A GROWING evidence base finding that e-cigarettes act as a gateway to cigarettes for young people is good reason to maintain strict regulations in Australia, say experts.

Research published in Paediatrics this month, out of Yale University in the US, found that past-month e-cigarette use predicted future conventional cigarette use across three longitudinal waves among 808 Connecticut high school students. Cigarette use did not predict subsequent e-cigarette use, however.

The study is the latest in a growing evidence base that was reviewed in a Perspective published online by the MJA today.

The authors, from the University of Newcastle, Hunter New England Health and the National Centre for Drug and Alcohol Research, cited the following research:

  • an August 2017 meta-analysis, published in JAMA Paediatrics, of nine studies involving over 17 000 young people which found that e-cigarette use among non-smokers quadrupled the odds of past 30-day cigarette smoking;
  • a systematic review, commissioned by the World Health Organization, which found that young non-smokers (mean age, 20 years) who used e-cigarettes at baseline had an increased adjusted odds ratio of being tobacco users at follow-up; and
  • a report from the Surgeon General of the US, which found that “prevention efforts must focus on both adolescents and young adults because among adults who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age (88%), with 99% of first use by 26 years of age”.

“The consistency and strength of the findings from meta-analyses suggest that young non-smokers who use e-cigarettes are between two to five times more likely to subsequently initiate combustible tobacco smoking,” the MJA authors wrote.

Professor Stanton Glantz, from the Center for Tobacco Control Research and Education at the University of California, San Francisco, told MJA InSight that the MJA article was “very sensible”, and that he was increasingly frustrated with advocates for e-cigarettes.

“I think my friends here in the US, and in the UK and places like New Zealand [who advocate for the use of e-cigarettes] have collectively lost their minds,” he said.

“They’re impervious to evidence, it seems. It’s very frustrating.

“The evidence of adverse effects on children is bombproof now.

“E-cigarettes have quite a different toxicology profile than cigarettes,” Professor Glantz said. “They deliver fewer carcinogens than cigarettes, but they deliver ultrafine particles that stimulate heart disease and lung cancer.

“They turn on more inflammatory processes in the lung than cigarettes do. Compared with cigarettes, e-cigarettes look like a Christmas tree [in terms of lighting up the lung].”

Professor Mike Daube, long-time Australian tobacco control researcher and policy advocate, told MJA InSight that “the [MJA] authors rightly point to the need for caution in relation to young people as well as claimed cessation benefits”.

“A further concern about e-cigarettes and other new products promoted by tobacco companies is that lobbying of various kinds has diverted attention from the evidence-based action we need.

“Decisions on e-cigarettes, as for any products with claimed therapeutic benefits, should be left to the Therapeutic Goods Administration, which has the relevant expertise and independence.

“In the meantime, governments should get on with measures that we know work – reviving the national tobacco media campaign (inexplicably dropped despite needing less than 0.5% of the government’s $10 billion plus revenue from tobacco tax), and curbing new industry product and promotional gimmicks would be a good start.”

Dr Kathryn Barnsley, from the University of Tasmania, told MJA InSight that the tobacco industry’s tactics regarding e-cigarettes mirrored their campaigns in the 1980s and 1990s introducing “filter ventilation” and menthol cigarettes.

“Women believed it and now they’re dying,” Dr Barnsley said.

“On the subject of e-cigarettes, Australia should be happy to be the control group. Let’s keep them unlawful until they’ve been proven [to be safe] in other countries.

“If smoking rates drop and health improves in the US, then we’ll think about it.

“Let’s remain fiercely independent and protect Australia’s population.”

Paul Grogan, Director of Public Policy at Cancer Council Australia, said that the observations in the MJA article reflected a growing body of evidence highlighting the potential risks of e-cigarettes to young people.

“The risks of e-cigarettes to young people, along with increasing evidence on their direct harms and ongoing uncertainty about their benefits as a quitting tool, are why all established public health organisations in Australia and governments recommend a precautionary approach to their availability.”

Mr Grogan said Australia’s intergovernmental Ministerial Drug and Alcohol Forum had recently called for renewed caution and, where appropriate, strengthening controls on the marketing and use of e-cigarettes in Australia.

He said the appeal of e-cigarettes to young people, and the potential for dual use of e-cigarettes and smoked tobacco products, could explain why the tobacco industry was the leading investor in the vaping market.

The third meeting of the Ministerial Drug and Alcohol Forum, held on 27 November 2017, issued the following statement on e-cigarettes:

“Members noted that the current evidence base in relation to e-cigarettes supports maintaining and, where appropriate, strengthening the current controls that apply to the marketing and use of these products in Australia. Members agreed to national guiding principles which reflect a precautionary approach to e-cigarettes and affirmed the current national regulatory framework remains appropriate.”

