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E-cigarette use as a predictor of cigarette smoking (bmj.com)
44 points by doctorpangloss 5 months ago | hide | past | web | favorite | 58 comments

"Smoked a cigarette in the last 12 months" is an incredibly low bar, to the point where I'd guess the study had a desired outcome.

The important question isn't "were vapers more likely to smoke 1+ times"--it's "how many cigarettes (from 0 to n) would the average vaper have smoked in the absence of vape options?"

The latter is a counterfactual, and thus much harder to study. It's almost as if valuable research is hard, and you can't just slap together a few variables and toss the "Science!" label on it.

Edit for context: I'm an ex 1-2 packs-a-day smoker, and vaping definitely helped me substitute a less harmful behavior. I smoke 5-30 cigarettes per year still, and vape about the same number of times per year. Having substitute options definitely helps avoid slipping back into cycles of addiction, to the point where I don't worry about that at all now.

The question wasnt even about "vapers". The qurstion was about underage vapers.

I've known vapers that would pick up a pack for the blizzard when they expect to get snowed in for days on end. Some of them quit vaping (and smoking) by the end of digging themselves out.

Ive known vape shop owners who were regular daily cigarette smokers in between vaping 0 nic. That's the most damaging thing possible - give that sticky tar glycerin to attach to in new ways. Give that glycerin new ways to get stuck in tar. And layer it up!

I may not like it, but I respect Britain's cutoff for tobacco leaf products. If you were born 2000 or later, you will only ever get to buy vapes. Not cigars, not cigarettes, not hookah nor dojah. They're banned from you.

Where the US is close to banning the cleaner nicotine option (salt nic vapes aside), Britain chose to ban the stuff that seriously clogs lungs.

> I may not like it, but I respect Britain's cutoff for tobacco leaf products. If you were born 2000 or later, you will only ever get to buy vapes. Not cigars, not cigarettes, not hookah nor dojah. They're banned from you.

Wait, what? I Googled pretty extensively and it appears that was just a vote between doctors with no legal binding. Did it actually become law?

No, this is absolutely not the case in the UK.

I submitted this partly to see how people would explain away the result.

4.78 RR for smoking one year after vaping for non-smokers is pretty huge. That’s definitely a clinically significant result. Smoking itself is the highest OR for lung cancer and therefore mortality of any behavior (in the 60s for Americans), and using cigarettes really dooms you to that outcome.

Nicotine patches, as transdermal delivery, don’t get people as high as Juul does, and that’s the likely reason you don’t observe either recreational use of them nor people becoming smokers from using them.

What these studies show is that kids who are likely to try smoking are also more likely to try vaping. That's it. That's the whole thing. It's correlation, and doesn't speak in any way to anything like a "gateway drug" phenomenon - and that has also been recognised in studies that bother to consider the possibility.

Oh, right, yeah. Because this line totally isn't directly from the paper's conclusion:

> These results contribute to the growing body of evidence supporting vaping as a one-way bridge to cigarette smoking among youth.

I'll see that study and raise you the UVic cohort study that found the opposite[0], among others if you're willing to look. The "growing body of evidence" is all about correlations in interview studies.


That link just goes to their homepage.

That line honestly just makes it sound like they already knew what their opinion was before doing the study

The easy social explanation for this is that people who vape are more likely to be around smoking anyways, and thus are far more likely to bum a cig off someone in a party than your average 19 year old. The only clinical result you can pull from this is 'people who vape are more likely to smoke >1 cigarette a year', and the fact that they couldn't produce a more significant result with any sort of correlation tells you the paucity of the data.

You've used some jargon here that I don't understand, so I'm probably just missing it, but I don't see where any of this addresses the claim that, "Smoked a cigarette in the last 12 months" is a strikingly low bar.

On the one hand, I don't want to condescend. Relative risk and odds ratio are best explained on Wikipedia.

If you want to get advice on smoking cessation, ask a doctor. There have been no clinical trials for Juul or any e-cigarette product. No doctor following the letter of what they're supposed to be doing is going to recommend an e-cigarette product to a person seeking smoking cessation.

