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E-cigarettes serve as gateway to smoking, says US study

9 September 2015

E-cigarettes serve as gateway to smoking, says US study

It is a hotly debated topic, but a new US study has suggested that e-cigarette use does act as a gateway to smoking for young people, contrary to the view of Public Health England, who recently endorsed their use as a means to quit smoking.

Conducted by the University of Pittsburgh Centre for Research on Media, Technology, and Health and the Darmouth-Hitchcock Norris Cotton Cancer Centre, and funded by the National Cancer Institute, this is the first study of its kind in the US to use a national sample of youth, which includes people older than 18 among its participants. The findings were published in JAMA Pediatrics.

Lead author, Brian A Primack, said: “E-cigarettes are not subject to many laws that regulate traditional cigarettes, such as age limits on sales, taxation and labelling requirements. They also come in youth-oriented flavourings that laws have limited in traditional cigarettes, such as apple bubble gum and chocolate candy cane.”

James M Sargent, co-author, added: “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.”

The researchers used a sample of 700 16 to 26 year old nonsmokers surveyed in 2012, and again in 2013. All participants were judged to be “non-susceptible” to initiating traditional cigarette smoking at the beginning of the study, as they had responded ‘definitely no’ when asked if they’d smoke if offered one by a friend in the next year.

By the following year, 38% of baseline e-cigarette users had initiated traditional cigarette smoking, compared to only 10% who’d started smoking but were not e-cigarette users.

Dr Primack noted: “These difference 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.”

Attempting to hypothesise why e-cigarettes may serve as a gateway to traditional cigarette smoking, the researchers suggested:

  • 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.

Dr Sargent concluded: “Recent data suggest that more youth than ever are using e-cigarettes and that as many as half of these adolescents are not smoking traditional cigarettes. 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.”


Many have dismissed the findings of this research, however, claiming its low number of actual participants invalidates its findings. Ann McNeill, professor of tobacco addiction at the National Addiction Centre, King’s College London, said: “Sadly this study cannot throw any light at all on what influenced a proportion of these 16 people to soften their attitudes towards cigarette smoking.”

Professor Robert West, Department of Epidemiology and Public Health, UCL, argued: "This kind of propaganda by major medical journals brings public health science into disrepute and is grist to the mill of apologists for the tobacco industry who accuse us of 'junk science'."

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