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High International Electronic Cigarette Use Among Never Smoker Adolescents

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      Discussion of electronic cigarettes (e-cigarettes) has focused primarily on their potential as a less dangerous alternative to cigarettes or as a smoking cessation aid for adult smokers. But because regular e-cigarette use is low among never smokers, these discussions have so far failed to consider seriously the rapidly rising e-cigarette use among adolescents [
      • Etter J.F.
      Electronic cigarettes: A survey of users.
      ,
      • Niaura R.S.
      • Glynn T.J.
      • Abrams D.B.
      Youth experimentation with e-cigarettes: Another interpretation of the data.
      ,
      • Hajek P.
      Electronic cigarettes for smoking cessation.
      ,
      • Hajek P.
      • Etter J.F.
      • Benowitz N.
      • et al.
      Electronic cigarettes: Review of use, content, safety, effects on smokers and potential for harm and benefit [e-pub ahead of print].
      ,

      Action on Smoking and Health. Electronic cigarettes. ash briefing. Available at: http://www.ash.org.uk/files/documents/ASH_715.pdf. Accessed August 22, 2014.

      ,
      • Bhatnagar A.
      • Whitsel L.P.
      • Ribisl K.M.
      • et al.
      Electronic cigarettes: A policy statement from the American Heart Association [e-pub ahead of print].
      ]. Indeed, in its 2014 policy statement on e-cigarettes, the American Heart Association stated, “Among never smokers, 0.7% were currently users (past 30 days), which indicates that few never smokers who try e-cigarettes continue their use” [
      American Heart Association
      American Heart Association issues e-cigarette Recommendations: Reinforces need for tough restrictions on sales and marketing to youth.
      ].
      Results from Poland [

      Goniewicz ML, Gawron M, Nadolska J, et al. Rise in electronic cigarette use among adolescents in Poland. J Adolesc Health 2014;55:713–5.

      ] challenge this assumption (Table 1). Goniewicz et al. [

      Goniewicz ML, Gawron M, Nadolska J, et al. Rise in electronic cigarette use among adolescents in Poland. J Adolesc Health 2014;55:713–5.

      ] found rapidly rising e-cigarette use among adolescents aged 15–19 years. Ever e-cigarette use increased from 16.8% in 2010–2011 to 62.1% in 2013–2014, and current e-cigarette increased from 5.5% to 29.9%. This increase in prevalence was nearly twice (1.7 times) the increase in prevalence for smoking conventional cigarettes (23.9%–38.0%). Prevalence of dual use of e-cigarettes and conventional cigarettes also increased from 3.6% in 2010–2011 to 21.8% in 2013–2014, with 72.4% of current e-cigarette users also smoking cigarettes in 2013–2014. If adolescents were adopting e-cigarettes as alternatives to conventional cigarettes, conventional cigarette smoking and dual use of e-cigarettes and cigarettes would have declined.
      Table 1Prevalence of electronic cigarette (e-cigarette) use and never cigarette smoking in cross-sectional samples of adolescents
      Footnotes provide detailed calculations for percentages not explicitly stated in manuscripts but that were calculable based on figures presented in the articles. As a result, these figures are unweighted.
      CountryAuthorsYear(s) data collectedAges of participants (years)E-cigarette use (%)E-cigarette use and never smoking (%)
      Number of e-cigarette users who were never cigarette smokers/participants in sample.
      Never smoking (%)
      Number of e-cigarette users who were never cigarette smokers/total number of e-cigarette users.
      Ever

      e-cigarette use
      Current

      e-cigarette use
      Ever

      e-cigarette use
      Current

      e-cigarette use
      Among ever

      e-cigarette users
      Among current

      e-cigarette users
      PolandGoniewicz et al.

      Goniewicz ML, Gawron M, Nadolska J, et al. Rise in electronic cigarette use among adolescents in Poland. J Adolesc Health 2014;55:713–5.