The strikingly low bar thing... People here defend Juul like people defended Theranos. Nobody wants to accept that the Juul guys are liars. Not yet anyway.

If e-cigarette companies had a study, much like Theranos, they'd publish it. They'd compare it to nicotine patches. They just don't. There's no secret, it's really just an agglomeration of personal experiences and unfortunate but real stories quitting addiction masquerading as a positive public health development.

This study shows pretty unequivocally that vaping can't possibly just substitute for cigarette smoking. If it did, we'd observe zero cigarette smokers in the vaping-only population. Correlation versus causation, whatever logic puzzles commenters invoke, it just distracts from both the evidence presented here and the total lack of a rigorous trial from e-cigarette sellers.

> There have been no clinical trials for Juul or any e-cigarette product.

Rubbish. Just 10 seconds on PubMed found me this:

Rahman et al. E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis. PLoS One. 2015. https://www.ncbi.nlm.nih.gov/pubmed/25822251

"Six studies were included involving 7,551 participants. … Use of e-cigarettes is associated with smoking cessation and reduction."

> No doctor following the letter of what they're supposed to be doing is going to recommend an e-cigarette product to a person seeking smoking cessation.

Also rubbish. Even if there were no studies, absence of data of effect is different from data of absence of effect. There are good reasons to believe (even pre-hoc) that vaping is safer than cigarettes.

As a student doctor and I would happily council a patient to consider vaping instead of smoking as a harm minimisation intervention.

> If e-cigarette companies had a study, much like Theranos, they'd publish it

Will this do? "In a nutshell, best estimates show e-cigarettes are 95% less harmful to your health than normal cigarettes, and when supported by a smoking cessation service, help most smokers to quit tobacco altogether."

From the extensive Public Health England study: https://www.gov.uk/government/news/e-cigarettes-around-95-le...

E-cigarettes are now available on prescription in the UK as one of the smoking cessation aids available to doctors.

No idea about Juul, they're not in the UK yet.

> This study shows pretty unequivocally that vaping can't possibly just substitute for cigarette smoking. If it did, we'd observe zero cigarette smokers in the vaping-only population.

What an absolutely insane claim.

E-cigarettes companies are in business of selling product, not doing research for once. Another thing you might be missing is that the only reason you can buy vape products with pocket change unlike the "researched" things like patches, gum etc. is that they do not sell them as any kind of medical treatment. If they tried to claim anything to that effect they would have been dealing with FDA and doing whatever expensive procedures FDA demands and their product would be as expensive as patches etc and they would have been out of business since their $100 per 10 ml "researched" juice would not stand a chance against the same compound but not researched and sold at $20/100ml. So, even if they had a study they would not publish it if they had any sense.

As for people you suspect being uninformed and defending a fraudulent business, all I can see people who actually quit smoking saying they did it through vaping. We don't know if they are just unique rare cases but, on the other hand, you rarely see people claiming this with patches and gum. Most mentions of these in relation to quitting smoking I've seen were "I tried patches/gum, they did not work". I am lazy to look up research but from what I remember, patches and gum are amazingly inefficient in any prolonged smoking cessation. So pushing patches might appear more similar to shilling for Theranos than you might have suspected.

You do know that both nicotine replacement users and people prescribed Champix, both well studied and proven to work sometimes smoke? Your bar means literally any and all things other than pure abstinence will fail. That’s ridiculous.

The other side of the abstinence issue is that it's difficult to find good information about the relative risks of different smoking behavior. Nearly all smoking advice and all smoking regulations are based on the notion that literally no amount of exposure is acceptable -- full stop, end of story, do not inquire further.

Even the CDC uses that kind of hysterical, unscientific language to describe the risks of secondhand smoke: "There is no risk-free level of secondhand smoke exposure." [0] That's a religious claim, not a scientific one.

[0] https://www.cdc.gov/tobacco/data_statistics/fact_sheets/seco...

From personal experience, the gum and the sprays definitely do get you a “buzz”.

I'm trying to follow the logic. E-cigarettes are already banned for those under-18 in America. Cigarettes and e-cigarettes are legal for those 18 and over. Because those who smoke e-cigarettes are more likely to smoke real cigarettes, we should ban e-cigarettes? Even though they are way less harmful than real cigarettes?

