On average tobacco smokers die significantly younger and spend more of their shorter lives ill. Because e cigarettes can be marketed to young people, there is a worry that if they did lead to more conventional smoking, they could have a potentially disastrous impact on public health.

This current study does suggest that e cigarettes may not be the harmless alternative some believe, and may be acting as a “gateway drug” to conventional smoking.

However, it does not prove that is the case. It is quite plausible that existing teenage smokers are also trying e cigarettes for a variety of reasons.

The debate about the safety and regulation of e cigarettes is likely to continue until more robust long term evidence emerges.

Where did the story come from?

The study was carried out by researchers from the Center for Tobacco Research and Education at the University of California, San Francisco, and was funded by the US National Cancer Institute.

It was published in the peer reviewed medical journal, JAMA Pediatrics.

The Mail Online coverage was balanced and discussed the pros and cons of e cigarettes. It also usefully brought in some wider research from 75,000 Korean adolescents “which also found that adolescents who used e cigarettes were less likely to have stopped smoking conventional cigarettes”.

What kind of research was this?

This was a cross sectional study looking at whether e cigarette use was linked to conventional cigarette smoking behaviour among US adolescents.

E cigarettes are devices that deliver a heated aerosol of nicotine in a way that mimics conventional cigarettes while delivering lower levels of toxins, such as tar, than a conventional combusted cigarette. They are often marketed as a safer alternative to regular smoking, or as a way of helping people quit traditional smoking.

The devices are not currently regulated in the US or the UK, meaning there are limited or vague rules concerning appropriate advertising. The researchers say e cigarettes are being aggressively marketed using the same messages and media channels that cigarette companies used to market conventional cigarettes in the 1950s and 1960s. These include targeting young people to get a new generation of smokers hooked on nicotine for life.

The researchers outline how studies have demonstrated that youth exposure to cigarette advertising causes youth smoking. Meanwhile, electronic cigarettes can be sold in flavours such as strawberry, liquorice or chocolate, which are banned in cigarettes in the US because they appeal to youths.

Given the potential for a new generation to be hooked on nicotine and then tobacco smoking in this unregulated environment, the researchers wanted to investigate whether e cigarettes were associated with regular smoking behaviour in adolescents.

What did the research involve?

The researchers used existing smoking data collected from US middle and high school students in 2011 (17,353 students) and 2012 (22,529) during the large US National Youth Tobacco Survey. They analysed whether use of e cigarettes was linked with conventional tobacco smoking and smoking abstinence behaviour.

The National Youth Tobacco Survey was described as an anonymous, self administered, 81 item, pencil and paper questionnaire that included

  • indicators of tobacco use (cigarettes, cigars, smokeless tobacco, kreteks southeast Asian clove cigarettes , pipes, and “emerging” tobacco products)
  • tobacco related beliefs
  • attitudes about tobacco products
  • smoking cessation
  • exposure to secondhand smoke
  • ability to purchase tobacco products
  • exposure to pro tobacco and anti tobacco influences

Smoking behaviour was categorised as

  • conventional cigarette experimenters adolescents who responded “yes” to the question “Have you ever tried cigarette smoking, even one or two puffs?”
  • ever smokers of conventional cigarettes those who replied “100 or more cigarettes (five or more packs)” to the question “About how many cigarettes have you smoked in your entire life?”
  • current smokers of conventional cigarettes those who had smoked at least 100 cigarettes and smoked in the past 30 days
  • ever e cigarette users adolescents who responded “electronic cigarettes or e cigarettes, such as Ruyan or NJOY” to the question “Which of the following tobacco products have you ever tried, even just one time?”
  • current e cigarette users those who responded “e cigarettes” to the question “During the past 30 days, which of the following tobacco products did you use on at least one day?”

Data on intention to quit smoking in the next year, previous quit attempts and abstinence from conventional cigarettes was also collected. The analysis was adjusted for potential confounding factors such as race, gender and age.

What were the basic results?

The main analysis included 92.0% of respondents (17,353 of 18,866) in 2011 and 91.4% of respondents (22,529 of 24,658) in 2012 who had complete data on conventional cigarette use, e cigarette use, race, gender and age. The mean age was 14.7, and 5.6% of respondents reported ever or current conventional cigarette smoking (of these, 5% currently smoked).

