Age of initiation to vaping, predictor of future smoking among adolescents?

A French study highlights two phenomena associated with the initiation of vaping before the first cigarette: if a first experiment could have a negative influence on the outcome of daily smoking, it is the age of this initiation which would be the determining factor in entry into smoking.

The ESCAPAD study, regularly conducted in France since 2000, takes stock of the health and consumption of 17-year-olds summoned during the Defense Preparation Call days and has given rise to numerous publications. One of the latest of these looked at the smoking habits of young people who had tried electronic cigarettes before traditional cigarettes.[1].

Early initiation as a major risk factor

Based on a sample of 24,111 participants, the study established for 2017 an average age of experimentation with smoked cigarettes before e-cigarettes at 14.2 years and an experimentation with e-cigarettes before smoked cigarettes at 15.1 years. Two findings are made in this study. The first is to observe that young people who experimented with e-cigarettes before smoked cigarettes would have 40% less risk of having become daily smokers between the ages of 17 and 18.5 years (age difference at the time of the study). The second is that the age of experimentation with vaping would be decisive in future smoking status, with young people who experimented with e-cigarettes earliest having a significantly greater risk of subsequently becoming daily smokers.

The authors analyse these results with those of studies conducted on the same theme. Many Anglo-Saxon studies have shown conversely that initiation to e-cigarettes could constitute a gateway to smoking, in contexts of very low smoking prevalence among young people (8% in the United States and 15% in the United Kingdom, in 2016). In France, the prevalence of smoking among young people is still very high with, according to ESCAPAD 2017, 25% daily smokers. On the other hand, while there are 16% vaping experimenters, fewer than 2% are daily vapers, while daily vaping in the United States was 11.6% in 2019. Thus, the stage reached by each country in the tobacco epidemic is interpreted as one of the reasons why young French people would be less inclined to e-cigarettes. Young people experimenting with e-cigarettes before tobacco would also be less in search of transgression and sensations than those who first start by experimenting with smoked tobacco. An early age of initiation to e-cigarettes would, on the other hand, be a factor aggravating the risks of subsequently becoming a daily smoker, as well as a polyuser of psychoactive substances; later experimentation with e-cigarettes would have a lesser impact on entry into active smoking.

Other arguments put forward by the authors to explain their differences in results include, on the one hand, the regulation of advertising and sales of electronic cigarettes to minors (supervised since 2016 in France, later or still in progress in Anglo-Saxon countries), and on the other hand, the nicotine content of e-liquids. In France, these contents are limited to 20 mg/ml, whereas they could reach 59.9 mg/ml in JUUL e-cigarette refills in the United States and Canada, which would explain the greater dependence of young North Americans introduced to nicotine through electronic cigarettes.

A causality still under discussion

This study raises many questions at a time when the whole world is questioning the merits of using electronic cigarettes and the tobacco industry is constantly promoting electronic nicotine delivery devices. While most publications indicate more pronounced effects of switching from electronic cigarettes to smoked cigarettes[2], some of them, although not suspected of being linked to the tobacco industry, point to a rather weak trend in this transition[3].

One of the limitations of the French study, which acknowledges that longitudinal studies highlight the role of vaping in the onset of smoking, seems to be its relevance over time. Addictions can develop gradually, sometimes over several years; it may therefore seem premature to announce that a 17-year-old who has not yet become a daily smoker will never become one. Furthermore, while regular vaping appears to be significantly less harmful than smoking, it is far from risk-free and could eventually lead to cardiac and respiratory pathologies similar to those of smoking.[4]. Furthermore, the use of electronic cigarettes as an effective smoking cessation tool has not yet been formally established. A US study has just shown that, during the thirties, previous use of electronic cigarettes by smokers is associated with a lower propensity to quit smoking.[5]. But like other studies analyzing this question, this is a retrospective study on a limited number of smokers and does not allow for a correct analysis of all confounding factors.

Most of these findings had already been established at the beginning of 2021 by the SCHEER report, which concluded that there was a "moderate" influence of the switch from e-cigarettes to smoked tobacco and a weak influence of vaping in quitting smoking.[6]. On the other hand, he confirmed the major role of nicotine in the development of an addiction and that of aromas in the attractiveness of electronic cigarettes.

Keywords: Electronic cigarette, Vaping, Youth, Smoking

©Tobacco Free Generation

M.F.

[1] Legleye S, Aubin HJ, Falissard B, Beck F, Spilka S, Experimenting first with e-cigarettes versus first with cigarettes and transition to daily cigarette use among adolescents: the crucial effect of age at first experiment. Addiction, 116, 6, June 2021, 1521–1531. https://pubmed.ncbi.nlm.nih.gov/33201553/

[2] Berry K, Fetterman J, Benjamin E, Bhatnagar A, Barrington-Trimis J, Leventhal A, Association of Electronic Cigarette use with subsequent initiation of tobacco cigarettes in US youths. JAMA Network Open 2019; 2:e187794.

[3] Sun T, Lim C, Stjepanović D, Leung J, Connor J, Gartner C, Hall D, Chana G, Has increased youth e-cigarette use in the USA, between 2014 and 2020, changed conventional smoking behaviors, future intentions to smoke and perceived smoking harms? Addictive Behaviors Volume 123, December 2021, 107073. Available online 30 July 2021. https://doi.org/10.1016/j.addbeh.2021.107073

[4] Eltorai AEM, Choi AR, Eltorai AS, Impact of Electronic Cigarettes on Various Organ Systems. Respiratory Care. 2019;64(3):328-336.

[5] Kosterman R, Epstein M, Bailey J, Furlong M, Hawkins D, The role of electronic cigarette use for quitting or reducing combustible cigarette use in the 30s: Longitudinal changes and moderated relationships. Drug and Alcohol Dependence

Volume 227, October 2021, 108940.

[6] Scientific Committee on Health, Environmental and Emerging Risks (SCHEER), Opinion on electronic cigarettes. Published on April 16, 2021, accessed on August 18, 2021.

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