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.




I do not recommend e-cigarettes as a smoking cessation tool
  • Strongly disagree (85%, 741 Votes)
  • Strongly agree (8%, 72 Votes)
  • Disagree (5%, 40 Votes)
  • Neutral (1%, 11 Votes)
  • Agree (1%, 7 Votes)

Total Voters: 871

Loading ... Loading ...

16 thoughts on “E-cigs and teens: evidence warns of harms and gateway effect

  1. Peter Morero says:

    Maintaining or enhancing restrictions on availability to young people and non-smokers is a different issue to the possible use as a smoking cessation aid in established smokers

  2. Anonymous says:

    Maintaining and enhancing restriction to young people and non-smokers is a different issue to potential as a cessation aid in established smokers

  3. Fiona says:

    Disagree with the above. I understand the concept of harm minimisation, but not by offering a strategy where evidence of unanticipated harm is emerging rapidly (particularly via a different mechanism).
    If a ‘therapeutic product’ is not approved by the TGA, practitioners should seek informed consent from the patient, outlining evidence of harm/risk as well as potential benefit, and bear medico-legal risk.
    The AMA commented on this (albeit for ‘medicines’) in the article “Lots to consider in going off-label”

  4. Suzanne says:

    I’d rather sit down-wind of an E-cig smoker than a real-cig smoker! And I’d rather breathe second-hand E-cig smoke than exhaust from a modern diesel car! ‘Harms’ are all relative – and anyway, nursing homes are brimming; do we all want to live to 100? (this from a never-smoker who loathes the habit but understands those who enjoy smoking – including the youth of today).

  5. Aki Nilanga Bandara says:

    The e-cigarette industry uses sophisticated online media to spread the word about the role of e-cigarettes as a tobacco cessation device. Globally, adolescents are being barraged by mixed messages about the benefits and the harm of e-cigarette. As adolescents, we are very puzzled on the mixed messages about the benefits and the harms of e-cigarettes.

  6. Marcus says:

    Fascinating double standard.
    The harmful effects of alcohol far outweigh the putative benefits of the anti-oxidants in red wine, yet we don’t prohibit the sale of alcohol.
    Perhaps if nicotine was as popular amongst researchers and policy-makers as is shiraz, we might see a different outcome.

  7. Andrew Watkins says:

    The tobacco industry would not be investing billions in advertising and in purchasing “expert” opinion, lobbyists etc if they didn’t see this as a gateway to their normal products.

    They have a long history of specific targeting of children and adolescents – remember the “Marlboro Man ”

    They need to do this because smokers are a dying breed – 50% of smokers will die as a consequence of their smoking. If the industry is to continue to thrive it needs more cannon fodder

    Keep the devices out of Australia

  8. Jane says:

    The tobacco companies are not funding “e cigs” or vapor products in any way. They pay their billions against vaping because vaping hurts their revenue and bottom line! It is not a gate way by any means. Do your own research, from reliable sources, and anyone can see that vaping is marginally less harmful. There is no tobacco in vape, there is not 1000’s of chemicals in the liquid. If you are trying to say that capers develop into smokers it’s quite the opposite in staggering numbers. More people use vaping to quit smoking cancer sticks! I’ve never met or heard of anyone who vapes turning to cigarettes.
    As for advertising to children, if you think the vaping industry is advertising to children you must think the same about alcohol, violence and weapons. It’s not the target, it is the idea of finding a new way to rebel and be “cool”. Any substance that can be abused and any item that can be harmful can be put into that same category.
    Vaping saved me after 14 years of smoking. I can smell and taste better than cigarettes had allowed me to, my lungs are clear, my breathing has improved. I am not arguing the addiction factor, nicotine is highly addictive. But you choose the level of nicotine down to 0mg.
    I am thankful for the opportunity to go from a pack a day habit at 28-32 mg in my nasty cigarettes to my 6mg vape, soon hopefully to 0mg. Tobacco hates the thousands like me who no longer rely on their cigarettes. Who no longer spend $10 a day o their tar and chemicals.
    Don’t get it twisted- big tobacco hates and fears vaping and are the ones funding the propaganda making the false scares of popcorn lung etc. which have all been proven false time and time again.

  9. Anonymous says:

    To Jane: For God’s sake, did you even read the article? Did you even notice the three cited research papers that provide solid evidence from reliable sources showing that what you are saying is pure bunkum? Are you even capable of acknowledging that you might actually be mistaken? No? Well, as Professor Glantz so succinctly put it, you and your vaper friends are “impervious to evidence”.