In 2011, 3.1% of the study sample had tried e cigarettes (1.7% dual ever use, 1.5% only e cigarettes) and 1.1% were current e cigarette users (0.5% dual use, 0.6% only e cigarettes).

In 2012, the 6.5% of the sample had tried e cigarettes (2.6% dual use, 4.1% only e cigarettes) and 2.0% were current e cigarette users (1.0% dual use, 1.1% only e cigarettes).

Ever e cigarette users were significantly more likely to be male, white and older. The rates of ever tried e cigarettes and current e cigarette smoking approximately doubled between 2011 and 2012.

The main analysis found use of e cigarettes was significantly associated with

  • higher odds of ever or current cigarette smoking
  • higher odds of established smoking
  • higher odds of planning to quit smoking among current smokers
  • among e cigarette experimenters, lower odds of abstinence from conventional cigarettes

How did the researchers interpret the results?

The researchers’ interpretation was clear “Use of e cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents.”

They added that, “In combination with the observations that e cigarette users are heavier smokers and less likely to have stopped smoking cigarettes, these results suggest that e cigarette use is aggravating rather than ameliorating the tobacco epidemic among youths. These results call into question claims that e cigarettes are effective as smoking cessation aids.”


This study found US adolescents who use e cigarettes are more likely to smoke conventional cigarettes. They also have lower odds of abstaining from conventional cigarettes than those who don’t try e cigarettes. On the flip side, e cigarette users were more likely to report planning to quit conventional smoking.

The research sample was large, so is likely to provide a relatively accurate picture of the smoking behaviour of US adolescents.

These results suggest that e cigarettes may not discourage conventional cigarette smoking in US adolescents, and may encourage it. However, because of the cross sectional nature of the information, it cannot prove that trying e cigarettes causes adolescents to take up conventional smoking. There may be other factors at play.

And indeed, smoking tobacco cigarettes may cause teenagers to take up e cigarettes. For example, the type of person who may want to try smoking in the past could only try conventional smoking. Nowadays, they have e cigarettes as an option too.

Retrospectively trying to work out if they would have taken up conventional smoking had they not tried e cigarettes first is not possible. This questi
on would require a cohort study that tracks behaviour over time. You would then be able to see which smoking method they took up first and if one led to the other. This was not possible using the data the researchers had to hand in the current study.

Conventional smoking has been a public health priority for many decades because, on average, smokers die significantly younger (more than a decade in some groups) and they spend more of their shorter lives ill. Consequently, any product that may increase the rates of conventional smoking among the young such as e cigarettes has serious and widespread health consequences.

Currently, regulation around e cigarettes is minimal, but there are plans to introduce stricter rules in the UK. In the meantime, this study provides some evidence that e cigarettes may not be the harmless, safe alternative some believe, and may be acting as a gateway drug to conventional smoking.

The research stops short of proving this, so the debate on whether e cigarettes should be treated similarly to conventional cigarettes, through advertising and sales restrictions, is likely to continue.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

E-cigarettes face restrictions as cities update smoking ordinances – our region – the sacramento bee

The electronic cigarettes flooding the U.S. market don&#x92 t technically emit smoke, but many cities have decided they&#x92 re not much different from ordinary cigarettes.

Last week, Rancho Cordova became the latest local government to pursue restrictions on e cigarettes the City Council directed staff members to treat them like regular smokes when they draft amendments to city code sections governing smoking. The Los Angeles City Council also voted last week to restrict e cigarette use where tobacco smoking is restricted, including restaurants, parks, bars, nightclubs, beaches and workplaces. Similar measures have been approved in a number of Bay Area cities, along with New York and Chicago.

The Davis City Council is scheduled to discuss e cigarettes tonight.

Representatives of the cities of Roseville and Folsom said e cigarettes are on their radar, too, though no decisions have been made.

&#x93 Our city attorney tells me that he&#x92 s just started looking at our existing smoking ordinance, adopted in 1994, and considering incorporating e cigarette restrictions,&#x94 said Sue Ryan, spokeswoman for the city of Folsom. She said the City Council likely will take up the matter within the next couple of months.

