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The Gateway Effect of Vaping on Adolescents

Article written by: Alyssa Strong - Gateway Effect of Vaping

One of the most controversial topics that comes up in regards to e-cigarettes is the debate on whether or not vaping has a gateway effect on our youth. With this being such a heavy subject, I made sure to cover all ground and went on to read all 298 pages of the Full Surgeon General Report and see what exactly was being said about our industry that is leading to all the constrictions and regulations being put into place. If you don’t wish to read the entire report or just simply don’t have the time, there is an Executive Summary provided that compresses the full report into a much smaller 28 pages. Continue reading this article below to learn more about the gateway effect of vaping.

Gateway Effect of Vaping

While you may find an abundance of information in the Surgeon General’s report, most of what is provided is either misleading, misinterpreted, or just flat out irrelevant. For instance, the report is about the effect of vaping on youth, but will go on to talk about the harms of conventional cigarettes. While we should all have knowledge on the harms of traditional cigarettes on our youth – it is not relevant to the topic at hand. The information I have put into this article are the snips I found that were used to mislead, be misinterpreted, or made to sound relevant when it is simply to scare you in a sense. It doesn’t matter if you smoke, vape, or none of the above, facts are facts for a reason. You should not have to be misled into making a decision. You have the right to make your decision for yourself.

To get a better understanding of the issues at hand, we are going to look at what the United States Surgeon General has to say about vaping and compare it the report from Public Health England. Two sources, both government based – this should be interesting.

*When reading the report from PHE, note that EC stands for electronic cigarettes

*Some statements may be found in multiple categories as they relate or pertain to various topics.

Surgeon General “Nicotine is a highly addictive substance, and many of today’s youth who are using e-cigarettes could become tomorrow’s cigarette smokers.”“Most e-cigarettes contain nicotine, which can cause addiction and can harm the developing adolescent brain.”
Public Health England
  • EC use is frequently misreported with experimentation presented as regular use. Increases in youth EC trial and use are associated with decreases in smoking prevalence in all countries, with the exception of one study from Poland.

  • In the survey by Kong et al., reported previously, it appears that 98.5% of experimenting students did not continue use. Reasons for discontinuation were assessed but unfortunately the most commonly chosen response was ‘other’ (23.6%, open-ended responses included “I don’t like it”, “I just tried once”) followed by “uncool” (16.3%) and health risks (12.1%) [61].

  • Vapers feel they are less dependent on EC than they were on cigarettes [126]; and non-smokers experimenting with EC do not find them attractive and almost none progress to daily vaping [127]. This contrasts with the fact that about half of adolescents who experiment with cigarettes progress to daily smoking [128].

  • …most regular EC users had also smoked tobacco. The authors commented that “the very low prevalence of regular use…suggests that ecigarettes are unlikely to be making a significant direct contribution to adolescent nicotine addiction”.

  • We strongly suggest that use of the gateway terminology be abandoned until it is clear how the theory can be tested in this field. Nevertheless, the use of EC and smoking requires careful surveillance in young people. The preferred option is that young people do not use EC but it would be preferable for a young person to use an EC instead of smoking, given the known relative risks of the EC and smoking cigarettes [10]

As you can see from this comparison, there is no evidence of a gateway effect of vaping taking place. Young people are and always will be curious beings. It is unfortunate for reasons such as this, but it is true nevertheless. While it would be best for all adolescents to never use neither e-cigarettes nor conventional cigarettes, this will most likely never be the case. Vaping is a lesser of two evils in this sense. The good news is that for those who do attempt using an e-cigarette, 98.5% do not continue using e-cigarettes as stated in the study listed above. So that just leaves you to wonder where the transition to smoking traditional cigarettes is taking place. Continue reading below the image to learn more about the gateway effect of vaping.