Why not just ban real cigarettes? Wouldn't that solve all the problems?

Oh yes... black markets, prohibition, arrests, expanding prison population, and on and on...

If we aren't going to throw cigarette smokers in jail, and e-cigarettes are already illegal for those under-18, then I'm not sure what else we can do. The state could aggressively fine retail stores who sell to those underage (although I doubt they sell them illegally). More likely, arrest 18 year old high school kids who buy them for their friends and underclassmen.

Alcohol and cigarettes were bought for me by the burnout and local junior college kids when I was in high school.

> Because those who smoke e-cigarettes are more likely to smoke real cigarettes, we should ban e-cigarettes?

The conclusion in the article suggests "restricting youth access to e-cigarettes." It's not talking about a general ban.

> e-cigarettes are already illegal for those under-18,

In the US, individual states have varying laws, and the FDA position has been evolving. Research like this presumably provides input to that ongoing process.

> Why not just ban real cigarettes?

They are already restricted at the federal level for under 18.

> Alcohol and cigarettes were bought for me by the burnout and local junior college kids when I was in high school.

The problem with personal anecdotes like this is that they give no idea of how many kids actually didn't do alcohol or cigarettes, or consumed less than they would have otherwise, because of restrictions.

Your unstated premise seems to be that restrictions like this don't work. If you look into that, you'll find that's incorrect.

Yes, they are already banned. So why should the FDA ban the sale of Juul entirely?

But...why? I smoked a pack a day for a little more than 10 years, got an e-cigarette and haven't looked back. I don't understand why anyone would do the reverse.

Practically every one of my friends either smokes, vapes, or does both.

Of the ones who only vape, most of them will still smoke the occasional dart. They'll smoke them if they can't use their e-cigarette (e.g. out of fluid, left it at home), because they're still addicted to nicotine they'll take what they can get.

There's also the social aspect of smoking cigarettes. I don't know why, but standing in a circle puffing on e-cigarettes just isn't as social as smoking a real cigarette, so if everyone else is smoking cigarettes the vapers will usually have a smoke too.

My experience has been that standing in a circle puffing on e-cigarettes is every bit as social if not more. Most cigarette smokers want to quit and they often get inspired by vapers standing around them.

The concern is that the e-cig brands have moved well beyond those attempting to quit smoking. Similar to the old Joe Camel ads, the thinking is that the e-cig companies are targeting kids with fruit and candy flavors. If they were really serious about them strictly being a tool for quitting, they should mandate that the only allowed flavor is wet ashtray. Seriously, what legitimate reason is there for a quitting tool to be more appealing than the thing being quit unless the goal is to hook people on the new thing?

That's ridiculous. One of the reasons nicotine gum isn't that successful is because of how nasty it tastes.

Why shouldn't those quitting smoking be allowed fruit flavours? I can only think you want them to fail and end up keeping on smoking tobacco.

Failed attempt at humor on my end apparently. No, I don't want those attempting to quit to fail. The point I was attempting to make is that by making them taste good (as opposed to at most flavorless) is that it both makes them more appealing to non-smokers (esp kids) and likely encourages many smokers to kick cigarettes but pick up a vaping habit rather than a tool to wean them off of nicotine.

Now one might say 'who in their right mind would want to start a nicotine habit?' Well centuries of tobacco use to more recent times with people eating detergent pods, huffing glue etc should readily provide the answer. Also, the tobacco industry knows what they're doing and I suspect it's not about getting people off nicotine but rather changing the delivery mechanism. (You do know big tobacco is big into vaping, right?)

I can see your point, but some kids are always going to try some of what's available - weed, tobacco, alcohol, vaping, glue sniffing etc. I doubt the flavour mattered much when cigs were the only choice, or before they'd learnt to like beer / vodka. It's far more peer pressure than advertising. yes, of course ads play a part too.

I would be comfortable with discouraging kids as far as possible, requiring ID and so on. For some of the adult ex smokers I know, including myself, I doubt they'd have quit without vaping with some of the sillier sounding flavours. Some of the quitters will be kids who regret starting smoking 5 years previously. I don't have good answers to balance the conflicting needs or to prevent it becoming a growth sector far beyond smokers wanting out.