      2010–201115–1916.85.51.6
      29 ever e-cigarette users who were never smokers of 1,760 adolescents.
      .6
      11 current e-cigarette users who were never smokers of 1,760 adolescents.
      9.8
      29 never-smoking ever e-cigarette users of 296 (16.8% of 1,760 students) ever e-cigarette users.
      11.3
      11 never-smoking current e-cigarette users of 97 (5.5% of 1,760) current e-cigarette users.
      2013–201415–1962.129.97.1
      140 ever e-cigarette users who were never smokers of 1,970 adolescents.
      2.0
      40 current e-cigarette users who were never smokers of 1,970 adolescents.
      11.4
      140 never-smoking ever e-cigarette users of 1,223 (62.1% of 1,970) ever e-cigarette users.
      6.8
      40 never-smoking current e-cigarette users of 589 (29.9% of 1,970) current e-cigarette users.
      United StatesCorey et al.
      • Corey C.
      • Wang B.
      • Johnson S.E.
      • et al.
      Electronic cigarette use among middle and high school students- United States, 2011-2012.
      (high school only)
      201114–184.71.5
      201214–1810.02.8.7
      178 (7.2% of 2,466) ever e-cigarette users who were never smokers/24,658.
      7.2
      United StatesBunnell et al.
      U.S. Department of Health and Human Services
      The health consequences of smoking- 50 Years of Progress.
      (middle and high school)
      2011–2013 pooled11–186.1.7
      288 never smoking ever e-cigarette users (.9% ever e-cigarette use among 32,027 [73.0% of 43,873] never smokers)/43,873.
      .2
      96 (.3% current e-cigarette use among 32,027 [73.0% of 43,873]) never smokers/43,873.
      10.8
      288 (.9% of 32,027) ever e-cigarette users who were never smokers/2,676 ever e-cigarette users.
      New York and ConnecticutCamenga et al.
      • Camenga D.R.
      • Kong G.
      • Cavallo C.A.
      • et al.
      Alternate tobacco product and drug use among adolescents who use electronic cigarettes, cigarettes only, and never smokers.
      2010–201114–182.4.2
      7 (9.2% of 76) current e-cigarette users who were never smokers/3,102.
      9.2
      UtahUtah Dept. of Health

      Utah Department of Health. Utah Health Status Update: Electronic Cigarette Use Among Utah Students (Grades 8, 10, and 12) and Adults. Salt Lake City: Utah Department of Public Health; 2013.

      201113–181.9
      20135.931.7
      KoreaCho et al.
      • Cho J.H.
      • Shin E.
      • Moon S.
      Electronic-cigarette smoking experience among adolescents.
      200813–180.5.1
      5 ever e-cigarette users who were never smokers/4341 students.
      22.7
      5 never-smoking e-cigarette users/22 e-cigarette users in sample.
      Lee et al.
      • Lee S.
      • Grana R.
      • Glantz S.
      Electronic-cigarette use among korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking.
      201113–189.44.71.4.5
      348 (.63% of 55,295) current e-cigarette users who were never smokers/72,285.
      14.9
      1.4% ever e-cigarette only users (never smokers)/9.4% e-cigarette users.
      9.8
      348 (.63% of 55,295) never smoking current e-cigarette users who were never smokers/3,555 (4.7% of 75,643) current e-cigarette users.
      Paris, FranceDautzenberg et al.
      • Dautzenberg B.
      • Birkui P.
      • Noel M.
      • et al.
      E-Cigarette: A new tobacco product for schoolchildren in Paris.
      201212–198.11.4
      47 never-smoking e-cigarette users/3,409.
      18.6
      a Footnotes provide detailed calculations for percentages not explicitly stated in manuscripts but that were calculable based on figures presented in the articles. As a result, these figures are unweighted.
      b Number of e-cigarette users who were never cigarette smokers/participants in sample.
      c Number of e-cigarette users who were never cigarette smokers/total number of e-cigarette users.
      d 29 ever e-cigarette users who were never smokers of 1,760 adolescents.
      e 11 current e-cigarette users who were never smokers of 1,760 adolescents.
      f 29 never-smoking ever e-cigarette users of 296 (16.8% of 1,760 students) ever e-cigarette users.
      g 11 never-smoking current e-cigarette users of 97 (5.5% of 1,760) current e-cigarette users.
      h 140 ever e-cigarette users who were never smokers of 1,970 adolescents.
      i 40 current e-cigarette users who were never smokers of 1,970 adolescents.
      j 140 never-smoking ever e-cigarette users of 1,223 (62.1% of 1,970) ever e-cigarette users.
      k 40 never-smoking current e-cigarette users of 589 (29.9% of 1,970) current e-cigarette users.
      l 178 (7.2% of 2,466) ever e-cigarette users who were never smokers/24,658.
      m 288 never smoking ever e-cigarette users (.9% ever e-cigarette use among 32,027 [73.0% of 43,873] never smokers)/43,873.
      n 96 (.3% current e-cigarette use among 32,027 [73.0% of 43,873]) never smokers/43,873.
      o 288 (.9% of 32,027) ever e-cigarette users who were never smokers/2,676 ever e-cigarette users.
      p 7 (9.2% of 76) current e-cigarette users who were never smokers/3,102.
      q 5 ever e-cigarette users who were never smokers/4341 students.
      r 5 never-smoking e-cigarette users/22 e-cigarette users in sample.
      s 348 (.63% of 55,295) current e-cigarette users who were never smokers/72,285.
      t 1.4% ever e-cigarette only users (never smokers)/9.4% e-cigarette users.
      u 348 (.63% of 55,295) never smoking current e-cigarette users who were never smokers/3,555 (4.7% of 75,643) current e-cigarette users.
      v 47 never-smoking e-cigarette users/3,409.
      This increase in adolescent use of e-cigarettes is higher than that observed in 2011 and 2012 in the United States. Among high school students in the U.S. National Youth Tobacco Survey (NYTS), ever and current e-cigarette use doubled between 2011 and 2012, with high levels of dual use of cigarettes and e-cigarettes [
      • Corey C.
      • Wang B.
      • Johnson S.E.
      • et al.
      Electronic cigarette use among middle and high school students- United States, 2011-2012.
      ] (Table 1). Ever and current e-cigarette use also rapidly increased among Korean adolescents 13–18 years old between 2008 and 2011 [
      • Lee S.
      • Grana R.
      • Glantz S.
      Electronic-cigarette use among korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking.
      ,
      • Cho J.H.
      • Shin E.
      • Moon S.
      Electronic-cigarette smoking experience among adolescents.
      ]. In Paris in 2012, 8.1% of students (ages 12–19 years) had tried an e-cigarette. [
      • Dautzenberg B.
      • Birkui P.
      • Noel M.
      • et al.
      E-Cigarette: A new tobacco product for schoolchildren in Paris.
      ] These data from Poland and three other countries show rapid growth of the adolescent e-cigarette market and high levels of dual use of e-cigarettes and cigarettes (Table 1).
      High levels of dual use raise the question of whether e-cigarettes are a “gateway” to smoking or whether adolescents start using e-cigarettes as a harm reduction strategy [
      • Niaura R.S.
      • Glynn T.J.
      • Abrams D.B.
      Youth experimentation with e-cigarettes: Another interpretation of the data.
      ,
      • Farsalinos K.E.
      • Polosa R.
      Youth tobacco use and electronic cigarettes.
      ]. Unfortunately, because all existing studies on adolescents, including Goniewicz et al. [

