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The future of electronic cigarette growth depends on youth uptake

Simon Chapman
Med J Aust 2015; 202 (9): 467-468.
doi:
10.5694/mja15.00304

Simon Chapman discusses the phenomenon of “e-cigarettes” and the potential risks associated with their use

The New South Wales Government recently announced that it will outlaw the sale of electronic cigarettes (ECs) to minors. For the unfamiliar, ECs are battery-powered vaporisers that produce an aerosol or vapour containing nicotine and other substances, rather than cigarette smoke, which the user inhales. Parallel laws banning sales of tobacco products to children have existed in Australian states since 1900.1 These laws have long been ignored by many retailers2 and are poorly enforced. Prosecutions are rare, with the laws being largely symbolic gestures.

The tobacco industry long ago perfected pious expressions of public concern about juvenile smoking, while knowing how essential new cohorts of young smokers are to its very survival as an industry. Private acknowledgement of its own duplicity was hardly surprising:3

… this is one of the proposals that we shall initiate to show that we as an industry are doing something about discouraging young people to smoke. This of course is a phony way of showing sincerity as we all well know.

Equally, any manufacturer or retailer of ECs wanting to maximise sales appreciates the critical importance of building demand for these products in the young, as well as the social and political unacceptability of being candid about this. Today, an ever-diminishing 12.8% of Australians aged 14 years and over smoke on a daily basis.4 The record low uptake of smoking by the young is most responsible for this. The prospect of the industry reversing this inexorably ruinous exodus has been given a major boost with the arrival of ECs.

Tobacco companies' investment in e-cigarettes

All tobacco transnationals have invested in ECs, with none desisting from their efforts to attack and dilute potent tobacco control policies nor announcing any phase-out of their combustible products. From this, we can conclude that the companies' best hopes are for people to smoke and to use ECs or “vape”, not to use ECs instead of smoking. At a population level, this would be harm increasing, not reducing.5 Successful EC start-up companies are being bought up by tobacco companies, so the future of ECs is likely to be in lockstep with those companies' ambitions, driven by their concern to preserve and grow immensely more profitable cigarette sales and to maximise the hours in a day when their products can be consumed.

Australian data on daily EC use are unavailable, with a 2013 national survey finding that 15.4% of smokers aged 14 years or over had used them at least once in the past 12 months,6 despite sales of nicotine liquid or “juice” being illegal here. In the United States, where ECs are freely available and heavily marketed, rising EC use by youths has now surpassed their falling cigarette smoking prevalence.7 EC advocates argue that there is thus no evidence for any gateway effect where nicotine initiation through vaping predicts uptake of smoking at higher rates than would occur without EC use. But smoking by young people has been in continual decline since 1994 in England8 and 1997 in the US9 and Australia,10 all well before the advent of ECs. Net transitioning to cigarettes or dual use with ECs in minors might be camouflaged by these broader declines. Future research will inform this important question.

Here though, a potential coalmine canary comes from a repeated Polish cross-sectional study, blithely dismissed as an outlier by vaping advocates. It found current use of ECs among Polish adolescents was dramatically higher in a 2013–14 sample than in a 2010–11 sample (29.9% v 5.5%) and that the prevalence of smoking tobacco cigarettes also increased (38% v 23.9%).11

The internet is awash with aggressive advertising for ECs,12 and the wide range of models available13 make them highly attractive to young people acutely hungry for ever-changing technology with edgy semiotics. A website sponsored by cigarette manufacturer Lorillard, which also sells Blu ECs, once stated knowingly:14

Kids may be particularly vulnerable to trying e-cigarettes due to an abundance of fun flavors such as cherry, vanilla, pina-colada and berry.

Many chemical flavourants in ECs have been approved for ingestion in foods, but not for inhalation15 up to 200 times a day, as occurs with ECs.16

The evidence relating to e-cigarette use

The volume and quality of the evidence for ECs being superior to unassisted quitting is small and often compromised by serious selection bias. EC users or “vapers” who have quit smoking understandably like to share their stories. But we have little population data on the extent to which ECs are causing prevarication about quitting, through erroneous beliefs that simply reducing smoking while dual using is harm reducing.17–19 One review concluded that real-world EC use is associated with significantly lower odds of quitting cigarettes.20

A recent systematic review of the evidence on the health risk profile of ECs concluded:21

Due to the many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up, no firm conclusions can be drawn on the safety of ECs …

Should the many hopes be realised that ECs do indeed pose minimal health risks and significantly assist in smoking cessation, future policy development in Australia will need to carefully consider how adult smokers wanting access to these products can best be facilitated without reversing the decades-long decline in youth smoking.

EC proponents argue that nicotine is almost benign in the doses obtained through vaping. However, there is growing evidence about the role of nicotine in carcinogenesis22 and the International Agency for Research on Cancer has recently prioritised the assessment of nicotine's carcinogenicity.23

Pied Pipers in the vaping and tobacco industries have attempted to argue that concern about EC uptake in youth who would have never used any nicotine product is nothing but barely disguised moralism, akin to railing against innocuous caffeine. If they are right, those urging caution about soft touch regulation will have simply been wrong. But if the EC advocates are wrong, a less than benign genie with its pharmacological clutches around millions of young people may be extremely difficult to put back in the bottle.

Provenance: 

Commissioned; externally peer reviewed.