  10. James says:

    What a shame that there’s no mention that the test subjects that were ‘predicted’ to have used ecigs as a gateway to traditional tobacco would probably have become users anyway.

    Another shame is that Australia continues to ignore potential life saving research showing that a harm minimisation device is at least 97% safer than smoking.

    Additionally smoking rates have dropped in the US, the UK now prescribes ecigs through the NHS and New Zealand has legalised the sale of nicotine by brich and mortar stores.

    Did this article also quote Professor Glantz who has been sacked from his job due to sexual harrassmet claims?!?

    Such a puff piece article that it could possibly could be classes as ‘Fake News.

  11. Donna Darvill says:

    Reply to Anonymous number 9. Would you really consider Professor Glantz to be a reliable source for information on this topic considering the recent news? http://www.dailycal.org/2017/12/06/former-ucsf-researcher-sues-uc-regents-ucsf-professor-alleged-sex-harassment/

    But getting away from the ad hom attacks on vapers and the supporters in the medical profession and scientific community, it’s worth really looking into the science. May I suggest the Royal College of Physicians https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjFoq-iioHYAhVBvpQKHWlkDw4QFggpMAA&url=https%3A%2F%2Fwww.rcplondon.ac.uk%2Fprojects%2Foutputs%2Fnicotine-without-smoke-tobacco-harm-reduction-0&usg=AOvVaw0sWjpp2olP5gmSN6ngfUxT and Cancer Research UK http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/e-cigarettes and the latest data http://www.mdpi.com/1660-4601/14/9/973/pdf.

    If you go back to 2010 when Australia had lower smoking rates than the UK and the US, you’ll see that they (UK & US) have progressively caught up and we have stagnated. Australia’s now has the same smoking rate as the UK and the US have overtaken us now with less smokers. The difference in those years where they have improved and we have stagnated is their embrace of Tobacco Harm Reduction via products such as vaping and snus.

    The latest AIHW data tells us that there has been no statistically significant reduction in smoking since 2013 despite plain packaging and the highest priced smokes in the world because of repeated huge taxation increases. This is not to mention the enormous black market in Australia.

    To sacrifice the existing smokers that have, could or would switch to vaping with nicotine is a human rights disgrace.

    I know I’m on the right side of history and many in Tobacco Control and Government that refuse to allow smokers a far safer alternative will be on the wrong side. Mark my words.

  12. Anonymous says:

    Does correlation equal causation? The answer to that question is a sturdy no. Every study I’ve read on this matter shows yes there is a correlation but nowhere do I see evidence that vapor products are a precursor to smoking, in fact the scientists performing the studies tend to come to that conclusion as well and recommend more studies to determine if it is a possibility.

    Despite our efforts especially in the last 30 years no matter what we do people smoke tobacco cigarettes and youth definitely experiment with tobacco, alcohol and drugs as it seems to be a part of the human experience. The only way to put an abrupt end to it would be absolute prohibition with maybe the death penalty for being caught with a prohibited substance. Alcohol prohibition failed, drug prohibition is failing as we’re finding out that treatment is lowering the number of drug users more than incarceration is, marijuana is being legalized in many countries across the globe, as for tobacco? Tobacco is too intertwined into society to even consider it and absolute prohibition obviously isn’t an option.

    If the studies aren’t showing that vapor products are a precursor to smoking then what is the correlation all about? Studies show that people, not just youth but all people that are open to experimentation with drugs/alcohol/mild stimulants are likely to experiment with different forms of each, there’s a correlation between those who use caffeine and nicotine but does that mean caffeine is a precursor to nicotine use does it? no, so youth that are likely to experiment with tobacco cigarettes are also likely to experiment with vapor products and vice versa. The evidence actually shows that youth that already smoke are more likely to try vapor products than those who don’t meaning there’s a chance that they could use them to stop the use of combustible tobacco cigarettes, the same goes for all age groups as 99%+ of full time vapers are people that smoke or have smoked.

    There is a lot of opinions when it comes to Tobacco Addiction after all the smoking of tobacco cigarettes is a very complex issue. There’s a statistic I’ve seen thrown around quite a bit in Tobacco Control/Public Health groups and that is “80% of smokers want to quit smoking” you need to ask yourself just how valid that statistic is. This is very very hard to explain to someone who has never smoked and they will likely never truly understand it but what it comes down to is people actually enjoy smoking, first there are the mild stimulant effects of nicotine which are enjoyable and although they may seem more powerful than caffeine that is because users can take larger doses of nicotine than caffeine without getting an upset stomach like what commonly happens when you drink too much coffee, unlike coffee there are also other addictive components to tobacco cigarettes than just the nicotine alone, there are components that are thought to potentially create the initial addiction found in tobacco cigarettes like monoamine oxidase inhibitors (MOAI’s) which trigger a physiological effect that associates smoking tobacco cigarettes with being happy eg: the brain can release more serotonin and dopamine altering your mood.

