Beyond vaping: the increased risks of smoking for Australian adolescents who vape

Australia’s efforts to prevent adolescent smoking have been undeniably successful. From 1996 to 2017, rates of both lifetime (ever) and current smoking among adolescents aged 12 to 17 declined by about 70% and 75% respectively, showcasing the effectiveness of the nation’s robust tobacco control strategies. These strategies include the introduction of plain packaging, stringent advertising bans, significant tax increases, and smoke-free policies in public places. Notwithstanding the impressive declines, smoking among Australian adolescents remains a public health priority. Recent data from 2022/23 concerningly indicates that more than 10% of 16–17-year-olds had smoked tobacco in the last twelve months, and 5% had smoked in the past month. Furthermore, a bi-annual tracking survey suggests a possible increase in current smoking among 14–17-year-olds in recent years, with rates rising from 2.1% in 2018 to 6.7% in 2022. These figures underscore the need for continued vigilance and adoption of effective measures to address evolving challenges in tobacco control.

One such challenge is the emergence of nicotine-containing consumer products beyond traditional tobacco, such as e-cigarettes (referred to hereafter as vapes). These products pose a risk of drawing successive generations of Australian adolescents into nicotine dependence, potentially hampering efforts to prevent youth smoking. The use of vapes — in stark contrast to the decline in tobacco smoking — has seen a considerable increase among Australian adolescents, with lifetime use rising from 13% in 2014, to 30% in 2022/23. This shift is alarming, not only because of the independent health hazards of vaping, but also because there is consistent evidence from multiple international prospective cohort studies suggesting that vaping may act as a gateway to adolescent smoking. For Australian adolescents, however, the possibility of vaping acting as a gateway to smoking has not been assessed empirically, until recently.

Alarming new research

Our recent article, published in the Australian and New Zealand Journal of Public Health, is the first assessment of whether vaping might be influencing the risks of subsequent smoking initiation among Australian adolescents.

Using recall data collected from over 5000 participants from the Generation Vape study, our retrospective cohort analysis offers compelling evidence that, like their counterparts in other countries, Australian adolescents are not immune to the increased risks of smoking associated with vaping.

Our findings indicate that Australian adolescents aged 12 to 17 who have vaped are five times more likely to initiate smoking compared to their peers who have never vaped. At the younger end of the age spectrum, the increased risks are even more pronounced, with 12-year-olds who have tried vaping being 29 times more likely to go on to try smoking, and 13-year-olds being 12 times more likely.

These figures highlight a disturbing age-related gradient of increased risks of smoking associated with vaping, with younger adolescents incurring the most severe consequences of being able to access vaping products. While manufacturers may claim that vapes are an effective smoking cessation aid for adult smokers, the stark age-related disparities that we observed underscore the public health importance of stringent legislative measures to restrict e-cigarette access and marketing to young Australians.

The impact of legislation

The Australian Parliament recently enacted legislation designed to prevent youth access to vapes and protect young Australians from becoming nicotine-dependent at an early age, thereby reducing long term public health risks. Since July 2024, non-pharmacy retailers have been prohibited from selling any type of vape. Initially, all vape users required a prescription to purchase a vape; however, since the start of October 2024, the regulation now allows vapes with lower nicotine concentrations to be dispensed in pharmacies only, but with strict requirements including medicine-style packaging and bans on flavours outside of tobacco and menthol/mint. Adults needing higher-nicotine concentration vapes, and people under 18, still require a prescription to ensure they are used for smoking cessation purposes under medical guidance.

As the new regulations take effect and are enforced, supported by anti-vaping public education campaigns and quit vaping supports, it is anticipated that adolescents will find it much more difficult to access vapes, their desire to vape will lessen, and vaping rates will begin to decline. While there is a concern that restricted access to vapes might lead some adolescents to turn to cigarettes instead, several factors mitigate this risk. Cigarettes are more expensive, harder to conceal, and carry a greater social stigma among adolescents compared to vapes.

However, our findings suggest that the allure of smoking can still be significant, even with these deterrents in place. This underscores the importance of continuing to strengthen tobacco control efforts maintaining stringent restrictions not just on vaping products but also on traditional tobacco products. The adoption of progressive laws that restrict vaping product sales to pharmacies contrasts with the relatively weak controls on how and where tobacco products are sold. The Australian National Tobacco Strategy aims to bring daily smoking prevalence among the adult population down to 5% or less by 2030, a goal that will only be achieved with strong, evidence-based policies that challenge the “business as usual” model of selling highly addictive and lethal products alongside everyday groceries and household goods.

Ongoing research needed

Although our study provides valuable insights into the patterns of vaping and smoking among Australian adolescents, it’s important to acknowledge its main limitation — the retrospective design. Unlike the more robust prospective cohort designs commonly used to explore this issue, our approach relied on participants recalling if, when, and in what order they began vaping and/or smoking. While this method allows us to analyse our data in a similar manner to prospective studies, it can introduce recall bias if many participants are not accurately recalling the timing and sequence of these events. Despite these challenges, retrospective studies have been used to yield significant insights, as demonstrated by historical epidemiological research requiring participants to recall behaviours such as smoking. Nonetheless, we strongly encourage future prospective cohort studies in Australia to confirm and expand on our findings.

Sam Egger is a senior biostatistician at the Daffodil Centre, the University of Sydney, a joint venture with Cancer Council NSW.

Professor Michael David is with the Daffodil Centre, the University of Sydney, a joint venture with Cancer Council NSW.

Alecia Brooks is the tobacco control unit manager with Cancer Council NSW.

Anita Dessaix is director of cancer prevention and advocacy at Cancer Council NSW.

Associate Professor Becky Freeman is with the School of Public Health at the University of Sydney.