Is the Association Between E-Cigarettes and Combustible Tobacco Use Bi-Directional?

Adolescents who reported use of electronic cigarettes (e-cigarettes) were more likely to initiate use of a combustible tobacco product over the next year, according to the results of a study published Aug. 18 in the Journal of the American Medical Association (JAMA).

Researchers evaluated reported e-cigarette use among 14-year-old adolescents at baseline, six months and 12 months to determine whether e-cigarette use led to first use of combustible tobacco products like cigarettes, tobacco and hookah. Data were collected from 3,383 adolescents at baseline, 3,293 at six months and 3,282 at 12-month follow-up.

The results of the study showed that e-cigarettes use at baseline was associated with combustible tobacco use at baseline. Further, e-cigarette users at baseline were more likely to have used at least one combustible tobacco product at six month and 12 month follow-ups. Reported use of any combustible tobacco product at baseline was positively associated with e-cigarette use at both follow-up periods.

“Collectively, these results raise the possibility that the association between e-cigarette and combustible tobacco use initiation may be bidirectional in early adolescence,” according to the study authors. The authors also note that non-smoking adolescents who are exposed to nicotine-rich e-cigarette aerosols could be more likely to experiment with other related products.

In an accompanying editorial, Nancy A. Rigotti, MD, states that “regardless of whether e-cigarettes are a gateway to tobacco product initiation, there is no reason for adolescents to use a product for which the hypothesized public health benefit is hard reduction for adult smokers.”

“Knowing the long-term consequences of tobacco use, it is mind boggling to think that anyone would assume e-cigarette use is acceptable among children, when for many it can function as an entry drug,” said ACC President Kim Allan Williams Sr., MD, FACC. “This research provides one more piece of evidence that what common sense tells us is likely true: inhaling an addictive chemical is not good for anyone. We should not wait for a new generation to become addicted tobacco users to regulate e-cigarettes and prohibit marketing to minors. Changes in attitudes about smoking, regulation of advertising and the resulting declines in tobacco use have contributed significantly to reductions in heart disease wherever implemented around the world in the last 30 years. We want to move ahead in preventing heart disease and not reverse our positive trends.”

In a related Viewpoint also published in JAMA, Andrew Y. Chung, MD, and Michele Barry, MD, examine the global health implications of e-cigarettes on developing countries. “Technology-interested youth in [low- or middle-income countries] are most likely to adopt e-cigarette smoking behaviors, making them an attractive target for recruitment,” they state. “Developing nations should not underestimate the availability and targeted marketing of [e-cigarettes] within their borders and should place e-cigarettes under the purview of their medical and pharmaceutical regulatory boards.” 

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Prevention, CHD and Pediatrics and Prevention, Smoking

Keywords: Adolescent, Aerosols, Developing Countries, Electronic Cigarettes, Global Health, Heart Diseases, Minors, Smoking, Tobacco Use

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