Expert Commentary

Teen vaping: Is it really a gateway to cigarette smoking?

We’ve summarized scholarship on adolescent vaping, such as work examining its prevalence and perceived risks, in this research roundup.

(Vaping360 / Flickr)

Cigarette smoking has declined among middle and high school students, dropping from 15.8 percent of high school students having reported smoking in the past month in 2011 to 7.6 percent in 2017, according to data from the U.S. Centers for Disease Control and Prevention. But overall nicotine use by teens is on the rise, thanks to the prevalence of vaping. In fact, it is so widespread that in December 2018 U.S. Surgeon General Jerome Adams declared vaping among youth an “epidemic.”

In 2018, 20.8 percent of high school students in the U.S. were current e-cigarette users – meaning they had vaped within the past 30 days, according to the CDC’s National Youth Tobacco Survey, which collects self-reported data from students nationwide. This was a vast increase from 2017, when 11.7 percent of high schoolers reported vaping.

E-cigarettes, battery-powered devices that deliver the addictive stimulant nicotine in a vaporized form, are rapidly gaining popularity with Americans under the age of 18. The widespread uptake of vaping among teens has sparked ongoing media coverage of the issue. Across the country, communities are calling for state and federal action to curb vaping among adolescents and young adults.

E-cigarette manufacturers like JUUL have faced criticism (and regulatory action) for their fruit-flavored products, which U.S. Food and Drug Administration Commissioner Scott Gottlieb views as appealing to children.

In November 2018, the FDA announced a policy framework aimed at preventing youth access to fruit-flavored tobacco products. Gottlieb argued that these products might be ushering in a new generation of people addicted to nicotine — a generation that might have otherwise abstained from the substance entirely. “The data make unmistakably clear that, if we’re to break the cycle of addiction to nicotine, preventing youth initiation on nicotine is a paramount imperative,” he said in a prepared statement announcing the initiative.

While e-cigarettes are sometimes hailed as a public health solution — a tool to help smokers quit, or a safer alternative to cigarettes — the devices don’t necessarily work as a cessation aid, and still expose users to harmful chemicals, including formaldehyde. A December 2018 advisory from the Surgeon General lists the dangers: “In addition to nicotine, the aerosol that users inhale and exhale from e-cigarettes can potentially expose both themselves and bystanders to other harmful substances, including heavy metals, volatile organic compounds, and ultrafine particles that can be inhaled deeply into the lungs.”

Moreover, adolescents who vape are more likely to smoke combustible cigarettes subsequently, as compared with peers who have never used e-cigarettes, according to a review and meta-analysis of studies that assessed the link between vaping and subsequent cigarette smoking.

We’ve summarized that paper — and other scholarship on adolescent vaping, such as work examining its prevalence and perceived risks — in this research roundup.

“Adolescent Vaping and Nicotine Use in 2017-2018 — U.S. National Estimates”
Miech, Richard; et al. New England Journal of Medicine, December 2018.  

This letter published in the New England Journal of Medicine offers recent statistics on vaping among adolescents in the U.S., collected from the University of Michigan’s Monitoring the Future, an ongoing study of American youth. The letter in NEJM looks at a nationally representative sample of 13,850 students in the eighth, 10th and 12th grades. The students answered questions about their use of tobacco products and whether they had vaped in the past 30 days.

Key findings:

  • In 2018, 20.9 percent of 12th-graders vaped nicotine, a 10 percentage-point increase from the previous year’s figure.
  • Nicotine vaping also increased among eighth-grade and 10th-grade students — from 3.5 percent to 6.1 percent of eighth-graders and 8.2 percent to 16.1 percent of 10th-graders.
  • “The overall use of nicotine with any product increased significantly [from 2017 to 2018], by 5.2 percentage points from 23.7 percent to 28.9 percent, in the sample of 12th-graders who answered questions on both vaping and use of tobacco products. This increase was driven solely by nicotine vaping, given that the use of each of the other six nicotine products declined (although not significantly).”
  • “The 1-year increases in the prevalence of nicotine vaping translate into approximately 1.3 million additional adolescents who vaped in 2018, as compared with 2017” – the largest absolute increase ever recorded by this survey in its 44 years of data collection on many substances.

“Association Between Initial Use of E-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-Analysis”
Soneji, Samir; et al. JAMA Pediatrics, August 2017.

Are e-cigarettes a gateway to combustible cigarettes? This meta-analysis reviews nine studies examining the relationship between e-cigarette use among people between the ages of 14 and 30 and subsequent cigarette smoking.

Key finding:

  • E-cigarette users were more likely to smoke cigarettes subsequently than those who never used e-cigarettes. The upshot, according to the authors: “Strong e-cigarette regulation could potentially curb use among youth and possibly limit the future population-level burden of cigarette smoking.”