      Goniewicz ML, Gawron M, Nadolska J, et al. Rise in electronic cigarette use among adolescents in Poland. J Adolesc Health 2014;55:713–5.

      ], are cross-sectional, we do not know what fraction of dual users start with e-cigarettes and move on to smoke conventional cigarettes and vice versa.
      This issue does not, however, apply to e-cigarette use among never smokers. Consistent with other studies (Table 1) [
      • Corey C.
      • Wang B.
      • Johnson S.E.
      • et al.
      Electronic cigarette use among middle and high school students- United States, 2011-2012.
      ,
      • Lee S.
      • Grana R.
      • Glantz S.
      Electronic-cigarette use among korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking.
      ,
      • Dautzenberg B.
      • Birkui P.
      • Noel M.
      • et al.
      E-Cigarette: A new tobacco product for schoolchildren in Paris.
      ,
      • Camenga D.R.
      • Kong G.
      • Cavallo C.A.
      • et al.
      Alternate tobacco product and drug use among adolescents who use electronic cigarettes, cigarettes only, and never smokers.
      ,

      Utah Department of Health. Utah Health Status Update: Electronic Cigarette Use Among Utah Students (Grades 8, 10, and 12) and Adults. Salt Lake City: Utah Department of Public Health; 2013.

      ], the Polish data show a rising prevalence of e-cigarette users who have never smoked cigarettes. In 2010–2011, 1.6% were ever e-cigarette users who had never smoked and .6% were current e-cigarette users who had never smoked. By 2013–2014, these rates had increase to 7.1% and 2.0%, respectively. Never cigarette smokers made up a substantial portion of adolescent e-cigarette users in both years. In 2010–2011, 9.8% of ever e-cigarette users and 11.3% of current e-cigarette users were never smokers. In 2013–2014, 11.4% of ever e-cigarette users and 6.8% of current e-cigarette users were never smokers (M. Goniewicz, written communication, August 18, 2014).
      These results are similar to those obtained from the 2012 U.S. NYTS high school sample [
      • Corey C.
      • Wang B.
      • Johnson S.E.
      • et al.
      Electronic cigarette use among middle and high school students- United States, 2011-2012.
      ] (Table 1). In addition, ever e-cigarette use among never smokers more than tripled among middle and high school students (the entire NYTS sample) from 79,000 students in 2011 to more than 263,000 in 2013 [
      • Bunnell R.E.
      • Agaku I.T.
      • Arrazola R.
      • et al.
      Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013 [e-pub ahead of print].
      ]. Also consistent with findings by Goniewicz et al. on never smoking were findings from high school students in the Northeastern United States in 2010/2011 [
      • Camenga D.R.
      • Kong G.
      • Cavallo C.A.
      • et al.
      Alternate tobacco product and drug use among adolescents who use electronic cigarettes, cigarettes only, and never smokers.
      ], Korean students (13–18 years old) in 2011 [
      • Lee S.
      • Grana R.
      • Glantz S.
      Electronic-cigarette use among korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking.
      ], and Parisian students (ages 12–19 years) in 2012 [
      • Dautzenberg B.
      • Birkui P.
      • Noel M.
      • et al.
      E-Cigarette: A new tobacco product for schoolchildren in Paris.
      ]. These results reveal that a substantial portion of adolescents are first exposed to nicotine through e-cigarettes.
      These numbers are lower bounds for the prevalence of youth who initiate nicotine addiction with e-cigarettes because some of the dual users of cigarettes and e-cigarettes also likely started nicotine use with e-cigarettes. Pooled data from the 2011, 2012, and 2013 NYTS samples of middle and high school students revealed that, among never cigarette smokers, e-cigarette users (43.9%) were more likely than never e-cigarette users (21.5%) to intend to smoke cigarettes in the future [
      • Bunnell R.E.
      • Agaku I.T.
      • Arrazola R.
      • et al.
      Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013 [e-pub ahead of print].
