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New research shows Australian adolescents who have vaped are five times more likely to initiate smoking compared to their peers who have never vaped.
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.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Vaping and smoking are certainly associated, but is it causal? this study provides no information. A plausible explanation is the vaping and smoking share a common cause(s), such as parental smoking, risk averseness (lack of), socio-economic status and genetics.
I argue that this is most certainly not compelling evidence for public health risks of vaping, but consistent with a variety of hypotheses around smoking.
Vaping may be displacing smoking rather than increasing it. Despite much alarmism, it is clear smoking is far more dangerous than smoking. In keeping with harm minimisation as a public health strategy, we should be encouraging vaping and easing access, not restricting.
In my capacity as a university lecturer I work with young people aged 18-30. I am extremely concerned as many of my students who had switched from smoking to vaping have now returned to smoking due to virtually non existent access to vapes under the pharmaceutical/prescription model and an increase in the price of black market vapes. They are now using black market tobacco- Manchester seems to be a favoured brand, or Double Happiness.
They have privately confided in me and most have expressed the view that “smoking is safer than vaping”. I believe this is due to public health campaigns designed by Tobacco Control and approved by the government that have sent a message stating that people who vape nicotine will suffer from popcorn lung or EVALI, will suffer brain damage, will get oral cancer and will die very quickly. This is blatant disinformation, however has achieved the goal of stopping youth vaping; only to see them turn to readily available cigarettes- a product left out of the messaging/discussion almost entirely.
Are you capturing black market use of tobacco in your data on tobacco use? I suspect smoking rates have escalated recently as I am seeing more smokers everywhere in Melbourne and more cigarette butts/discarded packaging in the street. I’m seeing less smoking in public spaces but far more in private spaces. I am also seeing many older people stealth vaping to avoid detection. I suspect this is due to people being stigmatised for using any nicotine product. I do not believe that Tobacco Control has succeeded in its goals to reduce smoking in Australia and I am distressed watching young people return to tobacco. I believe further restrictions on vaping products will not only encourage a flourishing black market but also see young and old people who have been using vaping as a safer alternative to smoking, return to deadly cigarettes. Full disclosure, I have no association with the tobacco or vaping industries. I am 51 years old & quit smoking using vaping almost 15 years ago. I am in excellent health according to my GP.
The study fills a significant gap by being the first Australian research to assess the link between vaping and smoking initiation. Its findings align with international studies, validating the potential gateway effect of vaping.
It uses data from over 5,000 participants in the Generation Vape study, providing a large sample size for meaningful analysis.
The retrospective cohort design introduces recall bias, as participants must accurately remember when they started vaping or smoking. This can affect the reliability of the findings.
Retrospective studies are less robust than prospective cohort studies, which track participants over time. The authors acknowledge this limitation and call for future longitudinal research to confirm the findings.
Implications for Protecting Vulnerable Children
The study highlights the urgent need for integrated tobacco and vaping prevention strategies. Vaping is not only a public health issue but also a youth mental health concern since nicotine dependence in adolescence can impair cognitive development and emotional regulation. Protecting adolescents requires:
Enhanced public education campaigns to raise awareness of the risks of vaping and nicotine dependence.
Strict enforcement of vaping regulations and monitoring of pharmacies to ensure compliance with sales restrictions.
School-based interventions and behavioral support programs to reduce the allure of both vaping and smoking.
Parental involvement and community engagement in anti-vaping initiatives to promote healthy behaviors.
These measures align with Australia’s national strategy to reduce smoking prevalence, highlighting that restricting access to vaping products alone is insufficient. Tobacco control policies must remain adaptive to address the evolving dynamics of nicotine use among adolescents.
Future Research Directions
Given the limitations of retrospective studies, future research should focus on prospective cohort studies to better understand the causal relationship between vaping and smoking initiation. Such studies could track adolescents over time, providing more reliable data and identifying risk factors associated with dual product use. Additionally, research should explore:
The mental health effects of vaping on adolescents.
The impact of public education campaigns on changing adolescent attitudes toward nicotine products.
The effectiveness of pharmacy-only access policies on reducing adolescent vaping rates.
This study offers compelling evidence that vaping is a significant public health threat among Australian adolescents, increasing their risk of smoking initiation. While Australia’s robust tobacco control strategies have reduced adolescent smoking rates, the rising prevalence of vaping demands immediate action. Legislative measures, combined with public education and community-based interventions, are crucial to protect vulnerable adolescents from dual nicotine epidemics. Addressing both vaping and traditional tobacco use is essential for ensuring that Australia’s progress toward a smoke-free future remains on track.
References:
Bandara NA, Herath J, Mehrnoush V. Addressing e-cigarette health claims made on social media amidst the COVID-19 pandemic. World J Pediatr. 2021 Feb;17(1):3-5. doi: 10.1007/s12519-021-00410-7. Epub 2021 Jan 21. PMID: 33475917; PMCID: PMC7818699.
Bandara NA, Wanniarachchi S, Mehrnoush V. Evidence-based tobacco-control legislation on e-cigarettes is urgently needed. CMAJ. 2020 Jan 20;192(3):E74. doi: 10.1503/cmaj.73819. PMID: 31959661; PMCID: PMC6970594.
Bandara NA, Jhauj R, Fernando J, Mehrnoush V, Wijesinghe N. Overlapping public health crises during the coronavirus disease pandemic. World J Emerg Med. 2021;12(2):151-153. doi: 10.5847/wjem.j.1920-8642.2021.02.011. PMID: 33728009; PMCID: PMC7947562.
This paper has sparked unnecessary alarm with its misleading claim of causality, feeding into the growing moral panic about youth vaping. By confusing correlation with causation, the authors have made a fundamental error.
A far more plausible explanation is “common liability.” (Vanyukov 2012) Young people who try both vaping and smoking are simply different from their peers. They are predisposed to experiment with nicotine, driven by many underlying smoking predictors like genetics, peer pressure, parental smoking, and socio-economic status.
If vaping caused young people to smoke we would expect to see increasing youth smoking rates. In fact we are seeing the opposite. Youth smoking rates have been falling faster than anticipated since vaping was available. (Delnevo and Villanti 2021; Pesola 2021 Levy 2019; Meza 2021; NHS Digital UK 2022; ASH NZ 2022)
In the most recent 2022-2023 ASSAD survey, just 0.3% of Australian students aged 12-17 reported daily smoking. Only 2.1% had smoked within the last week. Similarly, the NDSHS 2022-23 survey showed that only 3.5% of 14-17-year-olds had smoked in the past 30 days. Most youth smoking is experimental and not sustained. (Sun 2023; Friedman 2019)
Studies suggest that youth vaping may be displacing smoking overall rather than encouraging it. (Foxon 2020, Selya 2021, Sokol 2021)
In summary, this cross-sectional study shows that youth vaping is ASSOCIATED with youth smoking but it does not prove that vaping CAUSED subsequent smoking as claimed.
My blog explains this in more detail: https://colinmendelsohn.com.au/gateway-2/ and here https://colinmendelsohn.com.au/vaping/#gateway.