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NOTHING has inflamed the e-cigarette debate like fears that vaping will entice young people to take up smoking. This concern has led to calls for a very precautionary and restrictive approach to their use in Australia.
However, public policy on vaping should be based on a calm assessment of the best available evidence. It should also take into account the overall public health impact of any regulatory decisions and the ethical issues involved. This article reviews the latest evidence on some of the key issues in this debate.
How common is regular vaping by teenagers?
Contrary to alarming claims, regular vaping by young people is rare and is almost exclusively confined to current or past smokers.
Most studies have inflated the prevalence among youth by defining vaping as “past 30-day use” (even a single puff), thereby ignoring the frequency of use. This misrepresents the fact that most teen vaping is experimental and short-lived. Teenagers are curious, vaping is seen as a fun thing to do and some kids try it.
However, more frequent vaping is very uncommon among teenagers. In the largest study to date of over 60 000 teenagers in the UK, only 1–3% reported regular vaping (at least weekly). Regular use by teens who had never smoked was very rare, less than 0.5%, and there was little or no evidence of progression to smoking.
In the 2014 US National Youth Tobacco Survey , past 30-day vaping was reported by 9% of 15–18 years old, most of whom were current or past smokers. Less than 0.1% of non-smokers vaped regularly (10 days or more in the past month). The majority of youth who vaped did so on only 1–5 days in the past month.
Is vaping a “gateway” to smoking?
The scientific evidence does not support or rule out the “gateway theory”; that is, that young people who would never have smoked cigarettes try vaping, become addicted and then go on to regular smoking.
Observational studies have found that some teenagers who experiment with vaping go on to smoke when followed up later. However, as experts have pointed out, cause and effect cannot be established from studies of this kind. Many other unknown and unmeasured confounders could explain the association.
Moreover, many studies equate just one puff of a cigarette in the past 30 days with regular smoking at follow-up. This exaggerates the real uptake of smoking as only a minority of teenagers who try smoking will progress to daily smoking.
A plausible alternative explanation for the link between smoking and vaping is a “common liability” for substance use. Young people who are impulsive, rebellious and sensation-seeking are more likely to try both behaviours. Furthermore, the reverse pathway is much more common. Most teens who experiment with vaping are already regular smokers.
The claim that adolescents will become addicted to nicotine from vaping and then progress to cigarettes for a bigger nicotine hit is overstated because the majority of adolescent vapers do not use nicotine. The US Monitoring the Future survey, in 2016, reported that only one in four 17–18-year-olds who vaped used nicotine. Similar low rates of nicotine use have been reported in other countries.
Vaping may also be a “reverse gateway” out of smoking, as some teens use vaping to quit smoking.
How is adolescent vaping affecting smoking rates?
The uptake of vaping in those countries that allow sales has coincided with significant falls in youth smoking rates. If vaping was attracting young people to smoke, an increase in youth smoking rates would be expected.
The Monitoring the Future survey shows that youth smoking in the US has declined faster over the past few years than at any time in the 40-year history of the survey. Youth smoking rates in England are also continuing to fall unabated.
A recent Canadian review concluded that it is likely that “vaping is replacing — rather than encouraging — the smoking of tobacco cigarettes”. It is possible that young people who experiment with vaping may otherwise have smoked if the low-risk alternative had not been available. Vaping may be more enjoyable and socially acceptable and may prevent the uptake of the more harmful behaviour. It is obviously better for young people not to use vaping devices, but vaping is preferable to smoking and is at least 95% safer.
Two large studies in the US also support the theory that vaping is a substitute for smoking. Both found that the introduction of bans on the sales of vaporisers to minors in two states was associated with a significant increase in adolescent smoking compared with states without bans. However, a third study with different methodology found the opposite effect.
Is nicotine harmful to adolescent brains?
Concerns have been raised from animal studies that nicotine may harm the developing brain in adolescence. Although this is a potential risk, it is unclear how these findings translate to humans. However, there is no evidence of any significant health harm so far.