“Electronic Cigarette Use and Smoking Initiation Among Youth: A Longitudinal Cohort Study”
Hammond, David; et al. Canadian Medical Association Journal, October 2017.

This study also examines whether high school students who use e-cigarettes are likely to switch over to the real thing. This study followed over 44,000 Canadian teens from 2013 to 2015 to answer the question.

Key finding:

  • E-cigarette use was strongly associated with smoking later on – both infrequently and daily.

“Querying about the Use of Specific E-Cigarette Devices May Enhance Accurate Measurement of E-Cigarette Prevalence Rates among High School Students”
Morean, Meghan E.; et al. Nicotine & Tobacco Research, November 2018.  

What’s in a name? A lot, if you’re talking about survey methodology. This study asked 1,960 students at two Connecticut high schools about “e-cigarette” use, as well as use of five different e-cigarette devices by name (including both brand name products and categories of devices). The hypothesis: “Confusion resulting from the fact that a multitude of devices (e.g., vape-pens, JUULs) fall under the umbrella term ‘e-cigarettes,’ the use of different names to refer to e-cigarettes (e.g., vapes, electronic vaping devices), and the use of different terminology to refer to e-cigarette use (e.g., ‘vaping,’ ‘JUULing’) may lead some young e-cigarette users to incorrectly indicate non-use.”

Key findings:

  • Some 31.5 percent of adolescents who said they had used a specific e-cigarette device did not report general “e-cigarette” use.
  • The authors suggest that asking high school students about specific, brand name devices could lead to more accurate assessments of e-cigarette use. Further, they suggest that questioning about general e-cigarette use “leads to an underestimation of actual use compared to assessing lifetime use of a range of different e-cigarette devices.”

“Tobacco Retail Licensing and Youth Product Use”
Astor, Roee L.; et al. Pediatrics, January 2019.

Across the United States, youth are barred from purchasing cigarettes. Local tobacco retail licensing ordinances fund compliance checks, which ensure that vendors are not selling tobacco products to minors. But enforcement and compliance varies from place to place, since some jurisdictions might not mandate a license fee, or a fee sufficient to fund enforcement efforts, in their local ordinances. This study looks at the impact of varying ordinances on e-cigarette use rates. It analyzes survey data from 2,097 11th and 12th grade students from southern California about their cigarette and alternative tobacco product use, such as vaping, by political jurisdiction, which were each assigned a letter grade for the restrictiveness of its tobacco product ordinance.

Key findings:

  • Respondents who lived in areas with the strictest ordinances were less likely to have ever smoked a cigarette and to have smoked a cigarette within the past month.
  • These respondents were also less likely to start smoking when they reached the legal age of purchase.
  • Youth in areas with stronger ordinances also were less likely to start using e-cigarettes.
  • “The results suggest that a strong local [tobacco retail licensing] ordinance that provides adequate resources to fund regular compliance checks and enforcement may result in large reductions in the use of cigarettes and may also result in reduced e-cigarette use.”

“Longitudinal Associations between Youth Tobacco and Substance Use in Waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study”
Silveira, Marushka L.; et al. Drug and Alcohol Dependence, October 2018.

This study examines associations between e-cigarette use and the use of other substances –including non-prescribed painkillers, sedatives and stimulants, as well as cocaine, heroin, inhalants, solvents and hallucinogens –among nearly 12,000 U.S. youth between the ages of 12 and 17. The study, which was conducted in two waves, first asked respondents whether they had ever used e-cigarettes. Then the researchers followed up, asking respondents about their use of other substances over the past year.

Key findings:

  • E-cigarette use was linked to subsequent substance use across all substances assessed, except for non-prescribed painkillers/sedatives. The strongest associations were for non-prescribed Ritalin/Adderall and other drugs, defined as “cocaine and other stimulants, heroin, inhalants, solvents, and hallucinogens.”
  • E-cigarette use was also associated with higher odds of alcohol use.

“Electronic Cigarette Harm and Benefit Perceptions and Use Among Youth”
Bernat, Debra; et al. American Journal of Preventive Medicine, September 2018.

This study looks at 14- to 17-year-olds’ perceptions of the harms and benefits associated with electronic cigarettes, and how these beliefs were associated with e-cigarette use. The sample included survey results from 22,884 Florida high school students.

Key findings:

  • “Less than one half of the sample reported that e-cigarettes are harmful to their health and less than two thirds reported that individuals can get addicted to e-cigarettes.”
  • E-cigarette users and youth who were susceptible to begin using e-cigarettes – that is, kids who said they intended to use e-cigarettes “soon or in the next year,” or were not sure whether or not they intended to use them — were less likely to think e-cigarettes were harmful to their health and addictive, compared with committed abstainers. E-cigarette users and susceptible respondents also were more likely to say they thought it would be easy to quit using e-cigarettes.
  • “Susceptible never users and all use groups were also more likely to perceive benefits of e-cigarette use including having more friends, looking cool or fitting in, feeling more comfortable in social situations, and stress relief compared with committed never users.”
  • In sum, teens who use e-cigarettes or are likely to use them perceive minimized harms and greater benefits of e-cigarette use compared with teens who are committed to not using them.