Gateway Effect of Vaping Article

Surgeon General “To protect the public from both secondhand smoke and secondhand aerosol, smokefree air policies should be modernized to include e-cigarettes. Such policies will maintain current standards for clean indoor air, reduce the potential for renormalization of tobacco product use, and prevent involuntary exposure to nicotine and other aerosolized emissions from e-cigarettes (Ingebrethsen et al. 2012; Schripp et al. 2013; Goniewicz et al. 2014; Offermann 2014; Schober et al. 2014). Updating existing policies to cover e-cigarettes (and all electronic nicotine delivery systems) will eliminate the introduction of airborne toxins into enclosed spaces and establish a uniform standard for preventing the use of both combustible and electronic tobacco products in public and private spaces, including schools, offices, restaurants, bars, casinos, and airplanes.”“This principle supports intervention to avoid possible health risks when the potential risks remain uncertain and have been as yet partially undefined (Bialous and Sarma 2014; Saitta et al. 2014; Hagopian et al. 2015). However, the interventions should be appropriate to the currently perceived risk for future health consequences, in this case from e-cigarette use by youth, young adults, and pregnant women, as well as from the secondhand exposure of nonusers to e-cigarette vapor.”“However, although e-cigarettes generally emit fewer toxicants than combustible tobacco products, we know that aerosol from e-cigarettes is not harmless.”
Public Health England
  • Cigarette smoking among youth and adults has continued to decline and there is no current evidence in England that EC are renormalising smoking or increasing smoking uptake. Instead, the evidence reviewed in this report point in the direction of an association between greater uptake of EC and reduced smoking, with emerging evidence that EC can be effective cessation and reduction aids.

  • Since EC arrived on the market in England, smoking prevalence has continued to decline among both adults and youth (Figures 1, 7 and 8). Evidence to date therefore conflicts with any suggestion that EC are renormalising smoking. Whilst other factors may be contributing to the decline in smoking, it is feasible that EC may be contributing to reductions in smoking over and above any underlying decline.

  • Trends in EC use and smoking: Since EC were introduced to the market, cigarette smoking among adults and youth has declined. In adults, overall nicotine use has also declined (not assessed for youth). These findings, to date, suggest that the advent of EC is not undermining, and may even be contributing to, the long-term decline in cigarette smoking.

  • Recent studies support the Cochrane Review findings that EC can help people to quit smoking and reduce their cigarette consumption. There is also evidence that EC can encourage quitting or cigarette consumption reduction even among those not intending to quit or rejecting other support.

  • The prevalence of EC use (2.4% overall) among people aged between 11 and 18 was therefore lower than among the general population. In comparison, 21% of all 11 to 18-year olds reported having tried cigarettes, of whom 54% only tried once (11.4% of all respondents). Current smoking was reported by a total of 6.7%; 2.7% smoked less than weekly and 4% at least weekly. Experimentation increased with age: 2.9% of 11-year olds and 20.2% of 18-year olds had tried EC. In comparison, among 11-year olds, 3.9% had tried cigarettes (0.7% current smokers), whereas 40.9% of 18-year olds had tried cigarettes (14.3% current smokers)

  • Four studies examined nicotine exposure from passive vaping. Long et al., 2014 measured nicotine content of EC exhalations. EC exhalations contained eight times less E-cigarettes: an evidence update 65 nicotine than cigarette exhalations [78]. Estimating environmental nicotine exposure, however, has to take into account the fact that side-stream smoke (ie the smoke from the lighted end of the cigarette, which is produced regardless of whether the smoker is puffing or not) accounts for some 85% of passive smoking and there is no side-stream EC vapour. A study measuring nicotine residue on surfaces in houses of smokers and vapers reported only negligible levels from vaping, 169 times lower than from smoking [79].

  • Goniewicz and Lee 2014 found that nicotine from EC vapour gets deposited on surfaces, but at very low levels [81]. This poses no concerns regarding exposure to bystanders. At the highest concentration recorded (550 μg/m2 ), an infant would need to lick over 30 square metres of exposed surface to obtain 1mg of nicotine.

  • EC release negligible levels of nicotine into ambient air with no identified health risks to bystanders.

