Monday, July 11, 2016

Findings from New Pediatrics Study are Not Relevant to Overall U.S.

A new study published today in the journal Pediatrics concludes that overall nicotine product use among youth is increasing and that many youth who would not otherwise have used a nicotine product are doing so because of e-cigarettes.

(See: Barrington-Trimis JL, et al. E-cigarettes, cigarettes, and the prevalence of adolescent tobacco use. Pediatrics 2016; 138(2):e2015983.)

The study reports the prevalence of current cigarette smoking and e-cigarette use among a cohort of youth reaching 11th and 12th grade, after having been followed for a period of two to 12 years. The youth sample was drawn from schools in 12 southern California communities. Based on the finding that the combined use of cigarettes and/or e-cigarettes increased from 2004 to 2014, the authors conclude that overall nicotine use among youth is increasing due to e-cigarettes, meaning that many youth who would not have smoked cigarettes are becoming vapers.

Specifically, cigarette smoking among high school seniors at these schools dropped from 9.0% in 2004 to 7.8% in 2014, e-cigarette use increased from 0% in 2004 to 9.8% in 2014, and the combined use of cigarettes and e-cigarettes rose from 9.0% in 2004 to 13.7% in 2014.

The Rest of the Story

The most important thing for readers to understand is that this study pertains to 12 specific schools in southern California, so the results cannot be generalized to the overall United States. In fact, comparable data from the national Monitoring the Future survey refute the findings in this paper. On a national level, there was a HUGE decline in current smoking among high school seniors from 2004-2014, which was accompanied by a large increase in e-cigarette use, such that the overall use of nicotine products among these youth did not change much. Nationally, overall nicotine use has remained about the same, but the profile of that use has changed, with a shift from combustible tobacco products (tobacco cigarettes) to electronic (non-tobacco cigarettes).

Further, the data from California is not comparable to the overall U.S. because the youth smoking trends in California are vastly different than in the rest of the nation. For example, while the reported smoking prevalence for high school seniors in this article for 2004 is just 9%, the Monitoring the Future study for 2004 reports current smoking prevalence for high school seniors nationally of 25%. This is a drastic difference. While youth smoking prevalence in the overall U.S. declined markedly in the past decade, this paper found very little decrease (from 9% to 8%). Clearly, what happened in California is atypical so it is important not to draw generalized conclusions from this study for the national situation.

It is also important to point out that the survey in this study did NOT ask youth whether or not they were actually using e-cigarettes with nicotine. The Monitoring the Future study reported that about 60% of youth vapers use e-cigarettes without nicotine (they only contain flavorings). Therefore, it is still possible that overall nicotine use among these California youth did not go up (since the majority of the youth e-cigarette users may not have been using nicotine-containing e-cigarettes).

It is also important to recognize that this study is defining “current” e-cigarette use as any use within the past 30 days. This should not be equated with “regular” e-cigarette use, or with a youth being a “vaper.” It is very possible that many of these youth are using e-cigarettes in an experimental fashion, at parties, on an occasional basis, but that they are not becoming addicted to nicotine or using the product frequently enough to experience any adverse health effects.

Finally, even if it is true that among this specific population, the overall use of nicotine has increased, that is not necessarily a bad thing for the overall public health. We do not know whether e-cigarette use among youth has any significant adverse health impact, so it is possible that the benefits from the observed decline in cigarette smoking far outweigh minor risks associated with the use of non-tobacco vaping products.

Taken as a whole, this study does not change my overall assessment that nationally, the benefits from the huge observed decline in cigarette smoking among youth far outweigh the minor risks associated with youth vaping. Moreover, it does not change the important fact that nationally, the drastic increase in youth use of e-cigarettes has been associated with a dramatic decline in cigarette smoking, which argues against the hypothesis that e-cigarettes are a gateway to smoking and strongly suggests that these products may actually be deterring youth from smoking by serving as a more popular alternative to smoking.

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