Is Vaping a Gateway to Cigarettes for Kids?

Lara Salahi

April 03, 2023

Vaping may not be a gateway to long-term cigarette use for adolescents, a new study published in JAMA Network Open suggests.

Many studies have found that youth who vape are more likely to take up cigarette smoking, but whether that new habit lasts for a month or a lifetime has been unclear.

The percentage of adolescents who move on to smoking after starting to vape remains low, and those who do start smoking are unlikely to continue doing so for a long time, the new research shows.

Dr Ruoyan Sun

"If they simply experiment with smoking but do not continue, their risks of smoking-related adverse health outcomes are low," said Ruoyan Sun, PhD, assistant professor with the Department of Health Policy and Organization at the University of Alabama at Birmingham and the study's lead author. "But if they do become regular or established smokers, then the risks can be substantial."

Sun and her colleagues analyzed data from several waves of the longitudinal Population Assessment of Tobacco and Health (PATH) study. Participants included 8671 children and adolescents aged 12 to 17 years. Among teens who had ever vaped, 6% began smoking cigarettes and continued to smoke in the subsequent 3 years, the researchers found (95% CI, 4.5% to 8.0%), compared with 1.1% among teens who never vaped (95% CI, 0.8% to 1.3%).

"The real concern is whether vaping is inducing significant numbers of young people to become confirmed smokers," said Sun. "The answer is that it does not."

Previous studies using PATH data have suggested that adolescents who use e-cigarettes are up to 3.5 times more likely than nonusers to start smoking tobacco cigarettes and that they may continue to use both products.

But in the new study, despite the low overall number of cigarette smokers, those in the group who used e-cigarettes were 81% more likely to continue smoking tobacco cigarettes after 3 years, compared to those who did not use e-cigarettes, researchers found (95% CI, 1.03 – 3.18).

Rachel Boykan, MD, clinical professor of pediatrics and attending physician at Stony Brook Children's Hospital, in Stony Brook, New York, said that despite the findings, the overall messaging to patients remains the same: Vaping is linked to smoking.

"There is still a risk of initiation smoking among e-cigarette users ― that is the take-home message," Boykan, who was not affiliated with the study, said. "No risk of smoking initiation is acceptable. And of course, as we are learning, there are significant health risks with e-cigarette use alone."

Among the entire group of teens, approximately 4% of the adolescents began smoking cigarettes; only 2.5% continued to smoke in the subsequent 3 years, the researchers found.

"Based on our odds ratio result, e-cigarette users are more likely to report continued cigarette smoking," said Sun. "However, the risk differences were not significant."

The low numbers of teens who continued to smoke also suggests that adolescents are more likely to quit than become long-term smokers.

Nicotine dependence may adversely affect the ability of adolescents to learn, remember, and maintain attention. Early research has suggested that long-term e-cigarette smokers may be at increased risk of developing some of the same conditions as tobacco smokers, such as chronic lung disease.

Brian Jenssen, MD, a pediatrician at Children's Hospital of Philadelphia and assistant professor in the Perelman School of Medicine at the University of Pennsylvania, said that the analysis is limited in part because it does not include changes in smoking and vaping trends since the pandemic started, "which seems to have increased the risk of smoking and vaping use," he said.

Data from the 2022 National Youth Tobacco survey found that although the rate of middle school and high school students who begin to use e-cigarettes has steadily decreased during the past two decades, those who vape report using the devices more frequently.

Subsequent use of cigarettes is also only one measure of risk from vapes.

"The goal isn't just about cigarettes," said Jenssen, who was not affiliated with the new study. "The goal is about helping children live tobacco- and nicotine-free lives, and there seems to be an increasing intensity of use, which is causing its own health risks."

The current study findings do not change how clinicians should counsel their patients, and they should continue to advise teens to abstain from vaping, he added.

Sun said it's common for youth to experiment with multiple tobacco products.

"Clinicians should continue to monitor youth tobacco-use behaviors, but with their concern being focused on youthful patients who sustain smoking instead of just trying cigarettes," she said

Some of the study authors received support from the National Cancer Institute of the National Institutes of Health and the US Food and Drug Administration's Center for Tobacco Products.

JAMA Netw Open. Published online March 27, 2023. Full text

Lara Salahi is a journalist living in Boston.

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.