Yes, we know. That was an earful, BUT the facts don’t lie. The Surgeon General’s report makes statements, while the second report from PHE backs up their statements with hard evidence from various studies and research. Statements about e-cigarettes without any scientific backing are just that: statements. What ground does the Surgeon General’s report hold compared to the report from PHE? Multiple studies show evidence of no dangerous health risk from intake of vapor or to bystanders. I am not endorsing the use of e-cigarettes inside of buildings. This isn’t due to any “secondhand vapor”. I simply just respect the views of others and know that not everyone is as accepting of vaping. Therefore, I wait until a moment where I find myself away from the crowd.

Surgeon General “Finally, other hazardous compounds and carcinogens have been detected in e-liquids, or in the heated aerosol produced by e-cigarettes, including formaldehyde, acetaldehyde, and acrolein.”“While these initial analyses indicate potential exposures, additional measures are needed because of challenges in measuring trace levels of metals.”
Public Health England
  • Previous studies detected the presence of aldehydes, especially formaldehyde, in the vapour from some EC, but at levels much lower than in cigarette smoke [138]. Across brands, EC released 1/50th of the level of formaldehyde released by cigarettes. The highest level detected was six times lower than the level in cigarette smoke [138].

  • A high level of formaldehyde was found when e-liquid was over-heated to levels unpalatable to EC users, but there is no indication that EC users are exposed to dangerous levels of aldehydes;

  • In a cross sectional study, vapers had much lower levels of acrolein and crotonaldehyde in urine than smokers [111].

  • There is no indication that EC users are exposed to dangerous levels of aldehydes.

  • Using a multi-criteria decision analysis (MCDA) model, the Independent Scientific Committee on Drugs selected experts from several different countries to compare a variety of nicotine products on variables of harm identified by the UK Advisory Council on the Misuse of Drugs [10]. EC were identified as having 4% of the relative harm of cigarettes overall (including social harm) and 5% of the harm to users, although it was acknowledged that there was a lack of hard evidence for the harms of most of the nicotine products on most of the criteria

You can see from the information above that multiple carcinogens can be found within e-cigarettes. Keep in mind that the list of carcinogens found within e-cigarettes is much lower than those found in traditional cigarettes. When you read the various studies that have been done, you find that not only are the levels of these carcinogens at a much lower level, but the one study showing high levels of formaldehyde was done by heating the vape juice to a level that no user would be capable of. When studied properly, the highest level found was still six times lower than regular cigarette smoke. Continue reading below the image to learn more about the gateway effect of vaping.

DaVinci IQ Vaporizer

Surgeon General “There is general agreement that exclusive use of e-cigarettes poses a lower health risk to the individual than the extremely high health risks of using conventional, combustible tobacco products (Farsalinos and Polosa 2014; Grana et al. 2014a,b), although more research is needed on this as more becomes known about the harmful constituents of e-cigarettes (Sleiman et al. 2016). The controversy reflects the relative degree of emphasis given to the potential harm to adolescents and young adults from using e-cigarettes at one pole compared with the potential for reduced risk for established adult users of conventional cigarettes at the other (if they transition completely to e-cigarettes).”“…e-cigarette products that deliver nicotine cannot be considered a risk-free alternative to conventional cigarettes or other combustible tobacco products” “As reviewed in Chapter 3, the long-term health risks of e-cigarettes will not be known for decades, although evidence to date suggests that they are generally less harmful than combustible products. However, less harmful is not the same as harmless.”“For youth, in particular, sufficient evidence shows that the use of nicotine is not safe regardless of the delivery device: combustible, non-combustible, or electronic (USDHHS 2014; see also Chapter 3).”
Public Health England
  • Using a multi-criteria decision analysis (MCDA) model, the Independent Scientific Committee on Drugs selected experts from several different countries to compare a variety of nicotine products on variables of harm identified by the UK Advisory Council on the Misuse of Drugs [10]. EC were identified as having 4% of the relative harm of cigarettes overall (including social harm) and 5% of the harm to users, although it was acknowledged that there was a lack of hard evidence for the harms of most of the nicotine products on most of the criteria.

  • While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals that are present pose limited danger. It had previously been estimated that EC are around 95% safer than smoking [10, 146]. This appears to remain a reasonable estimate.

