The increased consumption of electronic nicotine delivery systems (ENDS), including e-cigarettes, among young adults in recent years raises the question of how ENDS may affect cigarette smoking and nicotine use among young adults. The study by Pearson et al1 investigates the association between ENDS use and changes in the frequency or intensity of cigarette smoking among US young adult ever smokers during a 1-year period. The study uses 3 yearly waves of Population Assessment of Tobacco and Health (PATH) Study data. The study participants were 1096 ever cigarette smokers (aged 18-24 years) ENDS naive at wave 1 with complete data at wave 2 and wave 3. The study finds no statistically significant association between ENDS use at wave 2 and changes in wave 2 to wave 3 cigarette smoking frequency and intensity. The authors conclude that ENDS use was not associated with a decrease or increase in cigarette smoking among young adult ever smokers. The PATH Study is an ongoing, nationally representative (when weights are used) longitudinal cohort study of adults and youths in the US. It is relevant that all the wave 2 to wave 3 changes in cigarette smoking frequency and intensity reported in the study have positive values, implying increases in cigarette smoking frequency and intensity following ENDS use at wave 2. The increases were not statistically significant. Notably, the comparison between ENDS users for 6 or more days in the previous 30 days and never users indicated an increase of more than 44 cigarettes smoked during the previous 30 days, although it was not statistically significant. The authors decided not to use sampling weights in any of the analyses and estimates, which may be a source of lack of statistical significance for the changes in cigarette smoking.
Although there is general consensus that ENDS use has the potential to bring benefits to public health if their use by adult smokers leads to long-term cessation of traditional combustible cigarettes,2 there is an ongoing debate on the potential effects of ENDS use on cigarette smoking among young adult smokers. Some argue that ENDS may be used as effective smoking cessation aids or as less harmful alternatives to tobacco, while others argue that ENDS use may contribute to increasing the frequency and intensity of cigarette smoking.
Few other studies, with mixed evidence and with methods limitations, have examined the question of how ENDS use affects smoking cigarettes and nicotine use among young adult smokers. A 2019 review3 could not draw a conclusion about the effects of ENDS on cigarette smoking frequency and intensity among young adult smokers; none of the studies were randomized clinical trials (RCTs).
To put the findings of the study by Pearson et al1 and the other few related studies in context, while ENDS use has increased exponentially in recent years, at the same time, tobacco smoking has decreased among youth and young adults. For further context, although approximately 90% of all tobacco smokers begin younger than 18 years and 99% start smoking younger than 26 years,4 young adulthood (18-24 years) is when smoking patterns are not completely established, and ENDS use may influence these patterns. Although young adults underutilize proven cessation treatments, the evidence suggests that such treatments are as effective for young adults as they are for the general adult population.5 A 2016 Cochrane review6 found evidence from 2 RCTs supporting the conclusion that electronic cigarettes help adult smokers quit in the long term compared with placebo electronic cigarettes and that they may be as effective as nicotine patches. A 2019 RCT7 of adult smokers (N = 886) found that e-cigarettes were more effective for smoking cessation than nicotine replacement therapy, when both were combined with behavioral support. Those studies support exploring further, in RCTs, the possibility of ENDS use leading to young adult tobacco smoking cessation.
If ENDS use among young adults leads to sustained cigarette smoking cessation, the positive contribution to public health may be large. There is promising evidence that ENDS use contributes to cigarette smoking cessation in the general adult population. However, there is no conclusive evidence that ENDS use leads to increased or reduced cigarette smoking among young adult smokers. Large, adequately powered, RCTs of ENDS use among young adult smokers are needed to answer the question of whether ENDS are effective smoking cessation aids or whether ENDS may increase cigarette smoking and nicotine consumption.
Published: November 24, 2020. doi:10.1001/jamanetworkopen.2020.16121
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Meghea CI. JAMA Network Open.
Corresponding Author: Cristian I. Meghea, PhD, Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, 965 Wilson Rd, Room A627, East Lansing, MI 48824 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Meghea CI. Electronic Nicotine Delivery Systems Use and Cigarette Smoking Frequency and Intensity Among Young Adult Smokers. JAMA Netw Open. 2020;3(11):e2016121. doi:10.1001/jamanetworkopen.2020.16121
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