Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis | Adolescent Medicine | JAMA Pediatrics | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Singh  T, Arrazola  RA, Corey  CG,  et al.  Tobacco use among middle and high school students: United States, 2011-2015.  MMWR Morb Mortal Wkly Rep. 2016;65(14):361-367.PubMedGoogle ScholarCrossref
Bunnell  RE, Agaku  IT, Arrazola  RA,  et al.  Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013.  Nicotine Tob Res. 2015;17(2):228-235. PubMedGoogle ScholarCrossref
Bostean  G, Trinidad  DR, McCarthy  WJ.  e-Cigarette use among never-smoking California students.  Am J Public Health. 2015;105(12):2423-2425.PubMedGoogle ScholarCrossref
Wills  TA, Knight  R, Williams  RJ, Pagano  I, Sargent  JD.  Risk factors for exclusive e-cigarette use and dual e-cigarette use and tobacco use in adolescents.  Pediatrics. 2015;135(1):e43-e51.PubMedGoogle ScholarCrossref
Leventhal  AM, Strong  DR, Kirkpatrick  MG,  et al.  Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence.  JAMA. 2015;314(7):700-707.PubMedGoogle ScholarCrossref
Primack  BA, Soneji  S, Stoolmiller  M, Fine  MJ, Sargent  JD.  Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults.  JAMA Pediatr. 2015;169(11):1018-1023.PubMedGoogle ScholarCrossref
Wills  TA, Knight  R, Sargent  JD, Gibbons  FX, Pagano  I, Williams  RJ.  Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii.  Tob Control. 2016;(1):34-39. PubMedGoogle Scholar
Barrington-Trimis  JL, Urman  R, Berhane  K,  et al.  e-Cigarettes and future cigarette use.  Pediatrics. 2016;138(1):e20160379.PubMedGoogle Scholar
Spindle  TR, Hiler  MM, Cooke  ME, Eissenberg  T, Kendler  KS, Dick  DM.  Electronic cigarette use and uptake of cigarette smoking: a longitudinal examination of U.S. college students.  Addict Behav. 2017;67:66-72.PubMedGoogle ScholarCrossref
Miech  R, Patrick  ME, O’Malley  PM, Johnston  LD.  e-Cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students  [published online February 6, 2017].  Tob Control. doi:10.1136/tobaccocontrol-2016-053291PubMedGoogle Scholar
Murthy  VH.  e-Cigarette use among youth and young adults: a major public health concern.  JAMA Pediatr. 2017;171(3):209-210.PubMedGoogle Scholar
Bullen  C, Howe  C, Laugesen  M,  et al.  Electronic cigarettes for smoking cessation: a randomised controlled trial.  Lancet. 2013;382(9905):1629-1637.PubMedGoogle ScholarCrossref
Cobb  CO, Villanti  AC, Graham  AL,  et al.  Markov modeling to estimate the population impact of emerging tobacco products: a proof-of-concept study.  Tob Regul Sci. 2015;1(2):129-141. doi:10.18001/TRS.1.2.3Google ScholarCrossref
Levy  DT, Borland  R, Villanti  AC,  et al.  The application of a decision-theoretic model to estimate the public health impact of vaporized nicotine product initiation in the United States.  Nicotine Tob Res. 2017;19(2):149-159.PubMedGoogle Scholar
Wells  GA, Shea  B, O’Connell  D,  et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Accessed August 31, 2016.
Sterne  JA, Hernán  MA, Reeves  BC,  et al.  ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.  BMJ. 2016;355:i4919.PubMedGoogle ScholarCrossref
Higgins  JPT, Thompson  SG, Deeks  JJ, Altman  DG.  Measuring inconsistency in meta-analyses.  BMJ. 2003;327(7414):557-560.PubMedGoogle ScholarCrossref
Copas  JB, Shi  JQ.  A sensitivity analysis for publication bias in systematic reviews.  Stat Methods Med Res. 2001;10(4):251-265.PubMedGoogle ScholarCrossref
Carpenter  JR, Schwarzer  G, Rücker  G, Künstler  R.  Empirical evaluation showed that the Copas selection model provided a useful summary in 80% of meta-analyses.  J Clin Epidemiol. 2009;62(6):624-631.e4.PubMedGoogle ScholarCrossref
Schwarzer  G, Carpenter  J, Rücker  G.  Empirical evaluation suggests Copas selection model preferable to trim-and-fill method for selection bias in meta-analysis.  J Clin Epidemiol. 2010;63(3):282-288.PubMedGoogle ScholarCrossref
Schwarzer  G, Carpenter  JR, Rücker  G.  Meta-Analysis With R. Cham, Switzerland: Springer; 2015.
Primack  B, Shensa  A, Sidani  JE,  et al. Initiation of cigarette smoking after e-cigarette use: a nationally representative study [abstract]. Accessed July 15, 2016.
Unger  JB, Soto  DW, Leventhal  A.  e-Cigarette use and subsequent cigarette and marijuana use among Hispanic young adults.  Drug Alcohol Depend. 2016;163:261-264.PubMedGoogle ScholarCrossref
