E-cigarettes serve as gateway to smoking for teens, young adults

The results, published online and scheduled for the November print issue of JAMA Pediatrics, are particularly timely as the U.S. Food and Drug Administration considers how to regulate e-cigarettes, which are easier for adolescents to purchase and, in many respects, more attractive to young people than traditional cigarettes.

"E-cigarettes are not subject to many laws that regulate traditional cigarettes, such as age limits on sales, taxation and labeling requirements. They also come in youth-oriented flavorings that laws have limited in traditional cigarettes, such as apple bubble gum and chocolate candy cane," said lead author Brian A. Primack, M.D., Ph.D., director of CRMTH and assistant vice chancellor for health and society in Pitt's Schools of the Health Sciences.

James D. Sargent, M.D., professor of pediatrics at Dartmouth's Geisel School of Medicine and senior author on the study, adds that "It also is notable that electronic cigarettes are marketed on television. This represents the first time in more than 40 years that a smoking-related device has been advertised on this medium, which has tremendous reach and could drive appeal of these products among youth."

For the current publication, the research team analyzed data on a national sample of nearly 700 16- to 26-year-old nonsmokers surveyed in 2012 and again in 2013 through the Dartmouth Media, Advertising, and Health Study. All participants were considered "non-susceptible" to initiating traditional cigarette smoking at the beginning of the study, because they had responded "definitely no" when asked if they would try a cigarette offered by a friend or believed they would smoke a cigarette within the next year.

By the next year, 38 percent of the baseline e-cigarette users had initiated traditional cigarette smoking. In comparison, only 10 percent of the youths who were not baseline e-cigarette users started smoking traditional cigarettes.

"These differences remained statistically significant and robust even when we controlled for multiple known risk factors for initiating cigarette smoking, such as age, sex, race, ethnicity, socioeconomic status, sensation seeking, parental smoking and friend smoking," Dr. Primack said.

In the manuscript, Drs. Primack and Sargent, and their team, theorize why e-cigarette smoking may serve as a gateway to traditional cigarette smoking, including:

• E-cigarettes deliver nicotine more slowly than traditional cigarettes, allowing a new user to advance to cigarette smoking as he or she becomes tolerant of nicotine side effects.
• Unlike other forms of nicotine, such as smokeless tobacco, e-cigarettes are designed to mimic the behavioral and sensory act of cigarette smoking, allowing the user to become accustomed to the act of smoking.
• E-cigarettes are not subject to the same regulations as traditional cigarettes, potentially renormalizing the act of smoking after decades of public health efforts to shift public norms around smoking.

Regulating e-cigarettes is particularly controversial because they are sometimes used as harm reduction tools by established smokers.

"However, recent data suggest that more youth than ever are using e-cigarettes and that as many half of these adolescents are not smoking traditional cigarettes," Dr. Sargent said. "Therefore, it is important to continue surveillance of both e-cigarettes and tobacco products among young people so policymakers can establish research-informed regulations to help prevent e-cigarettes from becoming gateway products on the road to youth smoking."