Tying into the previous comparison, this goes to show that while e-cigarettes are not 100% safe, they are 95% safer and only have 4% overall relative harm including social harm. Again, the world would be a magical place if we were able to bring that percentage down to a complete 0 across the board, but that just isn’t realistic nor is it logical. Curiosity killed the cat, just like how cigarettes killed the smoker. Maybe with vaping, the cat can have a safer alternative to satisfy its curiosity without the ultimate consequence of death. An alternative that is already showing that it can be put down and walked away from and not have a long-lasting, permanent effect on the cat’s life. Something that can’t really be said as easily for conventional cigarettes.

Surgeon General “The concern, among youth, is that the availability of e-cigarettes with sweet flavors will facilitate nicotine addiction and simulated smoking behavior—which will lead to the use of conventional tobacco products (Kong et al. 2015; Krishnan-Sarin et al. 2015). Flavors have been used for decades to attract youth to tobacco products and to mask the flavor and harshness of tobacco (USDHHS 2012)…… Notably, 81.5% of current youth e-cigarette users said they used e-cigarettes “because they come in flavors I like” (Ambrose et al. 2015).”“The most commonly cited reasons for using e-cigarettes among both youth and young adults are curiosity, flavoring/taste, and low perceived harm compared to other tobacco products. The use of e-cigarettes as an aid to quit conventional cigarettes is not reported as a primary reason for use among youth and young adults.”
Public Health England
  • In youth, reasons for use has rarely been surveyed; one survey on reasons for experimentation among 1,175 students (middle school, high school and college) who had ever tried EC reported that the top three reasons for e-cigarette experimentation were curiosity (54.4%), the availability of appealing flavours (43.8%) and friends’ influence (31.6%). Compared with never smokers, however, ever cigarette smokers (OR=37.5, 95% CI: 5.0 to 283.3) and current cigarette smokers (OR=102.2, 95% CI: 13.8 to 755.9) were many times more likely to say they tried EC to stop smoking [61].

  • A survey of secondary schoolchildren was carried out under the auspices of the Health Behaviour of School Children (HBSC) study and more than 9,000 participants aged 11–16 from 82 schools were included [18]. Overall, 12.3% had tried EC, 1.5% were monthly users, compared with 12.1% reporting ever having smoked and 5.4% current smokers (reported smoking less than once a week or more frequently).

  • Additionally, around 1,500 10 to 11-year olds were surveyed in Wales, from 75 schools in the CHETS Wales study [18, 19] (Table 2). Overall, 5.8% (n=87) had ever used an EC; most reported only using once (3.7%, n=55 overall) and only 2.1% (n=32) reported using them more than once. Again, EC use was associated with smoking.

  • Regular use of EC among youth is rare with around 2% using at least monthly and 0.5% weekly. A minority of British youth report having tried EC (national estimates suggest around 12%). Whilst there was some experimentation with EC among never smokers, nearly all those using EC regularly were cigarette smokers.

  • The rates of ever having tried an EC in the ASH GB Smokefree adult survey are more than three times those of current use; in the ASH GB Smokefree youth survey, about five times as many respondents had tried an EC as were currently using an EC, indicating that most of those who try EC do not progress to current use.

  • Continued use was more common for those whose main reasons for trial included help to quit smoking or reduce harm. Those who did not continue use were asked for their reasons for stopping. The reason most often given was that they were just experimenting (49%)

  • Vapers feel they are less dependent on EC than they were on cigarettes [126]; and non-smokers experimenting with EC do not find them attractive and almost none progress to daily vaping [127]. This contrasts with the fact that about half of adolescents who experiment with cigarettes progress to daily smoking [128].

Yet again, we see the Surgeon General reporting statements that are inaccurate. The assumption of various e liquid flavors being produced to specifically attract youth to vaping is absurd. To state that the flavors can be appealing to young people would be accurate, but not that the reason behind those flavors is made directly for young people. The statement follows that these flavors will, in the end, lead to use of conventional cigarettes, which is yet another statement that is disproven in the studies provided by PHE. Are you starting to see the pattern yet? Continue reading below the image to learn more about the gateway effect of vaping.