Importantly, the great majority of vaping occurs in young people who already smoke. Any additional risk from vaping is undesirable, but it is minor in comparison to smoking.
What is the overall public health impact?
It is possible that some young people who would have never smoked will try vaping and become smokers. However, this small risk should be weighed against the much larger public health benefit of vaping as a tobacco harm reduction tool or cessation aid for adult smokers. Vaping is now the most popular quitting method in the US and UK and has been estimated to have helped millions of adult smokers to quit. Modelling studies have shown that, even when pessimistic assumptions are made about harm to youth, the overall impact of vaping on public health is likely to be large and positive.
The current crisis in tobacco control in Australia is the persistence of smoking in established adult smokers. Adult smoking rates have not declined since 2013 and two out of three continuing smokers will die prematurely of a smoking-related disease. It is cruel and arguably unethical to block adult smokers’ access to an effective harm reduction treatment on the basis of exaggerated estimates of potential harms to young people.
Australia needs a balanced regulatory policy that restricts vaping by young people while supporting its use for adult smokers who are otherwise unable to quit smoking or nicotine. The current blanket ban is driven by exaggerated fears about potential harms to adolescents and completely ignores the interests of adult smokers who want to use these products to improve their health.
Colin Mendelsohn is an associate professor in the School of Public Health and Community Medicine at the University of New South Wales.
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David Hoffman, quoting Stanton Glantz on this subject is showing just how little you know on the subject. I’m sorry to be so harsh, but the only thing that Stanton Glantz is interested in is making sure the grant dollars keep rolling in, and getting his name on as many papers as possible even if he didn’t write them. He’s a bully and the sooner tobacco controllers stop quoting him the more intelligent they will look. He looks like everyone’s favourite uncle and he has made a great career out of tobacco control, but the quit or die ideology has now run its course. Technology has changed and refusal to take an evidence based approach is killing people now, and will kill more people in the future. Eighteen thousand people a year in Australia. “Quit or Die” is not working, and it’s not ethical to continue down this road any longer. Things have changed.
The ways that gateway effect is made to appear real? Counting experimental use as regular use based on four students, counting the increase from almost no students vaping in 2011 (it wasn’t a “thing” then) to very low numbers experimenting with vaping in 2014 as a “900% increase”. That last one was the US Surgeon General. Then there’s the claims for lack of efficacy for vaping as a cessation tool, this despite the plummeting smoking rates in the US and the UK where they are even encouraging people to switch. These lies no longer stand up to any realistic scrutiny.
The lies that are being told about vaping – the gateway effect – aldehyde – claiming it is not effective… All of these have been blasted countless times by men far more intelligent than me and with no ties to the vaping industry or personal gain to be had except a wish to stop disadvantaged people dying from tobacco related disease.
I ask you: “Who is the greater fool. He who cannot understand or he who cannot make himself understood?” Believe me, we are trying very hard to be understood, and it’s very easy to understand if you approach this with an open mind rather one close-locked into a pre-determined ideology.
@Charlie McCracken Couldn’t have said it better myself. Australia needs to pull its socks up and forget its ‘we’re world leaders in tobacco control and we don’t need THR’ attitude.
David Hoffman, you seem to be guided by some of the most obstructionist views by some of the most obstructionist commentators and academics that are totally opposed to tobacco harm reduction in the world. Stanton Glantz, the mechanical engineer, is one of the most disrespected of researchers in the world, renowned for his cherry-picking biased research. The World Health Organisation is a closed-shop with no scrutiny of its abstinence-only policies and is fundamentally opposed to nicotine in any form. Others, such as Leventhal have been widely debunked. As for looking at the journalistic pursuits of old newspapers, I suggest you not believe everything you read in a paper and concentrate on actual evidence cited by those more qualified than Glantz or Chapman. The Australian Government through its Health Minister Greg Hunt and the Department of Health are complicit in the unnecessary deaths of thousands of Australian smokers by standing in the way of tobacco harm reduction for adult smokers, full stop.
