It’s no secret that e-cigarettes are popular. More than a quarter of U.S. adults have used them at least once in their lives, and more than half say they’ve heard about the devices. But what is it like for people who use e-cigs? A new survey suggests it could be a gateway drug — not just for those already addicted to traditional cigarettes, but also for those who haven’t smoked yet.
The study, published Thursday in JAMA Internal Medicine, found an uptick in e-cigarette use among adults in recent years — from 1.9 percent of people aged 18 to 34 in 2008 to 4.5 percent in 2017. Among adults 25 and older, usage jumped from 0.6 percent of users in 2008 to 3.8 percent in 2017. The researchers looked at data on nearly 40,000 adults over 20 years old from the Behavioral Risk Factor Surveillance System from five states (Arkansas, Iowa, North Carolina, Ohio and Tennessee) between 2008 to 2016.
“We found an increase in ever using e-cigarettes by more than 50 percent during this period,” said Dr. Michael Siegel, a professor of community health sciences at Boston University School of Public Health, who led the study. “If you go back even further, the increase was about 75 percent.”
E-cigs come in many forms. There are disposable models that look like candy cigarettes that users load with nicotine or liquid refills. Some can produce flavored vapor that looks like smoke. And then there are vaping pens, such as Juul, which allow users to inhale nicotine in liquid form through a small cartridge. They’re designed to mimic smoking behavior, often producing a tobacco flavor. While other studies have found that a majority of current smokers began with combustible cigarettes, the JAMA analysis didn’t find evidence that e-cig use increased the odds of smoking conventional cigarettes. Instead, the authors suggest that e-cigarette use may serve as a “gateway drug” leading to nicotine use — whether from cigarettes or any other source — and eventually traditional cigarette smoking.
There’s reason to believe that this may be happening. In the same time period, the number of young adults who reported having tried smoking cigarettes dropped from 13.2 percent in 2008 to 8.3 percent in 2016. Meanwhile, the percentage of adults reporting past year e-cigarette use rose from 2.1 percent to 6.6 percent in the same period. Those numbers were consistent across all age groups.
“When we talk about ‘vaping,’ we’re talking about e-cigarettes,” said Siegel. “People are saying they want to quit smoking cigarettes, but if you start out trying to quit smoking cigarettes with e-cigarettes, that doesn’t work very well.”
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While it’s possible that some people who try e-cigarettes might stick with them for a while, others likely will fall off the wagon.
“This is not something to be encouraged,” says Siegel. “Rather, it should be discouraged as part of a comprehensive approach to public health to reduce adult smoking rates.”
Still, he added, a key point here is that a lot of the research around e-cigarettes has been based on self-reported data, meaning that what people say about their habits is not necessarily accurate. So, while there may be an increase in e-cigarette use, it’s hard to know how much of that increase is real.
E-cigarettes aren’t a new idea, either. The industry traces its roots back to 2003 when two Chinese chemists created a device that allowed users to inhale nicotine without burning anything. It wasn’t until later that the technology was adapted into a product that resembled a cigarette.
In the United States, the first wave of interest in e-cigarettes came in 2007, when the Food and Drug Administration approved one brand called NJOY. Today, the FDA lists nine products on the market; three of those are devices that deliver nicotine via a patch, two deliver it through pills, three deliver it through gels, and one delivers it through a mouthpiece. None of these products are considered to be safe for long-term use, nor do they appear to help people quit smoking.
But the popularity of e-cigarettes has exploded. As of 2015, there were an estimated 2.6 million adult vapers in the U.S., according to the Centers for Disease Control and Prevention. That year, sales of e-liquids hit $1.4 billion. By 2018, the CDC estimated that 5.6 million Americans had used e-cigarettes in the prior 30 days. Sales of e-liquid hit $2.7 billion.
The rise in e-cigarette use coincides with a steep decline in smoking rates. From 1999 to 2014, regular cigarette smoking fell from 19.5 percent down to 12.4 percent of adults in the U.S. The decrease was largely driven by declines among men and women ages 18 to 24, who collectively went from 28 percent to 15 percent.
For teens, however, things look different. E-cigarette use among high schoolers actually rose from 7.9 percent in 2011 to 11.6 percent in 2014. While the rate of adolescent e-cigarette use remains relatively low, experts worry that kids are getting hooked on nicotine early, before they even know what they’re doing.
“You see an increasing trend of adolescents starting to use e-cigarettes,” said Dr. Robert West, a professor of pediatrics and psychiatry at Wake Forest Baptist Medical Center who specializes in addiction medicine. “That’s concerning because adolescents have a higher propensity to become addicted to substances. We don’t really understand why they would be using e-cigarettes, but if the trend continues, we’ll need to address that problem.”
West notes that the American Academy of Pediatrics recently issued guidelines stating that e-cigarettes shouldn’t be recommended for children under age 16. He thinks that’s wise, since it’s unclear exactly what effects e-cigarettes have on developing brains.
Another concern is that e-cigarettes may encourage adolescents to experiment with other drugs, including marijuana. A study published in July in Addiction showed that teens who’d used e-cigarettes were more likely to report using marijuana than non-users.
So, will e-cigarettes cause a big surge in traditional cigarette smoking? Not immediately. E-cigarettes don’t seem to be helping anyone quit smoking. That hasn’t stopped companies from making claims that their devices will help people quit smoking.
A recent study by the National Academies of Sciences, Engineering and Medicine found that e-cigarettes aren’t effective for quitting, citing lack of quality control, variability in manufacturing, and inconsistent regulation. The FDA requires certain standards for safety and effectiveness, but there’s no requirement for companies to provide proof that their products work.
Instead, the best advice seems to be to avoid e-cigarettes altogether. If you’re going to smoke anyway, don’t use a product that could make your habit worse.
“It’s important to recognize that e-cigarettes are not harmless, and that they are not risk free,” said West. “They’re not a replacement for cigarettes, and I think the jury is still out on whether they’re harmful.”
