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E-cigarettes are “gateway devices” for smoking among young people, say researchers

BMJ 2014; 348 doi: (Published 10 March 2014) Cite this as: BMJ 2014;348:g2034
  1. Zosia Kmietowicz
  1. 1BMJ

Adolescents who use electronic cigarettes were more likely to smoke conventional cigarettes and less likely to quit smoking, a study from the United States has found, leading the researchers to conclude that the nicotine delivery devices are “unlikely to discourage conventional cigarette smoking among youths.”

The researchers from the University of California in San Francisco (UCSF) looked at the tobacco use of more than 40 000 pupils from middle and high schools across the US who completed questionnaires as part of the 2011 and 2012 National Youth Tobacco Survey.

The data, published in JAMA Pediatrics, showed that the number of adolescents who had tried e-cigarettes more than doubled in a year, from 3.1% in 2011 to 6.5% in 2012.1

Among adolescents called “experimenters” (those that had ever had a puff on a cigarette), ever having used an e-cigarette was positively associated with being an established smoker (≥100 cigarettes) (odds ratio 6.31; 95% confidence ratio 5.39 to 7.39) and with current cigarette smoking (odds ratio 5.96; 5.67 to 6.27). Currently using e-cigarettes was also positively associated with ever having smoked cigarettes (odds ratio 7.42; 5.63 to 9.79) and current cigarette smoking (odds ratio 7.88; 6.01 to 10.32).

Using e-cigarettes was also associated with heavier smoking among those young people who also smoked conventional cigarettes (P=0.003 in 2011, P=0.001 in 2012) and reduced the chances of abstaining from conventional smoking cigarettes for 30 days, six months, or a year.

The researchers said their results “suggest that e-cigarette use is aggravating rather than ameliorating the tobacco epidemic among youth.”

Lead author Lauren Dutra, a postdoctoral fellow at the UCSF Center for Tobacco Control Research and Education, said: “Despite claims that e-cigarettes are helping people quit smoking, we found that e-cigarettes were associated with more, not less, cigarette smoking among adolescents.

“E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco.”

The study’s cross-sectional nature didn’t allow the researchers to identify whether the children questioned started to use conventional cigarettes or e-cigarettes first. But the authors noted that about 20% of middle school students and about 7% of high school students who had ever used e-cigarettes had never smoked regular cigarettes­—meaning that some children are introduced to the addictive drug nicotine through e-cigarettes, they said.

Stanton Glantz, senior author of the study and professor of medicine and director of the Center for Tobacco Control Research and Education, said, “It looks to me like the wild west marketing of e-cigarettes is not only encouraging youth to smoke them, but also it is promoting regular cigarette smoking among youth.”

The results are consistent with a similar study of 75 000 Korean adolescents published last year by the same group of researchers, which also found that adolescents who used e-cigarettes were less likely to have stopped smoking conventional cigarettes.2

E-cigarettes are not regulated by the US Food and Drug Administration and are sold in flavors such as chocolate and strawberry that are banned in conventional cigarettes because of their appeal to youth.

Last week the European Union passed legislation that says e-cigarettes may be regulated as medicine items if they are marketed to help people quit smoking or as tobacco products.3

In the United Kingdom the Medicines and Healthcare Products Regulatory Agency (MHRA) has said that all e-cigarettes and other electronic products containing nicotine will be regulated as medicines from 2016 to ensure their quality.4


Cite this as: BMJ 2014;348:g2034


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