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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Monday, July 11, 2016
Monday, June 13, 2016
New Pediatrics Study Provides Absolutely No Evidence that E-Cigarettes are a Gateway to Smoking
A new study published online today in the journal Pediatrics purports to show that electronic cigarettes are a gateway to smoking among youth. The study followed a sample of approximately 150 never-users of e-cigarettes and 150 ever users of e-cigarettes for one year. Both groups consisted entirely of never smokers. At one-year follow-up, the initiation of smoking was compared between the two groups. E-cigarette users were found to be six times more likely to have initiated smoking. Based on these findings, the paper concludes that e-cigarette use among youth increases the risk of progression to smoking: "These findings suggest that e-cigarette use may promote smoking during the transition to adulthood ... ."
(See: Barrington-Trimis JL, et al. E-cigarettes and future cigarette use. Pediatrics 2016; 138(1): e20160379. Published online ahead of print on June 13, 2016.)
The Rest of the Story
This study is virtually meaningless in terms of its evaluation of the “gateway” hypothesis.
Baseline e-cigarette use was defined as ever having taken even one puff of an e-cigarette. And smoking initiation was similarly defined as ever having taken even one puff of a cigarette. So the study did not document that even one subject in the study was ever a regular vaper. It is entirely possible (and in fact likely) that the majority of these kids had experimented with e-cigarettes, failed to become vapers, and then turned to regular cigarettes. In fact, it’s entirely possible that had these kids been able to stick with vaping, they would never have become smokers.
In addition, the study counted anyone who had even puffed a cigarette as being a smoker. So theoretically, a subject could have had a single puff of an e-cigarette and hated it, and then had a single puff of a cigarette and hated it, and they would be considered someone who initiated smoking because of first becoming addicted to vaping.
What the study does show, quite convincingly, is that kids who have a personality type that lends itself to experimenting with e-cigarettes are also more likely to experiment with regular cigarettes. There is no surprise here and had the researchers found anything different, one would have to question the validity of the study findings. Frankly, the study doesn’t really add any knowledge that we didn’t have already. It simply confirms what we already knew: kids who are more likely to experiment with e-cigarettes are more likely to experiment with tobacco cigarettes.
In fact, what this study is basically documenting is that having ever tried an e-cigarette is a better indicator of susceptibility to smoking than the traditional measures of smoking susceptibility. That’s really all one can conclude from the study. The key point is that the e-cigarette group consisted of youth who had ever puffed on an e-cigarette, not youth who reported being regular vapers. In order for the gateway hypothesis to be true, kids would have to become regular vapers – addicted to nicotine – and then move on to smoking. The paper provides no evidence that this is the case.
The rest of the story is that despite the way the results are being interpreted, the truth is that the study provides absolutely no evidence that electronic cigarettes are a gateway to smoking or that the use of vaping products increases rates of smoking initiation among youth. What the study demonstrates is merely that youth who experiment with e-cigarettes are more likely to experiment with cigarettes as well.
It is important to recognize that an equally plausible (and I think more likely) explanation of the results is that the ever e-cigarette using youth who progressed to smoking did so because they failed to take up vaping, rather than because they experimented with e-cigarettes. Had they become regular vapers, it is much less likely that they would have progressed to real smoking because after getting used to the sweet and tasty flavors of e-cigarettes, it is implausible that they would then become attracted to the harsh taste of real tobacco smoke.
Either way, the findings from this study do not provide any evidence to support the gateway hypothesis.
However, population-based data on trends in youth vaping and smoking released last week do provide evidence that relates to the gateway hypothesis. But those data suggest that e-cigarettes are a gateway away from smoking. In other words, as vaping has become more popular among youth, it has displaced cigarette smoking and contributed towards the de-normalization of cigarette smoking.
In fact, the strongest argument against the paper's interpretation of its findings is their inconsistency with the population-based data. If youth who experiment with e-cigarettes really were six times more likely to initiate smoking, then given the high level of experimentation, the observed rate of youth smoking would certainly be substantially higher than revealed by the Youth Risk Behavior Survey. Youth smoking rates would not have experienced a 41% decline concomitant with a 24-times increase in e-cigarette experimentation if e-cigarette use were really a substantial promoter of smoking initiation.
(See: Barrington-Trimis JL, et al. E-cigarettes and future cigarette use. Pediatrics 2016; 138(1): e20160379. Published online ahead of print on June 13, 2016.)
The Rest of the Story
This study is virtually meaningless in terms of its evaluation of the “gateway” hypothesis.
Baseline e-cigarette use was defined as ever having taken even one puff of an e-cigarette. And smoking initiation was similarly defined as ever having taken even one puff of a cigarette. So the study did not document that even one subject in the study was ever a regular vaper. It is entirely possible (and in fact likely) that the majority of these kids had experimented with e-cigarettes, failed to become vapers, and then turned to regular cigarettes. In fact, it’s entirely possible that had these kids been able to stick with vaping, they would never have become smokers.
In addition, the study counted anyone who had even puffed a cigarette as being a smoker. So theoretically, a subject could have had a single puff of an e-cigarette and hated it, and then had a single puff of a cigarette and hated it, and they would be considered someone who initiated smoking because of first becoming addicted to vaping.
What the study does show, quite convincingly, is that kids who have a personality type that lends itself to experimenting with e-cigarettes are also more likely to experiment with regular cigarettes. There is no surprise here and had the researchers found anything different, one would have to question the validity of the study findings. Frankly, the study doesn’t really add any knowledge that we didn’t have already. It simply confirms what we already knew: kids who are more likely to experiment with e-cigarettes are more likely to experiment with tobacco cigarettes.
In fact, what this study is basically documenting is that having ever tried an e-cigarette is a better indicator of susceptibility to smoking than the traditional measures of smoking susceptibility. That’s really all one can conclude from the study. The key point is that the e-cigarette group consisted of youth who had ever puffed on an e-cigarette, not youth who reported being regular vapers. In order for the gateway hypothesis to be true, kids would have to become regular vapers – addicted to nicotine – and then move on to smoking. The paper provides no evidence that this is the case.
The rest of the story is that despite the way the results are being interpreted, the truth is that the study provides absolutely no evidence that electronic cigarettes are a gateway to smoking or that the use of vaping products increases rates of smoking initiation among youth. What the study demonstrates is merely that youth who experiment with e-cigarettes are more likely to experiment with cigarettes as well.
It is important to recognize that an equally plausible (and I think more likely) explanation of the results is that the ever e-cigarette using youth who progressed to smoking did so because they failed to take up vaping, rather than because they experimented with e-cigarettes. Had they become regular vapers, it is much less likely that they would have progressed to real smoking because after getting used to the sweet and tasty flavors of e-cigarettes, it is implausible that they would then become attracted to the harsh taste of real tobacco smoke.
Either way, the findings from this study do not provide any evidence to support the gateway hypothesis.
However, population-based data on trends in youth vaping and smoking released last week do provide evidence that relates to the gateway hypothesis. But those data suggest that e-cigarettes are a gateway away from smoking. In other words, as vaping has become more popular among youth, it has displaced cigarette smoking and contributed towards the de-normalization of cigarette smoking.
In fact, the strongest argument against the paper's interpretation of its findings is their inconsistency with the population-based data. If youth who experiment with e-cigarettes really were six times more likely to initiate smoking, then given the high level of experimentation, the observed rate of youth smoking would certainly be substantially higher than revealed by the Youth Risk Behavior Survey. Youth smoking rates would not have experienced a 41% decline concomitant with a 24-times increase in e-cigarette experimentation if e-cigarette use were really a substantial promoter of smoking initiation.
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