E-cigarettes: Gateway to conventional smoking?

Close up of woman smoking e-cigarette

By Martina M. McGrath, MD
July 6, 2016

E-cigarettes are an increasingly popular method of tobacco use and a public health debate is raging as to their potential risks, benefits and appropriate regulation. Touted as a useful tool to help smokers quit, there is also a concern that unregulated marketing and availability of e-cigarettes, particularly to teenagers and young adults, could lead to increased recruitment to traditional cigarette use.

In a study published in JAMA Pediatrics in November 2015, Primack et al sought to investigate if the use of e-cigarettes increased progression to smoking. They reported a longitudinal cohort study of 694 young adults between 16 and 26 years who were identified as non-smokers with low susceptibility to start smoking. At baseline, 2.3% used e-cigarettes. At one year follow up, 37.5% of e-cigarette users progressed to smoking, while 9.6% of non-users had progressed.  Furthermore, a notable change in attitudes was seen with a significantly greater proportion of e-cigarette users than non-users reporting more openness to trying conventional cigarettes. In multivariate analysis, controlling for race, sex, maternal education, parental and peer cigarette use, the only variable significantly associated with increased progression to smoking was baseline e-cigarette use (adjusted odds ratio 8.3, 95% CI 1.2-58.6). This effect was consistently seen irrespective of statistical model used.

Smoking related illnesses lead to 480,000 deaths in the US per year and smoking rates are gradually falling (source: cdc.gov). Unlike traditional cigarettes, e-cigarettes are widely advertised, including on television, and marketed in flavors targeted at a young population. This and the potential for ‘renormalization’ of smoking behavior represents a challenge to public health authorities to maintain the progress achieved in smoking cessation efforts.

Progression to Traditional Cigarette Smoking After Electronic Cigarette Use Among US Adolescents and Young Adults. Primack BA et al.  JAMA Pediatr 2015, Nov;169(11):1018-23 PMID 26348249

Headshot of Dr. McGrath


Dr. Martina McGrath is an instructor in medicine at Harvard Medical School, and a member of the Renal Division, Department of Medicine, at Brigham and Women’s Hospital, both in Boston.

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