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Original Investigation |

Progression to Traditional Cigarette Smoking After Electronic Cigarette Use Among US Adolescents and Young Adults

Brian A. Primack, MD, PhD1,2,3; Samir Soneji, PhD4,5; Michael Stoolmiller, PhD6; Michael J. Fine, MD, MSc1,7; James D. Sargent, MD4,5,8
[+] Author Affiliations
1Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
2Center for Research on Media, Technology, and Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
3Division of Adolescent Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
4Norris Cotton Cancer Center, Geisel School of Medicine, Dartmouth University, Hanover, New Hampshire
5Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth University, Hanover, New Hampshire
6Oregon Social Learning Center, College of Education, University of Oregon, Eugene
7Center for Health Equity and Research Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
8Department of Pediatrics, Geisel School of Medicine, Dartmouth University, Hanover, New Hampshire
JAMA Pediatr. 2015;169(11):1018-1023. doi:10.1001/jamapediatrics.2015.1742.
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Importance  Electronic cigarettes (e-cigarettes) may help smokers reduce the use of traditional combustible cigarettes. However, adolescents and young adults who have never smoked traditional cigarettes are now using e-cigarettes, and these individuals may be at risk for subsequent progression to traditional cigarette smoking.

Objective  To determine whether baseline use of e-cigarettes among nonsmoking and nonsusceptible adolescents and young adults is associated with subsequent progression along an established trajectory to traditional cigarette smoking.

Design, Setting, and Participants  In this longitudinal cohort study, a national US sample of 694 participants aged 16 to 26 years who were never cigarette smokers and were attitudinally nonsusceptible to smoking cigarettes completed baseline surveys from October 1, 2012, to May 1, 2014, regarding smoking in 2012-2013. They were reassessed 1 year later. Analysis was conducted from July 1, 2014, to March 1, 2015. Multinomial logistic regression was used to assess the independent association between baseline e-cigarette use and cigarette smoking, controlling for sex, age, race/ethnicity, maternal educational level, sensation-seeking tendency, parental cigarette smoking, and cigarette smoking among friends. Sensitivity analyses were performed, with varying approaches to missing data and recanting.

Exposures  Use of e-cigarettes at baseline.

Main Outcomes and Measures  Progression to cigarette smoking, defined using 3 specific states along a trajectory: nonsusceptible nonsmokers, susceptible nonsmokers, and smokers. Individuals who could not rule out smoking in the future were defined as susceptible.

Results  Among the 694 respondents, 374 (53.9%) were female and 531 (76.5%) were non-Hispanic white. At baseline, 16 participants (2.3%) used e-cigarettes. Over the 1-year follow-up, 11 of 16 e-cigarette users and 128 of 678 of those who had not used e-cigarettes (18.9%) progressed toward cigarette smoking. In the primary fully adjusted models, baseline e-cigarette use was independently associated with progression to smoking (adjusted odds ratio [AOR], 8.3; 95% CI, 1.2-58.6) and to susceptibility among nonsmokers (AOR, 8.5; 95% CI, 1.3-57.2). Sensitivity analyses showed consistent results in the level of significance and slightly larger magnitude of AORs.

Conclusions and Relevance  In this national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e-cigarettes to adolescents and young adults.





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Sample size
Posted on September 10, 2015
Robert Cranfield MD
Conflict of Interest: None Declared
It seems the sample size of 16 e-cig users is too small to be meaningful.
The motivation of a non smoker to use e-cigs is often to divert themselves from smoking. So it would be impossible to say that these people were not motivated to try cigarettes, or even had the same level of motivation to try cigarettes. They likely were more motivated and hence more likely to try them than a never smoker, never vaper. The fact that you had so much trouble finding even a small sample size indicates that it is rare to pick up an e-cig unless you are motivated to smoke.
Electronic cigarettes - Solution turning to a big problem.
Posted on September 11, 2015
Rajiv Kumar
Faculty, Deptt. of Pharmacology, Government Medical College & Hospital, Chandigarh India.
Conflict of Interest: None Declared
I agree with the authors and this is very true, that the use of e-cigarettes is associated with progression to traditional cigarette smoking. In the year 2004 the first e-cigarettes, a Chinese invention, came from the Ruyan company as a pathway to the reduction of tobacco smoking or tobacco harm reduction (THR); e-cigarettes were marketed as less harmful alternatives to smoking.[1]. The Oxford Dictionary named \"vape\" the 2014 word of the year, marking the rise of a billion-dollar electronic-cigarette industry. E-cigarettes have become a fashion statement among young tobacco users & their use is booming as “gateway devices” for smoking among young people . Vaporizer refills of e-liquid (or “juice”) are available in little colored bottles in different flavors & nicotine concentrations and attracts infants and young children. There are reports of e-liquid poisonings in childrens and in adults [2].
E-cigarettes must be appropriately regulated to maximize the benefits and to minimize the risks. There is a need for well designed studies & pharmacovigilance programme for Electronic Nicotine Delivery Systems [3].
1. Backgrounder on WHO report on regulation of e-cigarettes and similar products. Geneva: World Health Organization (WHO), 26 Aug 2014.http://www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/
2. Re: First TV advertisement for e-cigarettes prompts complaint
3. Re: Regulation of electronic cigarettes
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