      ]. The fact that in the 2012 NYTS a larger percentage of middle school students were e-cigarette only users (20.3%) than high school students (7.2%) is consistent with a pattern of younger students initiating nicotine use with e-cigarettes then becoming dual users.
      For many youth, their first introduction to the addictive drug nicotine is e-cigarettes. Although switching established adult nicotine-addicted cigarette smokers to e-cigarettes would, at least in theory, be an improvement over the status quo, adolescent initiation of nicotine addiction with e-cigarettes is not.
      The health consequences of nicotine include cardiovascular diseases, immune suppression and related disorders, poor reproductive health outcomes, and perhaps cancer [
      U.S. Department of Health and Human Services
      The health consequences of smoking- 50 Years of Progress.
      ]. Perhaps even more important, the adolescent brain is very vulnerable to nicotine addiction [
      • Slotkin T.A.
      Cholinergic systems in brain development and disruption by neurotoxicants: Nicotine, environmental tobacco smoke, organophosphates.
      ,
      • Gogtay N.
      • Giedd J.N.
      • Lusk L.
      • et al.
      Dynamic mapping of human cortical development during childhood through early adulthood.
      ,
      • Goriounova N.A.
      • Mansvelder H.D.
      Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function.
      ].
      The heavy marketing of e-cigarettes to youth has likely contributed to the increasing popularity of e-cigarettes among adolescents [
      • Durbin R.J.
      • Waxman H.A.
      • Harkin T.
      • et al.
      Gateway to addiction? A survey of popular electronic cigarette manufacturers and targeted marketing to youth.
      ,
      • Bauld L.
      • Angus K.
      • de Andrade M.
      E-cigarette uptake and marketing A report commissioned by Public Health England.
      ,
      • Grana R.
      • Ling P.
      Smoking Revolution? A content analysis of electronic cigarette retail websites.
      ]. In addition to claims that e-cigarettes are safer than cigarettes and may provide health benefits, e-cigarettes come in youth-appealing candy flavors such as cotton candy and gummy bear, and e-cigarette advertisements include messages that appeal to youth, such as adult themes, independence, and rebellion [
      • Durbin R.J.
      • Waxman H.A.
      • Harkin T.
      • et al.
      Gateway to addiction? A survey of popular electronic cigarette manufacturers and targeted marketing to youth.
      ,
      • Grana R.
      • Ling P.
      Smoking Revolution? A content analysis of electronic cigarette retail websites.
      ,
      • Gostin L.O.
      • Glasner A.Y.
      E-cigarettes, vaping, and youth.
      ]. E-cigarette television advertising is rapidly increasing in the United States, particularly on channels and television programs with large youth audiences [
      • Duke J.C.
      • Lee Y.O.
      • Kim A.E.
      • et al.
      Exposure to electronic cigarette television advertisements among youth and young adults.
      ].
      Because of the advertising claims that promote e-cigarettes as a safer alternatives to cigarettes [
      • Durbin R.J.
      • Waxman H.A.
      • Harkin T.
      • et al.
      Gateway to addiction? A survey of popular electronic cigarette manufacturers and targeted marketing to youth.
      ,
      • Grana R.
      • Ling P.
      Smoking Revolution? A content analysis of electronic cigarette retail websites.
      ,
      • Yamin C.
      • Bitton A.
      • Bates D.
      E-Cigarettes: A rapidly growing Internet Phenomenon.
      ,
      • Lee S.
      • Kimm H.
      • Yun J.E.
      • et al.
      Public health challenges of electronic cigarettes in South Korea.
      ,
      • de Andrade M.
      • Hastings G.
      The marketing of e-cigarettes: A UK Snapshot BMJ Group Blogs.
      ], some adolescents (similar to adults) may view e-cigarettes as smoking cessation aids. However, no longitudinal data has been published on e-cigarette use and smoking cessation among adolescents. Although the Goniewicz et al.[