Hornik RC, Gibson L, Lerman C. POS5-30: prediction of cigarette use from six-month prior electronic and combustible cigarette use for a U.S. national sample of 13-25 year olds [abstract]. Accessed May 13, 2017.
Leonardi-Bee  J, Jere  ML, Britton  J. Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: a systematic review and meta-analysis. Thorax. 2011;66(10):847-855. PubMed
O’Loughlin  J, Karp  I, Koulis  T, Paradis  G, Difranza  J.  Determinants of first puff and daily cigarette smoking in adolescents.  Am J Epidemiol. 2009;170(5):585-597.PubMedGoogle ScholarCrossref
Romito  LM, Hurwich  RA, Eckert  GJ.  A snapshot of the depiction of electronic cigarettes in YouTube videos.  Am J Health Behav. 2015;39(6):823-831.PubMedGoogle ScholarCrossref
Goel  R, Durand  E, Trushin  N,  et al.  Highly reactive free radicals in electronic cigarette aerosols.  Chem Res Toxicol. 2015;28(9):1675-1677.PubMedGoogle ScholarCrossref
Pagano  T, Bida  MR, Robinson  RJ.  Laboratory activity for the determination of nicotine in electronic cigarette liquids using gas chromatography-mass spectrometry.  J Lab Chem Educ. 2015;3(3):37-43.PubMedGoogle Scholar
Miech  R, Patrick  ME, O’Malley  PM, Johnston  LD.  What are kids vaping? results from a national survey of US adolescents.  Tob Control. 2017;26(4):386-391. PubMedGoogle ScholarCrossref
Morean  ME, Kong  G, Cavallo  DA, Camenga  DR, Krishnan-Sarin  S.  Nicotine concentration of e-cigarettes used by adolescents.  Drug Alcohol Depend. 2016;167:224-227.PubMedGoogle ScholarCrossref
Wills  TA, Gibbons  FX, Sargent  JD, Schweitzer  RJ. How is the effect of adolescent e-cigarette use on smoking onset mediated: a longitudinal analysis. Psychol Addict Behav. 2016;30(8):876-886. PubMed
Barrington-Trimis  JL, Urman  R, Leventhal  AM,  et al.  e-Cigarettes, cigarettes, and the prevalence of adolescent tobacco use.  Pediatrics.2016;138(2):e20153983.PubMedGoogle Scholar
Wills  TA, Sargent  JD, Gibbons  FX, Pagano  I, Schweitzer  R.  e-Cigarette use is differentially related to smoking onset among lower risk adolescents  [published online August 19, 2016].  Tob Control. doi:10.1136/tobaccocontrol-2016-053116Google Scholar
Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE. Use of alcohol, cigarettes, and number of illicit drugs declines among U.S. teens. Table 1: trends in lifetime prevalence of use of various drugs in grades 8, 10, and 12. Published December 16, 2014. Accessed January 30, 2017.
Vansickel  AR, Eissenberg  T.  Electronic cigarettes: effective nicotine delivery after acute administration.  Nicotine Tob Res. 2013;15(1):267-270.PubMedGoogle ScholarCrossref
Farsalinos  KE, Spyrou  A, Tsimopoulou  K, Stefopoulos  C, Romagna  G, Voudris  V.  Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices.  Sci Rep. 2014;4:4133.PubMedGoogle ScholarCrossref
Foulds  J, Veldheer  S, Yingst  J,  et al.  Development of a questionnaire for assessing dependence on electronic cigarettes among a large sample of ex-smoking e-cigarette users.  Nicotine Tob Res. 2015;17(2):186-192.PubMedGoogle ScholarCrossref
DiFranza  JR, Savageau  JA, Rigotti  NA,  et al.  Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study.  Tob Control. 2002;11(3):228-235.PubMedGoogle ScholarCrossref
Gervais  A, O’Loughlin  J, Meshefedjian  G, Bancej  C, Tremblay  M.  Milestones in the natural course of onset of cigarette use among adolescents.  CMAJ. 2006;175(3):255-261.PubMedGoogle ScholarCrossref
DiFranza  JR, Savageau  JA, Fletcher  K,  et al.  Symptoms of tobacco dependence after brief intermittent use: the Development and Assessment of Nicotine Dependence in Youth–2 study.  Arch Pediatr Adolesc Med. 2007;161(7):704-710.PubMedGoogle ScholarCrossref
Kandel  DB, Hu  MC, Griesler  PC, Schaffran  C.  On the development of nicotine dependence in adolescence.  Drug Alcohol Depend. 2007;91(1):26-39.PubMedGoogle ScholarCrossref
Doubeni  CA, Reed  G, Difranza  JR.  Early course of nicotine dependence in adolescent smokers.  Pediatrics. 2010;125(6):1127-1133.PubMedGoogle ScholarCrossref
Dierker  L, Mermelstein  R.  Early emerging nicotine-dependence symptoms: a signal of propensity for chronic smoking behavior in adolescents.  J Pediatr. 2010;156(5):818-822.PubMedGoogle ScholarCrossref
Original Investigation
June 26, 2017

Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Dartmouth-Hitchcock Norris Cotton Cancer Center, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire
  • 2The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire
  • 3Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles
  • 4University of Hawaii Cancer Center, Honolulu
  • 5Annenberg School for Communication, University of Pennsylvania, Philadelphia
  • 6currently a medical student at Warren Alpert Medical School of Brown University, Providence, Rhode Island
  • 7Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 8Oregon Research Institute, Eugene
  • 9Institute for Social Research, University of Michigan, Ann Arbor
  • 10Department of Psychology, Virginia Commonwealth University, Richmond
JAMA Pediatr. 2017;171(8):788-797. doi:10.1001/jamapediatrics.2017.1488
Key Points

Question  Is there an association between e-cigarette use and cigarette smoking among adolescents and young adults?

Finding  A systematic review and meta-analysis showed strong and consistent evidence of an association between initial e-cigarette use and subsequent cigarette smoking initiation, as well as between past 30-day e-cigarette use and subsequent past 30-day cigarette smoking.

Meaning  To minimize the potential public health harm from e-cigarette use, the US Food and Drug Administration, as well as state and local agencies, will need to engage in effective regulatory actions to discourage youths’ use of e-cigarettes and prevent the transition from e-cigarettes to other combustible tobacco products.


Importance  The public health implications of e-cigarettes depend, in part, on whether e-cigarette use affects the risk of cigarette smoking.

Objective  To perform a systematic review and meta-analysis of longitudinal studies that assessed initial use of e-cigarettes and subsequent cigarette smoking.

Data Sources  PubMed, EMBASE, Cochrane Library, Web of Science, the 2016 Society for Research on Nicotine and Tobacco 22nd Annual Meeting abstracts, the 2016 Society of Behavioral Medicine 37th Annual Meeting & Scientific Sessions abstracts, and the 2016 National Institutes of Health Tobacco Regulatory Science Program Conference were searched between February 7 and February 17, 2017. The search included indexed terms and text words to capture concepts associated with e-cigarettes and traditional cigarettes in articles published from database inception to the date of the search.

Study Selection  Longitudinal studies reporting odds ratios for cigarette smoking initiation associated with ever use of e-cigarettes or past 30-day cigarette smoking associated with past 30-day e-cigarette use. Searches yielded 6959 unique studies, of which 9 met inclusion criteria (comprising 17 389 adolescents and young adults).

Data Extraction and Synthesis  Study quality and risk of bias were assessed using the Newcastle-Ottawa Scale and the Risk of Bias in Non-randomized Studies of Interventions tool, respectively. Data and estimates were pooled using random-effects meta-analysis.

Main Outcomes and Measures  Among baseline never cigarette smokers, cigarette smoking initiation between baseline and follow-up. Among baseline non–past 30-day cigarette smokers who were past 30-day e-cigarette users, past 30-day cigarette smoking at follow-up.

Results  Among 17 389 adolescents and young adults, the ages ranged between 14 and 30 years at baseline, and 56.0% were female. The pooled probabilities of cigarette smoking initiation were 23.2% for baseline ever e-cigarette users and 7.2% for baseline never e-cigarette users. The pooled probabilities of past 30-day cigarette smoking at follow-up were 21.5% for baseline past 30-day e-cigarette users and 4.6% for baseline non–past 30-day e-cigarette users. Adjusting for known demographic, psychosocial, and behavioral risk factors for cigarette smoking, the pooled odds ratio for subsequent cigarette smoking initiation was 3.50 (95% CI, 2.38-5.16) for ever vs never e-cigarette users, and the pooled odds ratio for past 30-day cigarette smoking at follow-up was 4.28 (95% CI, 2.52-7.27) for past 30-day e-cigarette vs non–past 30-day e-cigarette users at baseline. A moderate level of heterogeneity was observed among studies (I2 = 56%).

Conclusions and Relevance  e-Cigarette use was associated with greater risk for subsequent cigarette smoking initiation and past 30-day cigarette smoking. Strong e-cigarette regulation could potentially curb use among youth and possibly limit the future population-level burden of cigarette smoking.