When I first tried vaping one of the few flavours I got was tobacco - which was awful, and never tried again. It took some months to step down the strengths to zero, and kept on vaping a while at 0 nicotine. That was 7 or 8 years ago, and no vaping or tobacco since.

Regulation in the US and UK is very different for vaping, but here big tobacco seems to be badly failing at vaping. Every shop that sells cigarettes now has a selection of the tobacco company's cartridge style "pretend cigarettes" vaping at five or ten times the cost of the simple juice bottles. I've only ever seen one person using one. Most towns have gained a juice stall selling cheap flavours.

But nicotine by itself isn't really that harmful to your body. So why should we care if some kids pickup vaping habits?

I mean, it we remove all the bad part of being addicted to nicotine, why is it still bad to be addicted to nicotine?

It's like the experiment of a room with monkeys, ladder, banana and water hose.

By the way, there's nothing preventing one to use nicotine-free fruity vaping liquid.

The whole "marketing to kids" with fruit flavors seems like a straw man. I have asked everyone who mentions it to show me one ad targeting kids, and no one yet has been up to the challenge. I think it's the whole "think of the children" excuse when advocacy groups want to amp up regulations on things.

I personally chose the fruit flavors when I was quitting cigarettes so I could distance myself from the flavor of tobacco, and it worked well for me. I cannot even finish a real cigarette now without feeling nauseated (even though I always seem to try after a few beers). I'm thankful for those fruity flavors every day.

> Seriously, what legitimate reason is there for a quitting tool to be more appealing than the thing being quit

If the quitting tool is less appealing, then it makes people more reluctant to quit. That's just simple logic.

What if your quitting tool is so appealing, that people who don't have addictions are appealed, start using the "quitting tool" (as it is often used today), and start being addicted to nicotine as well?

I don't get why this isn't obvious.

Yep, a really good tool to get people off of cigarettes will inevitably lure some people to try it who weren't smoking cigarettes to start with.

> and start being addicted to nicotine as well?

Then they'll be addicted to nicotine. And?

You're dropping that like it's some sort of trump card, but the reality this is about harm reduction, and trying to find a policy that will lead to optimal outcomes. If you can get X smokers to switch to vaping while Y non-smokers also start vaping, is that good? Depends on the harm of smoking, the harm of vaping, and the size of X relative to Y. Just yelling that Y is non-zero number without all the other information we need is just pointless noise.

If "...and then they'll be addicted!" was a compelling argument, we'd be banning Starbucks.

And? Unless you can prove “getting group X less addicted” is more valuable than “getting group Y addicted”, that’s just a bogus argument. Considering Y is more likely to be younger people, I find that unlikely.

> Unless you can prove “getting group X less addicted” is more valuable than “getting group Y addicted”

If group X is larger and/or the harm avoided from their switching to less harmful behaviours is more serious, then a simple utilitarian calculation says yes, it is more valuable.

What data I've seen is still tentative, but suggestive that this is the case.

Do you have data to show the opposite?

Maybe the same reason people go from smoking heroin to shooting it: it’s a stronger high (ie more nicotine)

E-cigarettes can contain any concentration of nicotine, and can have powerful enough heating elements to release huge quantities of it. E-cigarettes can deliver far more nicotine than cigarettes if you build them that way. But the user titrates the dose to the subjective effects, so dose per inhalation doesn't matter much.

However, in most cases e-cigarettes deliver only nicotine, while tobacco also also contains harmala alkaloid monoamine oxidase inhibitors. In animal studies[0][1] these have a synergistic effect in producing addiction when combined with nicotine, and anecdotally many humans report whole tobacco alkaloids having a subjectively different effect than pure nicotine.

