4.1 Do e-cigarettes appeal to adolescents?

Yes, but it’s complicated. The first thing we need to do is actually understand what is going on.  Most adult or illicit products or behaviours will appeal to some adolescents – this applies to alcohol, drugs, gambling, pornography etc  Adolescence is a transition from childhood to adulthood. There has been a recent rapid increase in e-cigarette use by American adolescents. But the definition used includes anyone taking one puff in the past 30 days before the survey. Drilling down into this data shows most US teen vaping is infrequent. Among frequent users, the vast majority had already smoked and for them, e-cigarettes may be beneficial. Amongst users with no prior tobacco use, there is little sign of adolescent vaping causing addiction.

The most common reason given by US adolescents for taking up vaping is ‘curiosity’ (not flavours) – see CDC.

Reason given (top 5 only)E-cig only usersE-cig and other tobacco users
I was curious about them56.1%38.4%
Friend or family used them23.9%22.2%
They are available in flavors, such as mint, candy, fruit, or chocolate22.3%26.6%
I can use them to do tricks22.0%29.0%
They are less harmful than other forms of tobacco, such as cigarettes17.0%19.1%

It is quite possible that the publicity surrounding youth vaping in the United States has stimulated curiosity and so contributed to its cause. An own goal.

Further reading

  • Clive Bates, Research suggests broader causes for youth vaping uptake than flavours, 2019 [link]

4.2 Is there a ‘youth vaping epidemic’ in the United States?

No. This has been hyped up into a national and international moral panic.   There has been a rise in the use of vaping products by adolescents, and in the United States, this has risen rapidly to from 2017 (11.8%) to 2019 (27.5%).  This is a concern, but it is necessary to drill down to understand what is really going under the headline numbers.

  1. The definition of teen vaping is very broad and includes anyone who took a single puff in the past 30 days.
  2. Most teen vapers are vaping infrequently – mostly experimental or just ‘party use’
  3. Nearly all of the daily or frequent users were already using tobacco, mainly smoking – for them vaping may be a beneficial diversion either now or in the future
  4. Among young people who have not  previously used tobacco, there is little sign of dependence among those who vape

Further reading

  • Clive Bates: The great American youth vaping epidemic. Really? 29 January 2019 [link]
  • West et al. QEIOS, Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey reveal about high school e-cigarette use in the USA? (2019 Preprint) [link]
  • Abrams et al. Most Young People Do Not Vape, and Even Fewer Vape Regularly, 2019 [link]

4.3 Is vaping a gateway to smoking?

No, there is no compelling evidence for this theory. However, we do see a quite strong association between young people who vape and then subsequently smoke. They are about four times as likely to smoke if they have vaped.  This has allowed some academics or activists to claim a gateway effect.  But this approach is flawed – you would need to know what the person would have done in the absence of vaping, and many would have progressed straight to smoking. It is most likely that ‘common liability’ explains the associations.  This means that the same factors that incline young people to smoke also incline them to vape. The factors might include genetics, family smoking history, home circumstances, mental health and personal efficacy, delinquency, educational attainment, social group etc.   Statisticians can try to eliminate these ‘confounding’ factors from the association to show that what is left of the association can be attributed to trying vaping. The trouble is that they can never do this completely – they will never have enough data or accurate models for confounding, and therefore never be able to eliminate these factors completely.

Further reading

  • Vanyukov, et al. Common liability to addiction and “gateway hypothesis” theoretical, empirical and evolutionary perspective. Drug Alcohol Depend. 2012. [link].
  • Phillips C V. Gateway Effects: Why the Cited Evidence Does Not Support Their Existence for Low-Risk Tobacco Products (and What Evidence Would). Int J Environ Res Public Health 2015;12:5439–64. [link]
  • Carl V Phillips, Science Lesson: How Understanding ‘Confounding’ Can Combat Anti-Vaping Junk Science, 20 November 2017 [link]
  • Lee PN et al. Considerations related to vaping as a possible gateway into cigarette smoking: an analytical review, 2019 [link]
  • Chan GCK, Stjepanovic D, Lim C, Sun T, Shanmuga Anandan A, Connor JP, et al. Gateway or common liability? A systematic review and meta‐analysis of studies of adolescent e‐cigarette use and future smoking initiation. Addiction. 2020 Sep 4; [link]

4.4 Should flavours be banned to stop youth vaping?

No. E-cigarettes and e-liquids are inherently flavoured products – all products, including the tobacco flavoured products – have flavouring agents added to give them flavour. Banning all or most flavours would be like banning all or most toppings on pizzas – it would effectively prohibit all or most of the products, leaving only the unattractive base or tobacco-flavoured liquids. This would make e-cigarettes nearly useless as alternatives to smoking for adults, promote a black market and may even increase risks to young people if it encourages them to smoke or to access black markets. It may make sense to ban certain flavour descriptors (the names given to flavours), if these are designed to appeal to youth.

Further reading

  • Clive Bates. The US vape flavour ban: twenty things you should know. 4 November 2019 [link]

4.5 Should e-cigarette sales be restricted to people aged 18 and over?

Yes, probably. It is widely held that under-18s should not be using any tobacco or nicotine products and therefore it should be against the law to sell such products to them. Though this is necessary to reassure parents and to give legitimacy to products and an industry aimed at adults, it may have possible unintended consequences. There is some evidence that when e-cigarette age restrictions were introduced in the United States, there was a relative increase in teenage cigarette smoking. It is possible that under-18s benefit from e-cigarettes by displacing or not initiating smoking and therefore that making them more difficult to access could be a source of unintended harm. So although there is near-universal support for age restrictions at 18 or 21 for sales of e-cigarettes, even this idea has potential harmful unintended consequences.

Further reading

  • Friedman AS. How does Electronic Cigarette Access affect Adolescent Smoking? J Health Econ: October 2015. [link]
  • Pesko MF, Hughes JM, Faisal FS. The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use. Prev Med (Baltim), February 2016 [link]

4.6 Does nicotine damage the developing adolescent brain?

No, this is a scare story and the claims do not bear scrutiny.  Some public figures, including the US Surgeon General, have suggested that nicotine damages the adolescent brain.  The evidence for this hypothesis comes only from a few rodent studies.  These are an unreliable guide to human risk because the rodent brain does not offer a reliable proxy for the human brain and it is difficult to design experiments that are controlled to give a mouse equivalent exposure to a human.

But this is not the main reason for doubt.  Over the last 60 years, millions of adolescent nicotine users have grown up as smokers and either continue to use nicotine or have quit.  The problem for the Surgeon General and others is that there is no sign of any cognitive impairment in the population of former teenage smokers and many of today’s finest adult minds were once young smokers. If a detrimental cognitive effect of nicotine existed in the human population, it is inconceivable that we would not already have seen extensive evidence of it from the study of smokers, non-smokers and ex-smokers over several decades.

Further reading

  • Arnold Foundation, Why Journalists Should Stop Publishing Studies Conducted With Mice, 2018 [link]

4.7 What can be done to protect young people?

Regulations to protect youth should always be targeted at youth and not indiscriminately affect adults (for example through flavour bans, nicotine limits, blanket advertising bans, or taxes). There are three main legitimate policy approaches to protect young people:

  1. control access by setting age limits and restricting where and how products can be purchased;
  2. control marketing, packaging and branding to prevent marketing targeted at adolescents;
  3. provide credible reality-based campaigns, information and warnings targeted at young people.

Pretty well everything else is either ineffective or counterproductive.

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