Pax 3 Portable Vaporizer

Surgeon General “Fundamentally, the public health challenge and the charge to policy development can be framed as balancing the potential use of e-cigarettes as a new technology to reduce the use of combustible tobacco products against the possibility of expanding tobacco use among non-using youth and young adults, long-term former smokers, and other vulnerable populations…Already, the e-cigarette companies are increasing the appeal of their offerings by enhancing the efficiency of nicotine delivery and using flavorings while they continue to advertise and promote their products aggressively”
Public Health England
  • In 1991, Professor Michael Russell, a leading English smoking cessation expert from the Institute of Psychiatry, argued that ”it was not so much the efficacy of new nicotine delivery systems as temporary aids to cessation, but their potential as long-term alternatives to tobacco that makes the virtual elimination of tobacco a realistic future target”, and he recommended that “tobacco should be rapidly replaced by cleaner, less harmful, sources of nicotine” [3].

  • If EC continue to improve in the speed of nicotine delivery, they are likely to appeal to more smokers, making the switch from smoking to vaping easier. It may be important in this context to note that if the smoking-associated risk is removed, nicotine use by itself, outside pregnancy, carries little health risk and in fact conveys some benefits.

When looking at this comparison, take into consideration everything else you have read within this article. There has been no evidence showing e-cigarettes becoming a prominent issue in adolescent lives and there is no evidence of transitioning, as of yet, to conventional cigarettes. Just how it was stated that flavors are directed towards youth, the Surgeon General’s report states that the vape industry is making advancement with their products and advertising to better lure in adolescents and yet again there is no evidence supporting this accusation. Young people are and always will be curious and want to experiment and that is typically where it ends, as previously shown. Advancements and improvements are done to offer a “cleaner, less harmful source of nicotine” for current smokers. The further the improvements, the better likelihood for tobacco elimination.

Surgeon General “Parental use of tobacco is one of many well-known risk factors for offspring initiation of tobacco, progression to heavy use, and nicotine dependence. Tobacco use by parents influences their children through social, environmental, cognitive, and genetic mechanisms (USDHHS 2012)”
Public Health England
  • Controlling for other variables associated with EC use, parental use of EC and peer smoking remained significantly associated with having ever used an EC. Having ever used an EC was associated with weaker antismoking intentions. Parental EC use was not associated with weakened antismoking intentions whereas parental smoking was [19].

This statement made by the Surgeon General absolutely baffles me. The statements clearly states it is about tobacco and tobacco use. This is something that has no relevance to vaping as vaping is tobacco free with the use of Tobacco Free Nicotine (TFN). I am not going to argue with the point of an adolescent’s surroundings and environment effecting the outcome of lifestyle choices and experimentation. This is simply something that happens with every human being. We are all effected by what we are surrounded with. The issue with this statement is that the Surgeon General’s report strays away from the topic of e-cigarettes to conventional cigarettes, which can ultimately be misleading and misinterpreted.

Surgeon General In 2013, an estimated 13.1 million middle school and high school students were aware of e-cigarettes (Wang et al. 2014). According to data from the National Youth Tobacco Survey, in 2011 the prevalence of current e-cigarette use (defined as use during at least 1 day in the past 30 days) among high school students was 1.5%; prevalence increased dramatically, however, to 16% by 2015, surpassing the rate of conventional-cigarette use among high school students (CDC 2016b; see Chapter 2). This equates to 2.4 million high school students and 620,000 middle school students having used an e-cigarette at least one time in the past 30 days in 2015 (CDC 2016b).
Public Health England
  • …much has been made of the increase in EC observed in the US using the cross-sectional Centers for Disease Control & Prevention (CDC) National Youth Tobacco Surveys [161-163].These reports and press coverage have been heavily criticised [164-166]. The most important feature of the NYTS data was the fall in smoking prevalence over the same period (as observed in the UK, France [167] and elsewhere). The CDC findings indicated that past 30-day use of EC increased among middle and high school students. For example, the 2014 data indicated that among high school students use increased from 4.5% to 13.4% between 2013 and 2014. Among middle school students, current EC use increased from 1.1% in 2013 to 3.9% in 2014. However, cigarette smoking had continued to decline during this period (high school students: 15.8% to 9.2%; middle school students: 4.7 % to 2.5%) such that smoking was at a 22-year low in the US. These findings strongly suggest that EC use is not encouraging uptake of cigarette smoking.