[0] https://www.ncbi.nlm.nih.gov/pubmed/16177026 [1] https://www.ncbi.nlm.nih.gov/pubmed/14592678

I used to smoke a pack a day, switched to ecigs, bought enough concentrated nicotine juice to last me for the next 100 years, mix my own juice so no worries about getting a bad product. It's been 5 years now and I can't stand being in a car or house full of cigarette smoke anymore. If nothing else my health has improved just from the fact I'm no longer being taxed into the poor house and can afford to buy healthier food. I don't know if there are going to be long term effects from ecig use but having lost my mom to lung cancer I know there are from using cigarettes. I am against kids smoking anything but I would say that kids that admit to trying ecigs are probably just more prone to high risk activities, I bet most of them also drank and did drugs too in the past 12 months that doesn't mean the vaping is the cause. As for your comment I agree that some people that vape still get cravings for what ever else is in tobacco as my dad will vape 99% of the time but still carries a pack of cigarettes of which he will smoke one or two of per week. Still much better that just smoking and when he does smoke he goes outside of his home, which has resulted in an added benefit that more non smokers come to visit him more often reducing the loneliness any widower will suffer from.

You can definitely get way more nicotine in a vape hit that you can from a cigarette.

You can get less, too - in fact, you can tinker with it to get pretty much anything you want.

As a vaper (ex-smoker), let me assert that vaping is like driving Tesla Model S P100D and smoking is akin to driving 2003 Ford Focus. I'd never gateway to Ford Focus 2003 from Tesla Model S P100D. Cheeky but true.

The biggest flaw in this study has gone unmentioned: smokers lie.

No one’s following these kids around to verify their responses are accurate. A sizable percentage of high school kids lie about anything for any number of reasons. Yeah man, I vape, can I go now? Yeah man, I smoke, are we done?

That alone is plenty to throw out this data. The agenda here is clear: more research funding to justify harebrained regulations supported by halfassed written surveys.

So we shouldn't research anything related to the social sciences because some people might lie about it? What leads you to believe that smokers lie more than nonsmokers if not social science research?

The term for this situation is ”streetlighting”, where the possible reigns over the correct.

“It’s dark in that alley. I’d never find my keys there.”

Doesn’t matter if it’s extremely difficult to get good data here. What matters is we can’t substitute bad data if that’s all we can come up with.

And although I stated it as smokers lying, the implication is that the nonsmokers are lying (by claiming to smoke).

It is my understanding that most surveys will include a margin of error. This story does not mention this, I wonder if this is just slight of hand while the east coast of the US falls into the sea?!

Or maybe the cable news sites are distracting me from this?!?

Where does hookah play into this? I seriously want to know as I’ve never smoked cigarettes or have a nicotine dependence.

Hookah is unfortunately one of the absolute worst offenders health-wise. Think one hookah session is easily multiple cigarettes, likely on the much higher side too

Nicotine addictive, vaping seen as a way to hook the next generation by tobacco execs, and other unsurprising facts tonight at 11.

Vaping: MAYBE it's not as unhealthy as smoking, but it's definitely not as cool.

Interestingly enough, vapers themselves seem to be the ones reinforcing this. Every vape shop I've ever seen is filled with thick clouds, run by teenagers or burnouts, and just generally a pretty low-class place.

On the other hand, I know several people who are successful professionals that vape. They order their stuff online, and don't advertise the fact that they vape.

Increase tax on tabacco products and include e-cigs

Why the heck are e-cigs illegal for anyone? They're as harmless as theater haze.

The carrier liquid might be the same thing as theater haze, but theater haze doesn't contain nicotine (which has known health risks even without combustion products), doesn't contain flavorings that are only tested for food use (and the example of "popcorn lung" from diacetyl shows that inhaling flavorings directly is not the same as using them in food), and is inhaled in much lower concentrations. E-cigs are safer than smoking, but to call them "harmless" is a strong claim that requires evidence.

(Full disclosure: I run a small business making and selling flavoured e-cigarette liquid) The levels of diacetyl from a conventional cigarette can be around 750x that of what you'd get from an e-cigarette containing such a flavouring. Most concentrate manufacturers have removed or replaced any flavours that contain this or other known irritants wherever possible, and provide material safety data sheets for all ingredients. As far as I am aware, there have been no reported cases of "popcorn lung" from vapers or smokers.

If I am mistaken or unaware of any contradictory information, I would really appreciate being pointed in the right direction.


I'm not sure why we collectively decided to trust the tobacco industry on this issue, this can't be overly surprising given their level of interest in this emerging market.

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