Use of e-cigarettes, alternative tobacco products may lead to increased tobacco use

"Alternative tobacco products represent a new challenge in the 75-year-old war against tobacco," says commentary co-author Michael Weitzman, MD, a professor of Pediatrics and of Environmental Medicine at NYU Langone. "With the increasing numbers of young adults using alternative tobacco products, we have every reason to be concerned."

In "Alternative Tobacco Products as a Second Front in the War on Tobacco," Dr. Weitzman and Stephen M. Amrock, MD, a former NYU Langone medical student who is now an intern in internal medicine at the University of Oregon, highlight research on the use of alternative tobacco products by young adults published earlier this year in JAMA Pediatrics by Brian A. Primack, MD, PhD, and colleagues at the University of Pittsburgh School of Medicine. That paper reported the results of a longitudinal study of 1596 young adults ranging in age from 15 to 23, including 1048 who had never smoked prior to the study. The study authors showed that use of water pipes, also known as hookahs, and other alternative tobacco products is associated with a 2.5 times increase in later cigarette use.

"The findings in the JAMA Pediatrics paper corroborate what many of us in the public health field are tremendously worried about," says Dr. Weitzman.

Public health specialists consider cigarette smoking to be a pediatric disease since nine out of 10 adult smokers started smoking as children. Although cigarette use overall has decreased by 33 percent in the past decade in the United States, the use of alternative tobacco products such as hookahs has increased an alarming 123 percent, with nearly 20 percent of high school seniors smoking hookahs. Dr. Weitzman says this increase can be attributed, in part, to a general unawareness of the dangers of alternative tobacco products by the public, the medical community, and the media.

There is a misperception that alternative tobacco products are safer than cigarettes, but the evidence says otherwise. "Other researchers have demonstrated that a typical 45 minute hookah session is equivalent to smoking as many as five packs of cigarettes," Dr. Weitzman says. In a study published last year in the journal Tobacco Control, Dr. Weitzman and colleagues discovered potentially hazardous levels of second hand smoke and other air pollutants, as well as evidence of nicotine, in New York City hookah bars. And water pipes in particular, Dr. Weitzman says, "are a terrible mechanism for spreading infectious diseases."

The increasing popularity of alternative tobacco products threatens to undermine the gains seen in the last several years with the decline in cigarette use. The U.S. Food and Drug Administration proposes extending its tobacco authority to additional tobacco products, including e-cigarettes and hookahs, not already under the FDA's authority. Dr. Weitzman argues that the same tactics used to decrease cigarette smoking in the United States--taxation, education, and restrictions on advertising and sales to minors--need to be applied to alternative tobacco products. And, he says, more research needs to be done to determine what is being burned and inhaled with these products.

"Nicotine is the most addictive substance," Dr. Weitzman says. "The use of alternative tobacco products by children can be the beginning of an addiction that can lead to later cigarette use. Tobacco use is the leading preventable cause of death worldwide, causing more deaths than HIV, tuberculosis and malaria combined."