  • Most other estimates indicate that a very small minority of youth, less than 3%, currently or recently used EC. Whilst EC experimentation is increasing, regular or current use of EC appears to be largely concentrated in those already smoking conventional cigarettes.

To wrap it all up, I leave you with this last comparison that shows the Surgeon General showcasing big, frightening numbers to mislead you once again. All the other information provided in this article shows that, while these numbers are high, the percentage of young people who pick up vaping as a continuous habit is rare. What is even rarer is the occurrence of a young person transitioning from e-cigarettes to conventional cigarettes. For the youth who are continuous e-cigarette users, most of them transitioned from traditional cigarettes to e-cigarettes.

Interesting, isn’t it?

In conclusion, adolescents should always be a primary concern and steps should be taken to protect them and their well-being. When it comes to e-cigarettes, however, it has been proven that there is no potential of extreme harm or danger. That is not to say that young people should all have the ability to go out and buy all the vape products they want. That is not the case at all and that is not the point of this article. The point that needs to be made is this – While the well-being of adolescents is of high priority, the health of current smokers is of high priority as well.

“Surveys from the US also suggest that from 2010 to 2013, the proportion of current smokers aware of EC who believed that EC were less harmful than smoking cigarettes declined considerably [65]. Youth in the US appear to have a less realistic perception of the relative harm of EC compared with cigarettes than UK youth. In the 2012 National Youth Tobacco Survey, of those who were aware of EC, around one-third perceived them to be less harmful than cigarettes and around half were unsure [66, 67]” – Public Health England

This is the road we are heading down. The number of people who believe e-cigarettes to be as harmful or more harmful is more than likely to increase over time if the same misleading information is permitted. Current smokers are going to be less likely to believe the truth that e-cigarettes are the lesser of two evils and are more likely to continue smoking or make more failed attempts at quitting with alternatives that are known to have a lower success rate (view Section 6, Figure 14 in PHE report).

Gateway Effect of Vaping on Adolescents

Margaret Malandruccolo photographer

We can fight for what is right for our youth, but we cannot afford to forget about previous generations of current smokers. Prevention of adolescents getting their hands on e-cigarettes can be done without scaring off the adult smokers from a cleaner source of nicotine that could prevent various consequences that come from smoking cigarettes. Each and every human being’s health and well-being should be taken into consideration before any further steps are taken against the vape industry.

“We here highly resolve that these dead shall not have died in vain - that this nation, under God, shall have a new birth of freedom - and that government of the people, by the people, for the people, shall not perish from the earth.” – Abraham Lincoln

Article written by: Alyssa Strong

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Click Here to Leave a Comment Below - January 19, 2017 Reply

This is a very well written and informative article. It’s actually pretty difficult to find trustworthy health related articles in this field. Thank you for sharing.

    VapeExpert - January 19, 2017 Reply

    Yes, I agree it is hard to find articles such as this one. This was a guest post by Alyssa Strong.

Jackie - January 19, 2017 Reply

Parents need to have enough control to watch over their own children. The environment kids grow up in is the biggest influence on how they will act when situations and decisions like vaping occur. Very well written article. - January 19, 2017 Reply

The Surgeon General report on Vaping and Youth does seem a bit misguided and not on point. It’s pretty much common sense that children should not use tobacco/nicotine and until they are of legal age should not be able to access it. Vaping may make it easier for youth to go under the radar, but you can’t blame advances in technology if it is to occur. Vaping has many different aspects to it.. there is vaping which uses no harmful chemicals, there is vaping that uses medical cannabis, there is vaping which does have nicotine and tobacco ingredients.. Just because you see a puff of smoke does not necessarily mean that it is packed with the bad stuff.. could just be flavored mist..

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