@David Hoffman
Stanton Glantz is well known as an activist supported financially by the pharma and tobacco industries, his funding relies upon perpetrating the myths and lies for which he is so famous. Almost all of his work has been condemned by much more qualified and respected authorities with no conflicting interests. He has possibly done more harm to harm reduction than anyone else in the world with the possible exception of Australia’s Chapman.
The Daily Mail? You’re not from England are you… The Mail is a rag which is renowned for click bait articles and has only one objective, to sell newspapers. As far as the Mail is concerned, truth and journalistic integrity are secondary considerations.
Because e-cigarette use is growing so rapidly among a sector of society that is vulnerable to media marketing and misinformation, clarifying whether or not this is a product that benefits adolescents or harms them is crucial. Best evidence information based on systematic reviews are indeed provide contradictory information (1, 2, 3,4).
REFERENCES:
(1). Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, Yang J, Primack BA, Andrews JA, Miech RA, Spindle TR, Dick DM, Eissenberg T, Hornik RC, Dang R, Sargent JD. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis.JAMAPediatr. 2017 Aug 1;171(8):788-797. doi: 10.1001/jamapediatrics.2017.1488.
(2). Surgeon General’s report (2016) US Department of Health and Human Services. E-cigarette use among youth and young adults: A report of the Surgeon General-http://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf.
(3). World Health Organization (WHO)- Adolescent health-Available at: http://www.who.int/topics/adolescent_health/en/ Accessed Jan 22, 2018.
(4). Gottlieb S, Zeller M. A nicotine-focused framework for public health. N Engl J Med 2017 (Epub ahead of print: 16 Aug 2017).doi:10.1056/NEJMp1707409
An excellent piece relying on scientific facts rather than ideology. Our aim as doctors should be to help smokers reduce harm. This is not about tobacco companies, it is about helping smokers by allowing them access to a less harmful alternative.
I find it bizarre how a majority of those polled can believe that vaping is a ‘gateway’ drug despite the evidence, well-summarized by Dr. Mendelsohn, not showing any such thing. I find the problem analogous to the popularity of ever-increasing cigarette taxes (where smokers actually subsidize the rest of society by billions of dollars annually, above and beyond their calculated costs to others) — cognitive dissonance is powerful with people (Australian docs especially, I have found) who are instinctively paternalistic.
@David Hoffman Yet in countries where where vaping is common the smoking rates are falling at an unprecedented speed.
You mention Stanton Glantz, even he admits that vapor products are less harmful however he will never support them because he is a very misguided person that believes cessation only is the only way which otherwise known as a quit or die. Personally I feel that if people want to use nicotine via inhalation or if they cannot quit smoking at the very least products with significantly reduced risks should be available to them, even if the risk was reduced by 50% society would still benefit from them.
Quit or die is inhumane and is unethical when there is an option that could prevent deaths.
Yes David, let’s see how your preferred policy works. Vaper threatened with 2 years jail in Queensland. Do you really want to punish people who give up smoking?
https ://www.facebook.com/LegaliseVaping/videos/203953626823051/
Because e-cigarette use is growing so rapidly among a sector of society that is vulnerable to media marketing and misinformation, clarifying whether or not this is a product that benefits adolescents or harms them is crucial. Public health community can get involved and promote comprehensive prevention programs, social media campaigns, public educational awareness, as well as build solid evidence-based information on e-cigarettes, give appropriate guidance to adolescents, and encourage the public health community to provide credible research findings in a way that is accessible and understandable to adolescents and their maturity level.
Yet another unbalanced blog from Colin Mendelssohn for the vaping industry – ignoring the real-world evidence that vaping is a gateway to tobacco smoking – see Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med. 2016 Feb;4(2):116-28.
Abstract is online see https://www.ncbi.nlm.nih.gov/pubmed/26776875 ; have a look around the world Colin, see how a “balanced regulatory policy” doesn’t work – on second thoughts, read the papers eg http://www.dailymail.co.uk/health/article-3213676/E-cigarette-industry-funded-experts-ruled-vaping-safe-Official-advice-based-research-scientists-pay-vaping-companies.html#v-2653364063001