Deciphering the Correlation Between Youth e-Cigarette and Tobacco Use

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Teens who use e-cigarettes or other tobacco-related products are more likely to later initiate cigarette use, according to a new study in JAMA Network Open.

Youths who previously engaged in e-cigarette or other tobacco-related product use were more likely to smoke combustible cigarettes in the future, according to a new study in JAMA Network Open on the link between electronic cigarette and tobacco use among US teens and young adults.

The authors analyzed data from 3 waves of the Population Assessment of Tobacco and Health (PATH) study, which represents a large sample size of the US population, to measure the correlation between e-cigarette use and conventional cigarette smoking over a 2-year period. PATH used a 4-stage, stratified probability sample to collect and evaluate data on tobacco use. The first wave of data was collected between September 2013 and December 2014, the second wave was gathered between 2013 to 2015, and the third was collected between 2015 and 2016. The study included a sample of 6123 total participants between the ages of 12 and 15 who were tobacco naïve at wave 1.

The final wave of the study found that cigarette use (6.1% overall) was more prevalent among youths who previously used e-cigarettes (20.5%) compared with youths who had never used tobacco (3.8%). Also, reported 30-day use of cigarettes (2.1% of total sample) was greatest among past users of another tobacco product (8.2%) followed by those who used e-cigarettes (5.9%) and those with no history of tobacco use (1.4%).

After thorough data analysis, the authors estimated tobacco use initiated by e-cigarette use can be attributed to 21.8% of new ever cigarette use and 15.3% of current cigarette use. In comparison, noncigarette products were only attributed to 12.8% of cigarette initiation and 13.7% of current use.


“These estimates suggest that the proportion of smoking attributable to e-cigarettes may be larger than the proportion attributable to all other products combined,” the authors wrote. As e-cigarette use continues to rise among US youths, growing concerns over whether they will be propelled to smoke combustible cigarettes in the future continue to escalate.

The number of US youths using electronic cigarettes has increased exponentially at an alarming rate between 2011 (1.5%) to 2018 (20.8%). Trends show that the most dramatic rise occurred between 2017 and 2018, when use nearly doubled by 78%. Concerns that e-cigarettes may support streamlined tobacco use among a new generation of teens have continued to grow. The link between e-cigarette and traditional cigarette use can potentially reverse decades of progress lowering the prevalence of tobacco-related disease and mortality within the United States.

“This large, nationally representative study of US youths supports the view that e-cigarettes represent a catalyst for cigarette initiation among youths,” the authors warned. “The association was especially pronounced in low-risk youths, raising concerns that e-cigarettes may renormalize smoking behaviors and erode decades of progress in reducing smoking among youths.”

There are a multitude of reasons that can explain the rise in e-cigarette smoking among youths. According to the authors, low-risk youths are attracted to e-cigarettes because of their flavors, perceived safety, and higher acceptance among peers. Once youths start smoking e-cigarettes, they are at risk of subsequent initiation of cigarettes, “potentially through nicotine addiction, social and behavioral mechanisms including increased access and exposure to tobacco products or increased willingness to take risks, or through the development of a familiarity with the ritualistic procedures of smoking,” the authors explained. Hence, the market for e-cigarettes among teens and young adults is driven by peer pressure, misinformation that promotes e-cigarettes as a healthy alternative to combustible cigarettes, and the availability of flavors that appeal to a younger audience.

The authors advocated finding ways to make e-cigarettes and other tobacco-related products less obtainable for teens and young adults.

“These findings strengthen the rationale for aggressive regulation of youth access to and marketing of e-cigarettes to achieve future decreases in the prevalence of cigarette use among youths,” the authors concluded.


Berry KM, Fetterman JL, Benjamin EJ, et al. Association of electronic cigarette use with subsequent initiation of tobacco cigarettes in US youths. JAMA Netw Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794.