“Electronic Cigarette Marketing and Smoking Behaviour in Adolescence: A Cross-Sectional Study”
Hansen, Julia; et al. ERJ Open Research, October 2018.

Do e-cigarette ads work on impressionable teens? This survey of 6,902 German students looks at self-reported frequency of exposure to three ads – two of which ran on television and one that ran online — as well as use of e-cigarettes, cigarettes and hookahs.

Key findings:

  • Students who were exposed to e-cigarette ads were more likely to have used e-cigarettes, combustible cigarettes, hookahs or some combination therein within the past 30 days as well as at any point in the past.
  • Nearly 40 percent of students in the sample were exposed to e-cigarette ads.
  • Overall, 21.7 percent of students surveyed used e-cigarettes at least once in their lives and 21.8 percent used combustible cigarettes.

“E-Cigarette Openness, Curiosity, Harm Perceptions and Advertising Exposure Among U.S. Middle and High School Students”
Margolis, Katherine A.; et al. Preventive Medicine, July 2018.

This study analyzes responses from a nationally representative sample of 17,711 U.S. middle and high school students. The researchers suggest that curiosity and openness toward e-cigarettes might indicate increased likelihood of future use. Openness to e-cigarettes was gauged by responses to the questions: “Do you think you will try an electronic cigarette or e-cigarette soon?” and “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?” Curiosity to e-cigarettes was measured by responses to the question: “Have you ever been curious about using an electronic cigarette, or e-cigarette, even once or twice?” This study looks at the prevalence of these attitudes along with beliefs about the harms of e-cigarettes.

Key findings:

  • Among those who hadn’t used tobacco products, 24 percent were open to using e-cigarettes and 25 percent were curious.
  • Those who thought e-cigarettes cause a lot of harm were less likely to be open and curious about e-cigarettes.
  • Adolescents who had high levels of exposure to e-cigarette advertising in stores were more likely to be open to and curious about e-cigarettes, compared to those who were not highly exposed.

“Adolescents’ and Young Adults’ Use and Perceptions of Pod-Based Electronic Cigarettes”
McKelvey, Karma; et al. JAMA Network Open, October 2018.

This study surveys 445 adolescents attending racially and socioeconomically diverse high schools across California to get a sense of the popularity of pod-based electronic cigarettes. “Unlike other types of e-cigarettes that require users to add e-liquid, purchased separately, to the reservoir of the device, pod-based e-cigarettes use USB-shaped prefilled pods,” the authors write. Pod-based electronic cigarettes were introduced to the market in June 2015 by JUUL and quickly became popular with adolescents and young adults.

Key findings:

  • At some point in their lives, 15.6 percent of respondents used pod-based e-cigarettes (e.g., JUUL e-cigarettes). The average number of days they had used pod-based e-cigarettes in the past week was 1.5.
  • General e-cigarette use was higher — 30.4 percent of students said they had used them at some point.
  • Nearly one-quarter of respondents — 24.3 percent — said they had smoked combustible cigarettes.
  • Respondents were slightly more likely to have used fruit-flavored e-liquid for their first use of pod-based cigarettes (27.9 percent) compared with mint-flavored e-liquid (26.5 percent).

“Heated Tobacco Products Likely Appeal to Adolescents and Young Adults”
McKelvey, Karma; et al. Tobacco Control, November 2018.

Researchers examined data that one of the largest tobacco companies in the world, Philip Morris International (PMI), submitted in an application to the U.S. Food and Drug Administration for a heated tobacco product (“tobacco products that produce aerosols containing nicotine and other chemicals, which are inhaled by users, through the mouth”). While the application intended to demonstrate that the product would not appeal to adolescents and young adults, the researchers scrutinized PMI’s methodology and claims. They were concerned specifically with Philip Morris’s data on the appeal of their proposed product toward youth. Would it entice them to begin smoking? Would children understand the associated risks?

Key findings:

  • The tobacco company’s independently conducted research failed to prove that youth would not find their heated tobacco product appealing and would not view these products as risk-free.
  • “Further, PMI did not refer to independent studies conducted among adolescents which could influence their conclusions. Finally, their studies suffered from design and implementation flaws and cannot be relied on to support the proffered claims.”
  • The authors conclude that PMI’s data, along with research from other studies, indicate that new tobacco products might appeal to adolescents and young adults, which could result in their use, as well as the use of other tobacco products.


This photo, taken by Vaping360 and obtained from Flickr, is being used under a Creative Commons license. No changes were made.

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