E-cigarettes may lead to youth tobacco use

This past summer, the Atlanta suburb of Roswell, Georgia, banned use of e-cigarettes and vapor pens in public parks. Officials enacted the restriction not because of rampant use of the devices in the city but, as mayor Jere Wood said, to “get ahead of the curve. Smokeless device use is soaring. To fulfill demand, vapor shops are popping up all over. People are noticing, including children. Introduced in the United States in 2007, these battery-powered devices convert liquid nicotine, known as e-liquids, into a vapor that the user inhales (known as “vaping”). The tactile sensation is similar to that of smoking a conventional cigarette—minus the smoke, tars, carbon monoxide, and other harmful ingredients—while delivering nicotine vapor to the lungs. When exhaled, the vapor resembles a puff of quickly dispersing, odorless smoke. E-cigarettes are not subject to many of the regulations that limit cigarette smoking.

The products have a twofold allure: They’re viewed as a harmless way to enjoy nicotine without the stigma and health risks of smoking—while serving as a way to stop cigarette smoking. However, evidence is mounting that the devices are not as benign as advocates claim and may not be an effective means for quitting tobacco.

“Evidence of their effectiveness as an aid for quitting smoking is scant,” said former Centers for Disease Control and Prevention researcher Shanta Dube, PhD, MPH, associate professor of epidemiology and biostatistics at Georgia State University’s School of Public Health in Atlanta.

One major warning sign is the allure of the devices for youngsters. Marketers offer many kid-friendly e-liquids, vape juices, and e-juice cartridges, sold in flavors that mimic chocolate mint, piña colada, strawberry, and lemon pound cake. The flavors have names such as Apple Berry Cream Puff, by California Vaping, and Devil’s Punchbowl, by Khali Vapors.

Dube said that she sees e-cigarettes as a modern-day Trojan horse that courts children while forging a new route to nicotine addiction—reversing decades of progress persuading youngsters not to smoke. “My biggest concern is the pediatrics population because I think the use and lack of regulation around the products is going to potentially move us back in normalization of cigarette smoking.”

Dube said that conventional cigarettes and e-cigarettes are almost indistinguishable to children. “So, my concern is centered on uptake in the pediatric population of e-cigarettes, which we have seen has increased significantly since 2011.”

According to the Centers for Disease Control and Prevention, e-cigarette use has surpassed traditional cigarette use among middle and high school students.

A longitudinal cohort study published in the 8 September 2015 issue of JAMA Pediatrics, suggests that e-cigarettes often lead to young people trying cigarettes and possibly act as a gateway to nicotine addiction. Among 694 youth not susceptible to cigarette use, 38.8% of e-cigarette users advanced to combustible cigarettes after one year, whereas only 18.9% of those who had not smoked e-cigarettes tried a cigarette. Lead author Brian A. Primack, MD, PhD, is associate professor of medicine, pediatrics, and clinical and translational science at the University of Pittsburgh School of Medicine. He also directs the Center for Research on Media, Technology, and Health and is assistant vice chancellor for Research on Health and Society. According to Primack, the most salient finding is that, even among people who initially have no intention of traditional cigarette smoking, experimenting with e-cigarettes is strongly associated with progression to traditional cigarette smoking.

“I think 38% is a really high transition rate,” Primack said, “especially among people who were ‘certain’ at baseline that they were not interested in cigarette smoking.”

Primack said another important finding is that the results were so consistent even when they controlled for multiple predictors of smoking, such as demographics, sensation seeking, and smoking on the part of parents and friends.

Primack said he hoped people will learn that although vaping and smoking may seem so different that one should not lead to the other, initial e-cigarette use may predispose people to take up conventional smoking for several reasons. “Most e-cigarettes deliver nicotine more slowly than traditional cigarettes. So it’s sort of a perfect ‘starter cigarette’: New users can start with e-cigarettes and then progress to regular cigarettes when they need more nicotine.”

Another reason is that e-cigarettes are designed to mimic the behaviors and sensations of cigarette smoking—unlike other forms of tobacco/nicotine use such as smokeless tobacco.

“This might make the person more accustomed to the physical act of smoking, making it an easier transition.”

Home is one place adults could steer children away from e-cigarettes. A study in the 25 August 2015 issue of Academic Pediatrics found that is simply not happening and instead might be leading to their acceptance. According to lead author Jane Garbutt, MB, ChB, research associate professor of medicine and pediatrics at the Washington University in St. Louis School of Medicine, many parents who vape aren’t aware of the dangers to children. Their use may send mixed signals to impressionable children and might tempt them to try the e-cigarettes themselves.

In the study, 658 parents and guardians completed a self-administered paper survey during an office visit to 15 pediatric practices in the St. Louis area. Data were collected between 24 June and 6 November 2014. Attitudes toward use of e-cigarettes are reported for those aware of e-cigarettes before the survey. Almost all respondents knew about e-cigarettes; 20% had tried them, and 12.5% said a family member regularly used e-cigarettes. In two-thirds of homes where children were exposed to e-cigarettes, they also were exposed to regular cigarettes. Only 15% of e-cigarette users reported having told their pediatricians they were using the devices, and only 6% said doctors had discussed the use and safe storage of e-cigarettes—which leads to another hazard. Garbutt said cavalier attitudes toward securing the devices and e-liquids could lead to youthful experimentation of a substance that can be toxic when ingested.

Garbutt said many adults, including pediatricians, simply aren’t aware of the dangers. With evidence mounting about the link between e-cigarettes leading to smoking, she said parents and doctors must wfarn patients about the potential dangers.

“We strongly encourage pediatricians to ask parents about nicotine use, including e-cigarettes, and to discuss the risks of exposure,” Garbutt said. “Ingestion is bad, of course, but even skin exposure to e-liquid can harm children.”

A version of this article originally appeared in the Journal of the Nation Cancer Institute.

Featured image credit: Smoke Screen by micadew from US. CC BY-SA 2.0 via Wikimedia Commons.