E-cigarettes may lead to tobacco use among teens

Can the recreational use of e-cigarettes among young people lead to the use of traditional cigarettes and other tobacco products? A new report says yes.

According to a study funded by the National Institutes of Health (NIH), ninth-grade students who have used e-cigarettes are more likely than others in their age group to start smoking traditional cigarettes, cigars or hookah within the year.

“We’re seeing that young people and teenagers are now using e-cigarettes for recreational purposes—teens that were never really smokers,” says Adam Leventhal, associate professor of preventive medicine and psychology at the University of Southern California, and lead author on the study, “While previous studies have surveyed teens at a single point in time and show that those who use e-cigarettes are more likely to smoke regular cigarettes or one of the other combustible tobacco products and vice versa, it was difficult to determine which came first.”

Published in JAMA, the observational study followed 2,530 ninth graders from 10 public high schools in Los Angeles for 12 months, comparing tobacco use initiation among the 222 students who had used e-cigarettes but not combustible tobacco products with the other 2,308 students who had used neither e-cigarettes nor combustible tobacco products. After 6 months, combustible tobacco product use was more frequent among the e-cigarette users (30.7 percent) than non-users (8.1 percent). After 12 months, leading into the start of 10th grade, 25.2 percent of e-cigarette users had used combustible tobacco products, compared to just 9.3 percent of nonusers, showing that e-cigarette use was associated with a greater likelihood of use of combustible tobacco products.

Because e-cigarettes have traditionally served to help established smokers cut down or quit with a tobacco substitute, what motivated the study was the increased popularity of e-cigarettes and the diversity of its users over the past few years.  

“While the results could’ve gone a number of different ways, with one possibility being that the e-cigarettes were a diversion that could’ve actually prevented teens from experimenting with smokeable tobacco products, we found the opposite, and the implications of that are pretty important,” Leventhal adds. 

Leventhal and the other authors recommend further studies be carried out to determine whether the observed link between e-cigarettes and smoking initiation is causal or associated with an increased risk of ongoing frequent combustible tobacco use. However, he says the data still raise concerns. 

“Nicotine is addictive in any type of format it comes in, and recreational use of psychoactive substances, including nicotine, should be avoided among young people,” Leventhal says. “If this link is established and it’s extended to other outcomes besides just experimentation to full-blown smoking, then of course that could have really important downstream effects on public health where e-cigarettes play a role in new generations of smokers and increase the risk of smoking-related illnesses that we’re trying to prevent.” 

Leventhal says it’s important to educate young people and their parents on the effects of e-cigarettes so that transition never happens. Clinicians and community entities that play important roles in the lives of young people—schools, for example—can play a part in developing scientifically backed e-cigarette educational programs, which he says don’t currently exist.

“It’s not just about the harms of e-cigarettes—people need to know what they’re ingesting. People don’t know what’s in the e-cigarette solution that they’re using,” Leventhal says, adding that the field is seeing similar confusion with hookah among young people who don’t even know that it’s tobacco-based.