Sales of e cigarettes have skyrocketed in recent years. Big tobacco companies have been getting into the business, and ads for e cigarettes are now appearing on television, a space where traditional smokes have been banned for more than 40 years. The fast evolution of the market has left governments racing to keep pace.

&#x93 Our no smoking ordinance has been in effect for a long while, but technology has surpassed the ordinance,&#x94 said Kelly Stachowicz, Davis&#x92 deputy city manager. &#x93 We&#x92 re trying to see if we need to catch up or amend the ordinance.&#x94

On a federal level, the U.S. Food and Drug Administration is expected to propose regulations governing the e cigarette industry. The European Parliament took action last month, adopting measures to ban e cigarette advertising and require health warnings.

Electronic cigarettes typically use battery powered heat to vaporize a liquid solution containing nicotine that is held in the mouthpiece of the device. Under state law, it is illegal to sell or give e cigarettes to minors, but the law does not extend other smoking prohibitions to the devices.

Because they don&#x92 t burn, e cigarettes have been promoted as having fewer secondhand effects, but studies have shown that the vapor contains carcinogens and toxic chemicals, as well as nicotine, an element of tobacco that is highly addictive, said Rancho Cordova City Attorney Adam Lindgren. When the smoker exhales those vapors, they affect people around them, he said, likening the vapors to secondhand smoke.

Although some studies have indicated that e cigarettes can be effective in helping people quit smoking or reduce their tobacco use, the FDA has not declared them an effective cessation product, said Lindsey Freitas, policy manager for the American Lung Association in California. E cigarettes are not regulated by the FDA.

The American Lung Association in California advocates treating e cigarettes as tobacco products. &#x93 We&#x92 re really concerned that we just don&#x92 t know what is in them,&#x94 Freitas said.

Rancho Cordova Councilman David Sander said that although there is some evidence that e cigarettes may help people quit smoking, there also is evidence that they may entice kids to start smoking.

Freitas, of the American Lung Association, said many civic leaders have expressed particular concern that e cigarettes that come in such flavors as Cap&#x92 n Crunch and Gummy Bears are an enticement to youths.

Kate Cook, an attorney who researched e cigarettes for the Rancho Cordova City Council, said most e cigarettes come from China and that they are not all the same. Some might contain more carcinogens than others, and metal pieces have been found in some.

From a regulatory perspective, Lindgren said, restricting their use could be supported for public health and welfare reasons.

Attal Sadiq, owner of Gaga Smoke Shop in Rancho Cordova, said he attended the council workshop primarily to gather information.

&#x93 Sixty five percent of what we sell doesn&#x92 t have nicotine,&#x94 he told the council. Of the customers buying e cigarettes that do contain nicotine, he said, about 95 percent are doing so to quit smoking.

Diann Rogers, president and CEO of the Rancho Cordova Chamber of Commerce, said she found most businesses in the city were doing a &#x93 stellar job of self regulating.&#x94 Most, she said, are treating e cigarettes as regular cigarettes.

&#x93 The comments I received (from chamber members) is that it has become culturally unacceptable to smoke,&#x94 Rogers said. &#x93 The gist is, they would like to treat e cigarettes the same as tobacco.&#x94

The public will have plenty of opportunity to weigh in on any proposed changes in Rancho Cordova&#x92 s smoking ordinance. Once completed, the proposed ordinance will be the subject of two hearings before the City Council, Lindgren said.

Freitas said more than 45 communities in California have included e cigarette regulations in their smoking ordinances. Fifty nine include e cigarettes in their tobacco retailer license programs, meaning that those who want to sell e cigarettes must obtain a license. Also, 21 jurisdictions have included e cigarettes in smoking provisions that apply to housing complexes, she said.

Regulation of e cigarettes also was mentioned during a February meeting of the city of Sacramento&#x92 s Law and Legislation Committee in discussing a possible smoking ban in outdoor dining areas, said city spokeswoman Amy Williams. &#x93 However, no direction was given, and we don&#x92 t foresee it coming forward anytime soon,&#x94 she said.

Freitas said federal action is needed to determine the safety of e cigarettes. &#x93 We just want to reiterate that it is really important for the FDA to assert its authority over e cigarettes,&#x94 she said, &#x93 so we can get some clarity of what is actually in them.&#x94

Call The Bee&#x92 s Cathy Locke, (916) 321 5287.

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