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E-cigarettes: The New Gateway to Smoking for US Youths


A new study found that electronic cigarette use may lead some US youths to get hooked on traditional combustible cigarettes when they would otherwise never try smoking. 

A new study published in the February issue of the journal JAMA Network Open, has found that electronic cigarettes, or e-cigarettes, may lead some youths to get hooked on traditional combustible cigarettes (cigarettes) when they otherwise would never try smoking.1

Researchers estimated that e-cigarettes lead about 180 000 youths aged 12 to 15 years to at least try cigarettes, and almost 45 000 youths to become current cigarette smokers over 2 years.

“This large, nationally representative study of US youths supports the view that e-cigarettes represent a catalyst for cigarette initiation among youths,” wrote researchers led by Kaitlyn Berry, MPH, of Boston University School of Public Health, Massachusetts.

“The association was especially pronounced in low-risk youths, raising concerns that e-cigarettes may renormalize smoking behaviors and erode decades of progress in reducing smoking among youths,” they added.

E-cigarette use among youths has increased dramatically - between 2017 and 2018 it spiked by 78% among high school students in grades 9-12.2 This increase has raised concerns about whether e-cigarettes are starting a new generation on the road to cigarette addiction.

Next: The study


The Study

To understand the problem, researchers used data from waves 1 through 3 of the Population Assessment of Tobacco and Health Study, a nationally representative study conducted by the NIH and US FDA between 2013 and 2016. The study included questionnaire responses from 6123 youths who were tobacco naïve about timing and type of tobacco use at wave 1. Respondents were 49.5% female and 54.1% white, with a mean age of 13.4 years.

Results showed that 8.6% of respondents reported e-cigarettes as their first tobacco product by wave 3.

Over the 2 years of the study, teenagers who tried e-cigarettes first were 4 times more likely (OR, 4.09; 95% CI, 2.97-5.63), to go on to at least try cigarettes, and almost 3 times more likely, (OR, 2.75; 95% CI, 1.60-4.73) to become a current smoker vs teenagers who never tried e-cigarettes.

Interestingly, low-risk teenagers who would not engage in other risky behaviors like trying alcohol or drugs, were more likely to start smoking cigarettes as a result of using e-cigarettes. Compared to teenagers who never smoked e-cigarettes, low-risk teenagers who smoked them were 8.5 times more likely, (OR, 8.57; 95% CI, 3.87-18.97), to go on to smoke cigarettes while intermediate- and/or high-risk teenagers were 3.5 times more likely, (OR, 3.51; 95% CI, 2.52-4.89) to do so.

Because e-cigarettes are generally perceived to be safer than cigarettes, low-risk youths who might otherwise never try smoking may be tempted to try them. From there, it may be a slippery slope to cigarette addiction.

“[T]he youths initiating cigarettes through e-cigarettes represent a substantial public health challenge that may warrant stricter regulation of youths’ access to e-cigarettes,” the researchers concluded.

Next: Take home points


Take Home Points

  • Teenagers who tried e-cigarettes were 4 times more likely to at least try cigarettes and almost 3 times more likely to become current smokers in the next 2 years.

  • Low-risk youths who might otherwise not start smoking were at markedly increased risk of going on to smoke cigarettes.

  • E-cigarettes may initiate a new group of youths to cigarette addiction.

  • Teenagers’ access to e-cigarettes may need tighter regulation.


1. Berry KM, Fetterman JL, Benjamin EJ, et al. Association of electronic cigarette use with subsequent initiation of tobacco cigarettes in US youths. JAMA Netw Open. 2019;2:e187794.
2. Cullen KA, Ambrose BK, Gentzke AS, et al. Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students-United States, 2011-2018. MMWR Morb Mortal Wkly Rep. 2018;67:1276-1277.

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