cigarettes. This may suggest that the uptake potential of current ETPs is limited among youth. This finding is supported by the fact that all dissolvable tobacco products have been taken off of the market by tobacco companies owing to poor uptake of these products.²⁹ Moreover, given the timing of data collection, it is likely that students who first tried e-cigarettes tried a first-generation device, which anecdotally is considered to be much less effective in delivering nicotine than newer models.³⁰ In addition, only one student who initiated with an ETP (1.7%) was a daily user of any tobacco product (i.e., conventional cigarettes), compared to the 10% and 21% of current daily tobacco users who first tried conventional cigarettes and SLT, respectively. Though this finding should be interpreted with caution, it potentially indicates that current ETPs are not necessarily strong gateways to regular tobacco use."

The Rest of the Story

This is the first study designed to actually answer the question of whether electronic cigarettes are a gateway to smoking because it is the first one to assess whether e-cigarette use preceded or followed cigarette use. It is inexplicable why some tobacco control advocates (Stan Glantz) and public health agencies (the CDC) had already concluded that e-cigarettes are a gateway to smoking in the absence of a single study that actually examined this question.

This study found only three students, in a sample of 1,300, who had initiated nicotine use with e-cigarettes and progressed to smoking. Moreover, only one of the students who initiated nicotine use with e-cigarettes was still using e-cigarettes, and only occasionally.

These findings refute the claim that electronic cigarettes are a gateway to smoking. Moreover, they suggest that the addictive potential of electronic cigarettes is quite low. The results support my contention that the public health consequences of e-cigarette experimentation among youth are not as dire as is being claimed by anti-smoking groups and health agencies. The current evidence does not support the conclusion that e-cigarette experimentation is a significant cause of nicotine addiction and subsequent uptake of smoking among youth.

There is one major caveat with this research. The sample consisted of college students and at the time many of them were in high school, e-cigarette use was not as popular. Also, most of these students probably initiated with first generation e-cigarette products, which do not deliver nicotine as effectively as more recently introduced products. Thus, to definitively answer the gateway question, we need a similar study among younger youth.

Despite this limitation, the rest of the story is that based on the current available evidence, there is no basis for concluding that e-cigarettes are a gateway to smoking. The CDC should immediately retract its claim that these products are a gateway to smoking to ensure that public policy is formulated based on science, rather than ideology.