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Evidence Mounts That E-Cigarettes May Lead Youth To Start Smoking

E-cigarettes may set young people on the path to smoking regular cigarettes, according to a new study published in JAMA Pediatrics.

Between 2012 and 2013, researchers at the University of Pittsburgh Center for Research on Media, Technology, and Health and the Dartmouth-Hitchcock Norris Cotton Cancer Center  reviewed data from nearly 700 participants from ages 16 to 26 across the United States. While participants initially said they definitely would not smoke cigarettes, some changed their minds. The researchers found that 38 percent of those who used e-cigarettes progressed to regular cigarettes, compared to just 10 percent of participants who did not use e-cigarettes.

The e-cigarette users were also more likely to consider smoking in the future, when they previously opposed the idea.

The researchers only had 16 total e-cigarette users in their study—a small number when trying to draw conclusions. But Brian Primack, associate professor of medicine and pediatrics at the University of Pittsburgh and lead author of the report, says the results are consistent with other similar studies, such as a study published last month of more than 2,500 high-school students in Los Angeles. A recent study from the Centers for Disease Control and Prevention showed that e-cigarette use tripled between 2013 and 2014 among middle and high school students.  

Primack’s study is the first to track nicotine product use in both adolescents and young adults nationally. He says it’s important to look at people over the age of 18 because many choose to start smoking in their 20s.

Primack says it makes sense that e-cigarettes would serve as a gateway to real ones.

“E-cigarettes deliver nicotine more slowly than traditional cigarettes,” he says. “So it is sort of a perfect starter cigarette. A new user can start with e-cigarettes, and then progress to regular cigarettes when they need more nicotine.”

The U.S. Food and Drug Administration is considering new regulations for e-cigarettes, including an age requirement, but for now, there are many differences in how the two products can be marketed and sold.

E-cigarettes can advertised on television, unlike real ones. The last television ad for cigarettes ran in 1971, but e-cig ads have become common (see below). A law signed in 2009 by President Barack Obama prevents cigarette companies from using flavors besides menthol or tobacco. But e-cigarette companies are allowed to incorporate candy-like flavors into their products.  

Primack says the e-cigarette ads evoke many of the same attitudes as old cigarette ads, including rebelliousness and relaxation. And the flavors may draw more young people to vaping, before they try real cigarettes.

“It's potentially analogous to kids who start by drinking wine coolers . . . as teenagers,” he says. “And then they progress to shots of whiskey or tequila later on.”

With the lack of federal regulation, some states have begun regulating the products within their borders. For example, Hawaii made it illegal for anyone under 21 to buy or use cigarettes or e-cigarettes.

Proponents of e-cigarettes argue that they can help smokers cut back or quit. Primack acknowledged that e-cigarettes could certainly help some individuals, but he’s rarely seen it work with his patients and he’s seen no convincing data thate-cigarettes could be used as a long-term cessation technique. 

“I think this is going to be a tricky balance that I leave to the lawmakers,” Primack says, adding that his job is to gather the data. “Ultimately, it's going to be the lawmakers who will have to figure out the best balance for society.”


Jake Harper is an investigative reporter for Side Effects Public Media, and he is a co-host of the Sick podcast. He can be reached at