      Goniewicz ML, Gawron M, Nadolska J, et al. Rise in electronic cigarette use among adolescents in Poland. J Adolesc Health 2014;55:713–5.

      ] data did not include information on abstinence from cigarette smoking, cross-sectional data from the U.S. NYTS [
      • Dutra L.M.
      • Glantz S.A.
      Electronic cigarettes and conventional cigarette use among US adolescents a cross-sectional study.
      ] and Korea [
      • Lee S.
      • Grana R.
      • Glantz S.
      Electronic-cigarette use among korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking.
      ] showed that adolescent ever and current e-cigarette users were more likely to be planning to quit smoking but less likely to have actually recently abstained from smoking conventional cigarettes. In addition, youth who used e-cigarettes and had already tried smoking (one puff or more) were more likely to be lifetime cigarette smokers (100 cigarettes or more in lifetime) [
      • Dutra L.M.
      • Glantz S.A.
      Electronic cigarettes and conventional cigarette use among US adolescents a cross-sectional study.
      ]. These results are consistent with a recent meta-analysis of e-cigarette use and smoking cessation among adults [
      • Grana R.A.
      • Popova L.
      • Ling P.M.
      A longitudinal analysis of electronic cigarette use and smoking cessation.
      ] (mostly based on longitudinal studies) that found that, among all smokers, e-cigarette use was associated with significantly less cigarette cessation.
      E-cigarette use is increasing rapidly among youth around the globe. Although some public health researchers are hopeful about e-cigarettes' potential as a harm reduction product [
      • Etter J.F.
      Electronic cigarettes: A survey of users.
      ,
      • Niaura R.S.
      • Glynn T.J.
      • Abrams D.B.
      Youth experimentation with e-cigarettes: Another interpretation of the data.
      ,
      • Hajek P.
      Electronic cigarettes for smoking cessation.
      ,
      • Bhatnagar A.
      • Whitsel L.P.
      • Ribisl K.M.
      • et al.
      Electronic cigarettes: A policy statement from the American Heart Association [e-pub ahead of print].
      ], the business model that tobacco companies use to promote e-cigarettes (promoting addiction to maintain a strong consumer base) is inconsistent with the concept of e-cigarettes as a harm reduction tool [
      • Maziak W.
      Harm reduction at the crossroads: The case of e-cigarettes.
      ]. In combination with the existing literature, findings by Goniewicz et al. [

      Goniewicz ML, Gawron M, Nadolska J, et al. Rise in electronic cigarette use among adolescents in Poland. J Adolesc Health 2014;55:713–5.

      ] emphasize the fact that rapid penetration of the youth market, including use of e-cigarettes among never smokers, may be accompanied by increasing youth smoking with potential long-term health impacts.
      The same types of policies used to protect youth from cigarettes included in the World Health Organization Framework Convention on Tobacco Control [
      World Health Organization
      WHO Framework Convention on Tobacco Control.
      ] need to be implemented for e-cigarettes. E-cigarette advertising should be prohibited, as should sponsorship of events attended by youth (such as sporting and music events). The use of e-cigarettes should be prohibited wherever smoking cigarettes is prohibited, age restrictions should be placed on e-cigarettes for purchase, and the prices of e-cigarettes should be increased through taxation. Policy makers and researchers need to base e-cigarette policies on the fact that they are a source of nicotine initiation among youth not just a possible tool to help adult smokers quit smoking.

      Funding Sources

      L.M.D.'s work on this article was supported by National Institutes of Health grant 5R25CA113710-09 , and S.A.G.'s work was reported in this publication was supported by grant 1P50CA180890-01 from the National Cancer Institute and FDA Center for Tobacco Products. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration. The funding agencies played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the article for publication.

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