Friday, January 5, 2018

Another study finds teens who use non-cigarette tobacco products, like e-cigarettes, are more likely to try cigarettes

By Melissa Patrick
Kentucky Health News

Teens who use electronic cigarettes and other non-cigarette tobacco products are twice as likely to start smoking cigarettes a year later than teens who have never used those products, according to recently completed research.

Dr. Ellen Hahn
Ellen Hahn, a University of Kentucky nursing professor, said in an e-mail that the study adds to a growing body of research that youth who use e-cigarettes and/or other non-cigarette products, like cigars, hookah or smokeless tobacco, are more likely to smoke conventional cigarettes one year later.

"This is a serious concern, given that most adult smokers start when they are young, setting them up for a lifetime of suffering from addiction, chronic disease, and premature death," she said.

Hahn also runs the nursing college's BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) program and its Kentucky Center for Smoke-Free Policy.

The study was done at the University of California, San Francisco , where researchers noted that smoking as few as one cigarette per month in adolescence is associated with future daily smoking and smoking in adulthood, and that 90 percent of adult smokers tried their first cigarette before the age of 18.

Kentucky high-school students already have one of the highest smoking rates in the nation at 14.3 percent, according to the 2017 Kentucky Youth Risk Behavior Survey. The national rate is 8 percent.

The Population Assessment of Tobacco and Health study surveyed more than 10,000 youth between the ages of 12 and 17 across the U.S. who said they had never smoked. The participants were also asked if they had used electronic cigarettes, hookahs, non-cigarette combustible tobacco or smokeless tobacco. A year later, they were asked again about their tobacco use. The research was conducted between 2013 and 2015.

The study, published in the Journal of the American Medical Association Pediatrics, found that teens who had used e-cigarettes, hookahs, or non-cigarette tobacco products were twice as likely to have smoked cigarettes a year later, compared to those who hadn't used a non-cigarette tobacco product.

And those who had used more than one of the non-cigarette tobacco products were nearly four times as likely to try cigarettes a year later. The results were adjusted for socio-demographic, behavioral and environmental smoking risk.

At one-year follow-up, 4.6 percent of youth who hadn't smoked previously had tried a cigarette, and 2.1 percent had smoked one within the past 30 days. Cigarette ever use at follow-up ranged from 18.8 percent to 19.2 percent for youths who had reported using a non-cigarette tobacco product during the initial assessment.

"In light of these observed associations between non-cigarette tobacco use and future smoking, novel tobacco products have the potential to undermine public health gains in combating the smoking epidemic," the study authors wrote.

They were likely referring to the significant drops in teen smoking over the past 20 years. For example, the youth survey shows that in Kentucky, the teen smoking rate dropped from 47 percent in 1997 to its current rate of 14.3 percent. Nationwide, it dropped from 36 percent in 1997 to 8 percent in 2016.

And though e-cigarette and smoking rates are about the same in Kentucky (14.1 percent and 14.3 percent respectively), the 2017 "Monitoring the Future" survey found that nationwide more teens are vaping than smoking cigarettes. For example, it found that 9.7 percent of high-school seniors nationwide reported smoking tobacco, compared to 16.6 percent of them using electronic cigarettes.

The researchers called for policies that discourage teen use of all of these products, including pack size requirements and flavor restrictions.

"In policy terms, the findings provide a rationale to treat alternative cigarette products as a group and potentially extend policies that work for one product to the others (such as a ban on flavoring)," the authors concluded. "Even if youths do not progress to smoking cigarettes, any tobacco use is harmful. The estimated health risks of non-cigarette tobacco products should include the additional health consequences of future cigarette use."

Hahn said the most effective way to prevent youth from smoking is to raise the price of cigarettes and non-cigarette products, one of the main goals of the the newly formed Coalition for a Smoke-Free Tomorrow, of which the Kentucky Center for Smoke-Free Policy is a member.

She said, "It is estimated that 23,200 fewer youth in Kentucky would start to smoke if we raise the per pack tax by at least $1 as well as raise the tax accordingly on non-cigarette products."

Republican state Sen. Stephen Meredith of Leitchfield has filed a bill to raise Kentucky's cigarette tax by $1, with parallel increases in other tobacco taxes. The idea is supported by Kentuckians, with a recent poll showing 73 percent of the state's voters supporting the $1 tax increase on cigarettes. The current 60-cent tax is about a third of the national average of $1.71 per pack.


  1. The interpretation of the JAMA Pediatrics report as conclusive evidence that trying tobacco products is a “gateway” to cigarettes is inaccurate, because it omitted information that is critical to putting the findings in perspective. I reconstructed the omitted information and put it in context in a blog post. It turns out that the dominant gateway in this study was from no previous tobacco use to cigarettes.

    Brad Rodu
    Professor of Medicine
    Endowed Chair, Tobacco Harm Reduction Research
    University of Louisville