Simon Chapman, PhD, FASSA, HonFFPH
University of Sydney, Sydney, NSW.
Competing interests: 

No relevant disclosures.

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Re: The future of electronic cigarette growth depends on youth uptake

Add new comment (maximum 250 words)

Simon Chapman cites a cross sectional study from Poland as evidence for electronic cigarettes having a harmful effect on youth smoking rates. Without going into the flaws of this study I would think that the much more comprehensive and repeated data we have on youth EC and smoking rates in the UK and the US with more similar culture, smoking rates and tobacco controls have more relevance to Australia than an isolated Polish study.

Given that 30-day prevalence data will capture a large amount of youth experimentation (a youth who has one puff on an EC or cigarette in the last 30 days is counted as a smoker or vaper) we need to look at daily smoking data to get a good idea about how the increased use of EC's is affecting smoking prevalence.

This is seldom measured compared to monthly prevalence but when it is the results call into question Australia's place as a world leader in reducing tobacco use in youth.

AIHW data shows that daily smoking rates amongst youth aged 12-17 have stubbornly refused to go down for the last 6 years. In contrast, data from some US jurisdictions show a continued decline over the same period to the point where daily smoking rates in youth are now below Australia's.

A recent study on high school students in Hawaii (mean age 14.6) showed that although past 30-day EC use was measured at 29%, in Table 2 of this study (1) it showed that daily use of EC's was at the same level as daily use of marijuana at 2% and daily cigarette smoking rates were below 1%. This is perhaps another type of “canary in the coalmine” showing that high levels of EC experimentation, which may or may not have been with nicotine, (the question was not asked), is perhaps a powerful diversion from cigarette experimentation that does not lead to sustained use and is certainly worthy of more study with an open mind.

1. Wills TA, Knight R, Williams RJ, et al. Risk Factors for Exclusive E-Cigarette Use and Dual E-Cigarette Use and Tobacco Use in Adolescents. Pediatrics. doi:10.1542/peds.2014-0760


Competing Interests: 
No relevant disclosures
Attila Danko FRACGP, BMed
None
Atilla Danko refers to selected AIHW data (1) in writing that “daily smoking rates amongst youth aged 12-17 have stubbornly refused to go down for the last 6 years” in Australia.

Danko selects the years 2007 to 2013 where daily rates changed from 3.2% to 3.4%, a tiny (0.2%) increase and a small relative increase of 6.25% in 12-17 year olds. But had he selected 2004-2013, the change was from 5.2% to 3.4%, a relative decline of 34.6%. The declines in daily smoking in the next 18-24 age group were equally dramatic: from 20.2% in 2004 to 13.4% in 2013 (a relative decline of a third).

Parallel data from the Australian National Drug Strategy surveys of secondary school students (2) include measures of smoking in the past week. In 1999, 30% of Australian 16-17 year olds smoked in the past week, and 15% of 12-15 years olds. By 2011, this had fallen to 13% and 4% respectively.

Against this spectacular success, e-cigarette advocates would have us believe that the benefits of unleashing their products on the youth market would be a “powerful diversion” from smoking, rather than a means of re-socialising the richly semiotic smoking performance among a generation rapidly abandoning it, and exposing the teenage brain to worrying neurobiological effects (3) and everything the commercial e-cigarette industry can do to ensure many years of lucrative addiction.

Two studies of teenagers from the USA and England show that non-trivial proportions of those vaping have never smoked tobacco products. In the USA, “A fifth of senior high school [students who had vaped in the past month] and nearly a third of tenth graders using e-cigarettes had no lifetime cigarette or smokeless tobacco use” (4) and in England 15.8% had never smoked cigarettes (5). In the USA today, more teenagers have vaped in the last month than smoked (6). Most teenagers who vape are vaping as well as smoking, not instead of it, a fact that would delight the tobacco transnationals who have all invested in this important key to their future.

References.

1. AIHW. National Drug Strategy Household Survey detailed report: 2013 25 Nov 2014 updated: 12 Feb 2015 Table 3.4: Tobacco smoking status, people aged 12 years or older, by age, 2001 to 2013 (per cent) http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129548784

2. Tobacco in Australia: Facts and Issues. 2015. Figure 1.6.1 http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-6-prevalence-of-smoking-secondary-students#x15.

3. Schochet TL, Kelley AE, Landry CF. Differential expression of arc mRNA and other plasticity-related genes induced by nicotine in adolescent rat forebrain. Neuroscience 2005; 135(1):285-97.

4. Compton W. E-cigarettes and teens: how concerned should we be? BMC Series Blog 31 Mar 2015 http://blogs.biomedcentral.com/bmcseriesblog/2015/03/31/e-cigarettes-teens/?utm_campaign=BMC18155B7&utm_medium=BMCemail&utm_source=Teradata
5. Hughes K, Bellis MA, Hardcastle KA, McHale P, Bennett A, Ireland R, Pike K. Associations between e-cigarette access and smoking and drinking behaviours in teenagers. BMC Public Health 2015; 15:244 doi:10.1186/s12889-015-1618-4 http://www.biomedcentral.com/1471-2458/15/244
6. Michigan News. University of Michigan. E-cigarettes surpass tobacco cigarettes among teens Dec 16, 2014
http://monitoringthefuture.org/pressreleases/14cigpr.pdf
Competing Interests: 
No relevant disclosures
Simon Chapman AO PhD FASSA
School of Public Health, University of Sydney