Thursday, April 16, 2015

New CDC Report on E-Cigarettes Shatters Gateway Myth, Suggests Shift from Hazardous Smoking to Much Safer Vaping among Youth

A new CDC report released moments ago and published in tomorrow's MMWR (Morbidity and Mortality Weekly Report) presents new data from the 2014 National Youth Tobacco Survey which show a tripling of past 30-day ("current") e-cigarette use from 2013 to 2014 among both high school and middle school students.

(See: Arrazola RA et al. Tobacco use among middle and high school students -- United States, 2011-2014. MMWR, Vol. 64, No. 14, April 17, 2015.)

The report shows a dramatic and statistically significant increase in current use of e-cigarettes among both high school and middle school students over the period 2011-2014. The actual data are as follows:

Current (past 30-day) E-Cigarette Use 

High school students
2011: 1.5%
2012: 2.8%
2013: 4.5%
2014: 13.4%

Middle school students
2011: 0.6%
2012: 1.1%
2013: 1.1%
2014: 3.9%

In a press release issued by CDC, the director of the FDA's Center for Tobacco Products stated: "In today’s rapidly evolving tobacco marketplace, the surge in youth use of novel products like e-cigarettes forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened."

The Rest of the Story

The CDC, FDA, and anti-smoking groups are only telling one aspect of the story. There is indeed a "rest" of the story, and here it is:
What the CDC fails to mention in its report is that these new data pretty much shatter the gateway myth that the CDC has been disseminating over the past two years.

The CDC has been telling the public that its data from the National Youth Tobacco Survey provides evidence that e-cigarettes are a gateway to cigarette smoking among youth. Remember that the CDC misrepresented cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated, in response to the 2011-2012 increase in youth e-cigarette use: "Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes." In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."

However, today's CDC report reveals that something very different appears to be occurring. It appears that rather than serving as a gateway toward cigarette smoking, e-cigarettes may actually be acting as a diversion away from cigarettes. Perhaps the most important finding of the new report is that despite the dramatic increase in e-cigarette use among youth, the prevalence of smoking among youth has fallen dramatically during the same time period.

Among high school students, while current use of e-cigarettes increased from 1.5% in 2011 to 13.4% in 2014, current use of real cigarettes declined from 15.8% to 9.2%. Moreover, the prevalence of overall tobacco use among youth has remained steady during this time period, both among high school and middle school students.

These data do not support, and in fact, help to refute the CDC's assertions that e-cigarettes are a gateway to cigarette smoking among youth. These new data are simply not consistent with such a conclusion. Moreover, the data suggest the opposite. The data suggest that overall tobacco use among youth is not changing, but the form of that use is shifting dramatically: away from combustible cigarettes and towards non-tobacco-containing and much safer electronic cigarettes.

This is actually a good thing. While we of course do not want the reduction in smoking among youth to be "offset" by increases in the use of safer products, such as e-cigarettes, because we would prefer that youth not use any form of nicotine, the reality is that the observed shift away from real tobacco cigarettes and towards the fake cigarettes is actually a positive phenomenon in terms of improving the public's health. This shift is going to result in a great reduction in disease and death down the road, because vaping is far safer than smoking.

The truth is that the increase in e-cigarette use is not "offsetting" the decline in cigarette smoking because a large component of the increase in non-cigarette tobacco products is a dramatic rise in hookah use, which among high school students increased from 4.1% in 2011 to 9.4% in 2014.

The rest of the story, then, is that what the CDC data show, but the CDC fails to acknowledge, is that overall use of tobacco among youth is stable, but the form of that use is shifting from the most hazardous type of nicotine-delivering product (real tobacco cigarettes) to less hazardous products (especially electronic cigarettes). There is no question that we need to redouble our efforts to discourage youth from all forms of tobacco and that our goal should be to reduce all tobacco use, not just cigarette use. However, that goal does not justify misrepresenting the scientific data as indicating that the rise in e-cigarette use is troubling because it is going to lead to eventual smoking addiction.

The rest of the story is that the opposite phenomenon appears to be occurring. The advent of this novel product (e-cigarettes) actually appears to be diverting youth who are at high risk of smoking away from tobacco cigarettes and towards e-cigarettes. In essence, e-cigarettes are a gateway product, but they are a gateway away from, rather than towards cigarette smoking.

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