In a longitudinal study in this month’s issue of Pediatrics, Bold et al1 examined past-month cigarette and electronic cigarette (e-cigarette) use in high school students from 2013 to 2015 in Connecticut. They found that having used an e-cigarette in the past month significantly and strongly predicted combustible cigarette use. The odds of e-cigarette use at each wave predicting future cigarette use was 7.08 from wave 1 to 2 and 3.87 from wave 2 to 3. Not surprisingly, e-cigarette use leads to traditional product use.
In contrast, traditional combustible cigarette use did not predict future e-cigarette use. And a substantial proportion of both cigarette and e-cigarette users progressed to heavy use, reporting that they smoked 21 to 30 days in the past month at the 2-year follow-up. This is consistent with patterns of use seen with young people’s increasing addiction to nicotine in numerous studies.2 E-cigarette products were not part of young people’s efforts to quit. These findings add longitudinal data and evidence to the growing evidence base that reveals that the use of e-cigarettes by young people leads to smoking traditional cigarette products and, importantly, reveals that the reverse pattern is not true. E-cigarettes cause combustible smoking; they lead young people to cigarette use and nicotine addiction. And this pathway is a 1-way street.
The authors’ call for additional research on factors affecting these pathways to further our understanding of the mechanisms through which e-cigarette use increases the risk for future cigarette use is too cautious. The question is not how these pathways work; it is how can they be stopped, and the most obvious answer is to prevent initial exposure to nicotine, regardless of the source. The Food and Drug Administration’s responsibility is to protect adolescents from nicotine addiction and tobacco use under the Family Smoking Prevention and Tobacco Control Act. There is animal evidence for e-cigarette vapor’s harm to growing lungs3,4 and evidence that e-cigarette vapor produces immediate and harmful effects on both immune and arterial function, contributing to infectious diseases, heart disease, and triggering heart attacks.5,6 Substantial evidence reveals that flavoring added to combustible tobacco products encourages adolescent use and the removal of these flavors decreases use,7 and Harrell et al8 recently reported that 95% of college students and 71% of young adults reported that their first e-cigarettes were flavored to taste like something other than tobacco (usually fruit or candy) compared with 44.1% of older adults nationwide. With this study, we add longitudinal, causal evidence that the transition from e-cigarettes to combustible products, at least for adolescents, is a 1-way street.
Heat-not-burn tobacco products are the latest nicotine-containing innovation offered to smokers by the tobacco industry. These devices produce less toxins overall than conventional cigarettes but yield similar levels of some volatile organic compounds and nicotine and higher levels of some carcinogens than conventional cigarettes.9 Furthermore, the levels of these toxins, when measured independently, were a lot higher than Philip Morris had claimed.9,10 The claims as well as the attempts of the tobacco industry to avoid meaningful regulation follow the same pattern, as did efforts to promote e-cigarette use; it would be nice to avoid making the same mistakes when it comes to protecting the public’s health.
The World Health Organization, the surgeon general, numerous professional societies, and many others have called for policy makers to recognize the urgent need to protect youth from another generation of tobacco-related disease and death. Local and national jurisdictions can act through Tobacco 21 actions,11 smoke-free movie interventions, comprehensive flavor bans, clean indoor air laws, and the rapid inclusion of alternative products in strong protection for all nonsmokers.12 Acting now on these policy strategies can and will lower youth smoking and youth e-cigarette use. As Glantz13 recently and eloquently summarized, public health leaders and tobacco control scientists must be careful not to take the tobacco industry’s health claims at face value. Although the Food and Drug Administration action may continue to be delayed, state, county, and local health authorities can and should act quickly to protect youth.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-1832.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The American Academy of Pediatrics Julius B. Richmond Center of Excellence is supported by grants from the Flight Attendant Medical Research Institute.