    While it is true that 80% of smokers do want to quit, or well know they should quit smoking it’s not because they don’t enjoy it it’s because they know it is extremely harmful to their well being. Nicotine on it’s own at the levels smokers or vapers use it isn’t particularly harmful and carries about the same health risks as using caffeine if used at the same level, if it was very harmful it definitely wouldn’t be legal for youth to purchase NRT products like the nicotine patch or nicotine gum in almost every country in the world, at the very minimum the sale of it would be much more strictly regulated and it would be kept behind the counter.

    I personally feel that society could greatly benefit from vapor products, the health risks they have in comparison to the smoking of tobacco cigarettes are on completely different plains, one study calculated the carcinogens found in tobacco cigarettes to those of a electronic nicotine delivery device (ENDD) and found that the ENDD was 50,000 times less likely to cause cancer than tobacco cigarettes, even if the calculations were off by 90% if those who enjoy the use of nicotine were to switch to vapor products it would greatly reduce their exposure to toxins and improve their overall well being as they would be less likely to be inflicted with all diseases associated with the use of Tobacco Cigarettes.

    If people choose to continue the use of nicotine in the form of tobacco cigarettes because they enjoy it as a stimulant we should almost be shoving vapor products in their faces using them as a way to combat the tobacco epidemic instead of taking a cautionary approach to them by restricting access and forcing users of vapor products to use them in the same locations that people that are using something they want to quit (tobacco cigarettes), vapor products should be given more leeway than tobacco cigarettes, these people should be applauded for taking a step in the right direction and as for youth if they are using them to quit smoking that is a good thing and since they are less addictive than cigarettes even experimentation with them is less likely to lead to a life long addiction like tobacco does.

    To improve vapor products and to use them cessation tool for tobacco cigarettes instead of a simple nicotine replacement consumer product as they currently are considered I would hypothesize that the addition of MAOI’s in a more controlled environment such as prescription only pharmaceutical product it could greatly improve their overall effectiveness, you could start out with the amount of MAOI’s found in tobacco, slowly reduce the amount of MAOI’s over a period of time while maintaining nicotine levels that the user deems enjoyable and once the patient is down to no MAOI’s they can then move to the consumer market and continue use of the non pharmaceutical counterpart and if they wish they can lower their nicotine levels over time and stop use if they want to like some users are presently doing.

    We must accept that vaping isn’t smoking and the fact that society is benefiting from them being on the market otherwise we’ll be wasting an immense opportunity to reduce the death and disease caused by tobacco cigarettes.

  13. Pragmatic says:

    For James(10) & Donna Darvill(11)
    Are you really saying that an isolated and as yet unsubstantiated claim made against Professor Glantz invalidates his expert opinion?

  14. Cate Swannell says:

    EDITOR’S NOTE: Please refrain from commenting on any allegations made about Professor Glantz. This is not an appropriate forum for them. If they continue, I will close down the comments section on this article. CS

  15. Donna Darvill says:

    It’s worth asking the Medical Professionals that read this journal…..do you think it’s fair that people who vape like me after 32 years of smoking and being unable to quit any other way despite trying numerous times, should be subject to enormous fines and in some cases imprisonment for switching to vaping?

    These are the Penalties in Australia for either possession, acquiring or using nicotine for vaping.

    WA $45,000
    SA $10,000
    Vic $15,546
    NT $15,000 or 12 months in jail
    QLD $9,752
    NSW $1,100
    Tas $7,850 or up to 2 years in jail
    ACT $30,000 or jail for 2 years or both.

    Queensland Health even has a published dob in line for possessing nicotine e-cigarettes https://www.health.qld.gov.au/public-health/topics/atod/tobacco-laws/electronic-cigarettes and it’s used. Vapers who have quit smoking have had their homes raided and their nicotine and equipment seized and go back to smoking.

    QLD and WA vapers have had their packages seized at courier point by the respective State Health Departments (not customs) and have been forced back to smoking.

    Is this fair for people that are just trying to improve their health?

  16. Anonymous says:

    Nicotine in a cigarette?: Freely available over 18 years of age.
    Nicotine in eCig?: prohibited substance.
    Nanny-statism gone beserk.

Comments are closed.