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School of Public Health News April 05, 2023

A study first-authored by Ruoyan Sun, Ph.D., Assistant Professor in the UAB School of Public Health’s Department of Health Policy and Organization was recently published in the Journal of the American Medical Association (JAMA) Network Open and reveals limited prospective association between e-cigarette (vape) use and sustained cigarette smoking in adolescents.

Many research studies have found the use of e-cigarettes among adolescents to be associated with an increased risk of ever cigarette smoking. What was unknown, until this paper, was whether those "vaping-induced smokers" and their baseline e-cigarette use was related to continued cigarette-smoking a few years later, since many might simply experiment once or twice and then quit. The study, Association of Electronic Cigarette Use by US Adolescents With Subsequent Persistent Cigarette Smoking, found that while 12- to 17-year-olds who use e-cigarettes are more likely to continue smoking cigarettes two years after initiation than their non-vaping peers, the absolute risk of adolescents continuing smoking is low, regardless of their baseline e-cigarette use.

Due to the popularity of e-cigarette use among adolescents, an important concern among the public health community is the potential gateway effect of e-cigarettes, where e-cigarette use leads to subsequent cigarette use. Cigarettes remain overwhelmingly responsible for most tobacco-caused morbidity and mortality, according to the 2014 Surgeon General’s Report: The Health Consequences of Smoking – 50 Years of Progress. If youth simply experiment with smoking but do not continue, their risks of smoking-related adverse health outcomes are low. But if youth do become regular or established smokers, the risks can then be substantial.

Data on more than 8,600 adolescents provided by the national longitudinal cohort study, PATH, or the Population Assessment of Tobacco and Health were assessed. The sample included youth who were cigarette-naïve at the baseline wave. Continued or sustained smoking was defined as initiation at the follow-up wave one, or one year after baseline, and subsequent smoking at follow-up wave two, or three years after baseline. The authors considered a variety of continued cigarette use behaviors to reflect increasing commitment to smoking. The strictest behavior, defined as cigarette use on at least 20 or more days in the past 30 days, and 100 or more cigarettes smoked at follow-up wave two after initiation, mirrors the definition of frequent use among adult smokers.

Although there are significantly higher odds of continued smoking among e-cigarette users, the absolute risks of sustained smoking are very small, in addition to the minor risk differences in continued smoking between baseline e-cigarette users and non-users.

“This study highlights the importance of distinguishing experimenters from regular or established smokers,” said Sun. “It is common for adolescents to experiment with multiple tobacco products, but we have now confirmed that most adolescents who initiated cigarette smoking do not become regular or established smokers.” Sun feels that clinicians should continue to monitor youth tobacco-use behaviors, but with their concern being focused on youthful patients who sustain smoking instead of just experimenting with cigarettes.”

Ruoyan Sun, Ph.D. specializes in tobacco control with a focus on electronic cigarette use among adolescents. Her research interests also include the use of other substances, such as cannabis.

Additional researchers on this study include David Mendez, Ph.D. and Kenneth E. Warner, Ph.D. of the University of Michigan School of Public Health, with commentary by Cristine D. Delnevo, Ph.D., of the Rutgers University School of Public Health.

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