Young people across the United States who smoke electronic cigarettes are considerably more likely to start smoking traditional cigarettes within a year than their peers who do not smoke e-cigarettes, according to an analysis led by the University of Pittsburgh Center for Research on Media, Technology, and Health (CRMTH) and the Dartmouth-Hitchcock Norris Cotton Cancer Center. The study, funded by the National Cancer Institute (NCI), was the first to assess this relation in a national U.S. sample of youth, and to include people older than 18 among its participants.
The results, published online today and scheduled for the November print issue of JAMA Pediatrics, are particularly timely as the U.S. Food and Drug Administration considers how to regulate e-cigarettes, which are easier for adolescents to purchase and, in many respects, more attractive to young people than traditional cigarettes.
“E-cigarettes are not subject to many laws that regulate traditional cigarettes, such as age limits on sales, taxation and labeling requirements. They also come in youth-oriented flavorings that laws have limited in traditional cigarettes, such as apple bubble gum and chocolate candy cane,” said lead author Brian A. Primack, MD, PhD, director of CRMTH and assistant vice chancellor for health and society in Pitt’s Schools of the Health Sciences.
James D. Sargent, MD, professor of pediatrics at Dartmouth’s Geisel School of Medicine and senior author on the study, adds that “It also is notable that electronic cigarettes are marketed on television. This represents the first time in more than 40 years that a smoking-related device has been advertised on this medium, which has tremendous reach and could drive appeal of these products among youth.”
For the current publication, the research team analyzed data on a national sample of nearly 700 16- to 26-year-old nonsmokers surveyed in 2012 and again in 2013 through the Dartmouth Media, Advertising, and Health Study. All participants were considered “non-susceptible” to initiating traditional cigarette smoking at the beginning of the study, because they had responded “definitely no” when asked if they would try a cigarette offered by a friend or believed they would smoke a cigarette within the next year.
By the next year, 38 percent of the baseline e-cigarette users had initiated traditional cigarette smoking. In comparison, only 10 percent of the youths who were not baseline e-cigarette users started smoking traditional cigarettes.
“These differences remained statistically significant and robust even when we controlled for multiple known risk factors for initiating cigarette smoking, such as age, sex, race, ethnicity, socioeconomic status, sensation seeking, parental smoking and friend smoking,” Dr. Primack said.
In the manuscript, Drs. Primack and Sargent, and their team, theorize why e-cigarette smoking may serve as a gateway to traditional cigarette smoking, including:
- E-cigarettes deliver nicotine more slowly than traditional cigarettes, allowing a new user to advance to cigarette smoking as he or she becomes tolerant of nicotine side effects.
- Unlike other forms of nicotine, such as smokeless tobacco, e-cigarettes are designed to mimic the behavioral and sensory act of cigarette smoking, allowing the user to become accustomed to the act of smoking.
- E-cigarettes are not subject to the same regulations as traditional cigarettes, potentially renormalizing the act of smoking after decades of public health efforts to shift public norms around smoking.
Regulating e-cigarettes is particularly controversial because they are sometimes used as harm reduction tools by established smokers.
“However, recent data suggest that more youth than ever are using e-cigarettes and that as many half of these adolescents are not smoking traditional cigarettes,” Dr. Sargent said. “Therefore, it is important to continue surveillance of both e-cigarettes and tobacco products among young people so policymakers can establish research-informed regulations to help prevent e-cigarettes from becoming gateway products on the road to youth smoking.”
Additional authors on this research are Samir Soneji, Ph.D., of The Dartmouth Institute for Health Policy and Clinical Practice; Michael Stoolmiller, Ph.D., of the University of Oregon; and Michael J. Fine, M.D., M.Sc., of Pitt and the VA Pittsburgh Healthcare System.
This research was supported by NCI grants R01-CA077026, R01-CA140150 and R21-CA185767, and National Center for Advancing Translational Sciences grant KL2-TR001088.
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About Dartmouth-Hitchcock Norris Cotton Cancer Center
Norris Cotton Cancer Center combines advanced cancer research at Dartmouth College and the Geisel School of Medicine at Dartmouth with patient-centered cancer care provided at Dartmouth-Hitchcock Medical Center, at Dartmouth-Hitchcock regional locations in Manchester, Nashua, and Keene, NH, and St. Johnsbury, VT, and at 12 partner hospitals throughout New Hampshire and Vermont. It is one of 45 centers nationwide to earn the National Cancer Institute's "Comprehensive Cancer Center" designation. Learn more about Norris Cotton Cancer Center research, programs, and clinical trials online at cancer.dartmouth.edu.
About the University of Pittsburgh Schools of the Health Sciences
The University of Pittsburgh Schools of the Health Sciences include the schools of Medicine, Nursing, Dental Medicine, Pharmacy, Health and Rehabilitation Sciences and the Graduate School of Public Health. The schools serve as the academic partner to the UPMC (University of Pittsburgh Medical Center). Together, their combined mission is to train tomorrow’s health care specialists and biomedical scientists, engage in groundbreaking research that will advance understanding of the causes and treatments of disease and participate in the delivery of outstanding patient care. Since 1998, Pitt and its affiliated university faculty have ranked among the top 10 educational institutions in grant support from the National Institutes of Health. For additional information about the Schools of the Health Sciences, please visit www.health.pitt.edu.
About the Geisel School of Medicine at Dartmouth
Founded in 1797, the Geisel School of Medicine at Dartmouth strives to improve the lives of the communities it serves through excellence in learning, discovery, and healing. The Geisel School of Medicine is renowned for its leadership in medical education, health care policy and delivery science, biomedical research, global health, and in creating innovations that improve lives worldwide. As one of America’s leading medical schools, Dartmouth’s Geisel School of Medicine is committed to training new generations of diverse leaders who will help solve our most vexing challenges in health care.