Thursday, October 23, 2014

Unlike Data from U.S., Data on Youth Electronic Cigarette Use in Poland is Concerning

A new set of cross-sectional surveys of e-cigarette use among Polish students ages 15-19 was just published in the Journal of Adolescent Health.

(See: Goniewicz ML, et al. Rise in electronic cigarette use among adolescents in Poland. Journal of Adolescent Health 2014; 55:713-715.)

Like its U.S. counterpart (the National Youth Tobacco Survey), the survey from Poland found a dramatic increase in experimentation with electronic cigarettes during the period 2010/11 - 2013/14. Experimentation increased from 16.8% to 62.1%.

Different from the U.S. study, however, the Poland study found very high rates of current use of electronic cigarettes, which rose from 5.5% to 29.9%.

Most alarming, and completely different from results observed in the U.S., the prevalence of cigarette smoking during the study period increased substantially, rising from 23.9% to 38.0%.

The Rest of the Story

In and of itself, the increase in electronic cigarette experimentation in Poland is to be expected. However, there are two aspects of the data which are alarming.

First, not only did experimentation rise, but the rates of current use of electronic cigarettes are substantially higher than they are in the U.S. This suggests that not only are Polish youth trying these products, but the products seem to have more of a "stick" factor than they do in the U.S.

Second, and more alarming, is the finding that the dramatic increase in electronic cigarette use is occurring in the presence of a substantial increase in cigarette smoking. This is completely unlike the situation in the U.S., where the dramatic rise in experimentation with electronic cigarettes has been associated with a decline in youth smoking to its lowest level in recent history.

As the authors point, out the combination of the dramatic increase in e-cigarette experimentation, the high prevalence of current e-cigarette use, and both in the setting of a substantial increase in smoking prevalence do not appear to be consistent with the hypothesis that the use of electronic cigarettes among youth in Poland is displacing tobacco cigarettes.

Of course, this is only a cross-sectional study so it is premature to conclude that it is the electronic cigarette use that caused the observed increase in smoking. There are many other factors which could be at play. Nevertheless, these are the type of data which would cause me concern should they appear in U.S. surveys.

There are three major takeaways from this story.

First, having seen what concerning data about e-cigarette and cigarette use among youth would look like, this should be reassuring to public health advocates in the United States, where the data look very different and do not support the conclusion that e-cigarettes are serving as any sort of gateway to cigarette smoking.

Second, it may be that country-specific policies are necessary to regulate e-cigarettes, as the products being used and the use and popularity of the products may differ from country to country. A one size fits all approach may not make sense for such a complex phenomenon with an incredible diversity of types of products.

Third, comparing how different anti-smoking groups present the results of these findings along with those of the U.S. findings should be instructive in terms of identifying potential biases.

Those who report both the U.S. findings and Poland findings as demonstrating the gateway effect of youth moving from e-cigarettes to smoking (i.e., Glantz, Dutra, etc.) are clearly biased towards presenting the negative effects of e-cigarettes, rather than the truth.

Those who report both the U.S. findings and Poland findings as great news that should spare us concerns about the use of electronic cigarettes among youth are clearly biased towards electronic cigarettes and downplaying potential risks.

Those who report the U.S. findings and Poland findings differently (with the Poland findings showing reason for concern and the U.S. findings not ringing alarm bells about any significant gateway effects) are probably presenting a much more balanced and nuanced (and less biased) picture of the scientific data.

Disclosure: I have not received any funding or compensation from the tobacco, electronic cigarette, or pharmaceutical industries. However, I am seeking funding from several electronic cigarette companies to conduct a behavioral study on the effects of electronic cigarettes on smoking behavior. 

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