Tuesday, August 18, 2015

According to Campaign for Tobacco-Free Kids, New Study Suggests E-Cigs are a Gateway to Smoking

A new study published moments ago in JAMA reports the results of a one-year longitudinal follow-up study of 9th graders in Los Angeles schools who did not smoke cigarettes at baseline. Among the 9th grade students who had ever tried an electronic cigarette at baseline, the odds of progression to smoking initiation were 2.7 times higher than among students who had never tried an electronic cigarette. Importantly, the study defined smoking initiation as any cigarette use (even just a single puff).

(See: Leventhal AM, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. Published online ahead of print on August 18, 2015.)

Within hours of the release of the JAMA study, the Campaign for Tobacco-Free Kids issued a press release arguing that these data suggest e-cigarette use is "a gateway to use of other tobacco products, including regular cigarettes" and that "use of electronic cigarettes by youth who had not previously smoked could lead to use of cigarettes. ..." 

The press release closes by stating: "We cannot allow the tobacco industry to keep addicting kids and create another epidemic with a new generation of tobacco products."

The Rest of the Story

The rest of the story is that the Campaign for Tobacco-Free Kids is being too hasty in jumping on this study as providing evidence that e-cigarettes are a gateway to smoking. The study shows nothing of the sort, and the authors and commentators readily acknowledge that. Apparently, the Campaign is so anxious to demonize e-cigarettes and to support its pre-determined conclusions that it is willing to throw rigorous scientific analysis out the window when it sees an opportunity to pounce on a good headline.

There are three huge limitations of the study which make it essentially irrelevant to the question of whether e-cigarette use leads kids to start smoking. First, the study did not measure "e-cigarette use." It merely asked kids whether they had "ever" tried an e-cigarette. Kids who had ever tried an e-cigarette, even a puff, where compared with all kids who had never even puffed on an e-cigarette.

You can immediately see the problem here. Kids who would not even try an e-cigarette, despite their popularity, represent a different population than kids who would try a puff on an e-cig. Of course the subsequent smoking rates are going to be higher among the kids who were susceptible to trying the e-cigarette. There is really no news here. This is a phenomenon which has already been documented in the literature.

The second problem is that the study failed to document that any of these kids actually used e-cigarettes regularly and became addicted to them before proceeding to use real cigarettes. All the study documented is that these kids had tried e-cigarettes at least once. The study simply cannot infer that these students became regular users of e-cigarettes, that they became addicted to e-cigarettes, or even that they ever tried an e-cigarette again.

Third, the study defined smoking as any use of a cigarette, even a puff. Thus, even among the youth who supposedly initiated smoking, we don't know that they actually became smokers. They may simply have tried a puff on a cigarette and decided it was not for them. In fact, it is entirely possible that they tried a puff on a cigarette, decided that the e-cigarette was much better tasting, and that they chose to vape instead of smoke. In this way, e-cigarettes could have actually served as a deterrent to smoking among this population.

Ultimately, what this research demonstrates is that youth who experiment with electronic cigarettes represent a sub-population of youth which is at increased risk of tobacco product use. This is a natural finding that we expected to be true and which has been documented in other studies. The study does not show that e-cigarette use leads kids to start smoking or to become regular smokers. It does not demonstrate a gateway effect.

The study authors readily acknowledge this, with the lead author making it clear that: "we cannot conclude that e-cigarette use directly leads to smoking."

The accompanying editorial makes the same point, even more clearly: "Because the only outcome measure was any use of a tobacco product during the past 6 months, the analysis could not distinguish students who had just tried a few cigarettes from those who progressed to regular smoking during follow-up. The latter is the greater concern, and the current study cannot determine whether e-cigarette exposure was associated with that outcome."

Nevertheless, these cautions did not prevent the Campaign for Tobacco-Free Kids to draw its own conclusion - apparently a pre-determined one - that e-cigarettes are leading youth to try real cigarettes and to become addicted to them. Apparently, the Campaign for Tobacco-Free Kids doesn't need actual evidence to draw scientific conclusions; it just needs any potential headline that it can pounce on. That's exactly how I would describe the tobacco industry's behavior historically.

To make matters worse, the Campaign for Tobacco-Free Kids misleads the public by calling e-cigarettes "tobacco products," despite the fact that they contain no tobacco. And, it attacks the tobacco companies for addicting kids to e-cigarettes when it is not even clear whether or not any nonsmoking youth are addicted to e-cigarettes and if any are, it is not clear that any tobacco company e-cigarette brands are involved. After all, maybe it is the "gummy bear and cotton candy" brands (not manufactured by Big Tobacco) which are the ones implicated in the rapidly increasing rates of smoking that have been observed among America's youth contemporaneously with the dramatic rise in e-cigarette experimentation.

Check that. There are no rapidly increasing rates of smoking that have been observed among America's youth contemporaneously with the dramatic rise in e-cigarette experimentation. It is rapidly decreasing rates of smoking.

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