New Study Finds E-Cigs are a “New Route to Smoking Addiction for Adolescents”
A new piece of research looking at Korean adolescents has led to loud proclamations that e-cigs are a gateway to smoking addiction. The finding echoes concerns of late from hysterical anti-smoking campaigners and groups such as the CDC that e-cigs are some type of Trojan horse through which smoking is going to re-capture society.
Sadly for anybody hoping to stock up on ammunition for their misguided fight against a product with the potential to save millions of lives, the study actually provides no evidence of the sort, but the reasons for this are hidden within a web of methodological flaws, arguably constructed specifically to lead to the erroneous conclusion.
Researchers aimed to investigate the use of e-cigs amongst adolescents, the rates of dual use and how they impact on smoking habits.
Used data from cross-sectional study looking at “Risk Behavior” of over 75,500 Korean teens from 2011.
“Current e-cig user” is defined as anybody who’s tried vaping over the previous month, even if just once, and a “former smoker” is defined as somebody who hasn’t smoked in the past month but has had at least one puff before that.
The results reveal that e-cigarette use is associated with current cigarette smoking (“dual use”) and that those who use e-cigarettes consume more cigarettes on average than smokers who don’t.
Since this study doesn’t follow users over time, it’s impossible to draw cause-and-effect conclusions, but the researchers allege that e-cigs lead to increased smoking and prevent quitting.
The association is more plausibly explained by the common-sense ideas that current smokers are more interested in vaping (and more likely to vape) and that heavier smokers are more likely to attempt to cut down using e-cigs.
The researchers failed to find even a single case of somebody using e-cigarettes and then graduating to regular smoking.
How Common is Dual Use of E-Cigs and Tobacco Amongst Teens? Do E-Cigs Help Smokers Quit?
The questions the researchers set out to answer were simple enough, and to do so they looked at existing data from the 2011 Korean Youth Risk Behavior web survey. This provided them with an extremely large sample of over 75,500 South Korean teenagers (aged 13 to 18), and the survey already included questions about e-cigarette use. There were two yes-or-no questions: Have you ever used e-cigarettes?” and “Have you used e-cigarettes in the past 30 days?” The full text of the study (paywalled) also includes the questions asked about smoking, the main two being “Have you ever smoked, even one puff in your life?” and “How many days did you smoke, even one puff, in the past 30 days?” In addition, current smokers were asked how many cigarettes they smoked per day, on average, over the last 30 days, and whether they’d tried to quit in the past year.
The methodological problems with the study have already had their seeds sown. Firstly, as with the CDC e-cig survey which has stoked misguided concern about e-cigarette use among teens, the “current e-cig user” definition technically means “someone who’s had at least a single puff of the past 30 days.” “Current user” to most people would mean somebody who vapes every day (at least most days), but the existing survey data did not include this information, therefore crippling one of the core definitions in this piece of research.
The definition of “former smoker” was also particularly misleading. For the purposes of the study, a former smoker was defined as somebody who’d ever had as little as a single puff of a cigarette but hadn’t in the previous 30 days. By this definition, somebody who tried a cigarette once (at a party after a few drinks, perhaps) and didn’t like it (or never took it up full time for any other reason) is a former smoker, and therefore somebody who has “successfully quit” smoking, in the researchers’ later extrapolations.
In addition, the survey was cross sectional, meaning that the data collected represents the population at a specific point in time. It wasn’t a longitudinal survey, which follows the participants to look at how their behavior changes over time, so it’s hard to say anything about the potential cause-and-effect relationships at play. However, that’s precisely what the researchers did when drawing their conclusions.
Results: Are E-Cigs Really a “Gateway” to Addiction and Tobacco Use?
If you were to read study researcher Stanton Glantz’s accompanying blog post, you’d be forgiven for thinking that e-cigs really are a gateway to tobacco smoking. According to the findings, a total of 9.4 percent of the sample had ever used e-cigarettes, with 8 percent having been “dual users” of both e-cigs and tobacco cigarettes.
“Current” e-cig users only accounted for 4.7 percent of the sample, and 3.6 percent of those were dual users. This represents almost 20 times as many Korean students using e-cigs as in 2008 (although, that’s understandable since the market was still in its infancy then). As well as other sub-categories these users fell into (more likely to be male, have higher allowances e.t.c.), vapers were more likely to be current cigarette rather than former smokers, and were more likely to have attempted to quit in the previous 12 months than non-users. Only 0.6 percent of “current” e-cigarette users were non-smokers, whereas 50.8 percent of those who smoked every day were vapers. Additionally, the research showed that those who consumed more cigarettes were more likely to use e-cigarettes.
In the discussion of the findings, the researchers take up the angle they’d been gunning for all along, arguing that, “The findings of high dual use of cigarettes and e-cigarettes show that e-cigarettes are not being used as a substitute for cigarettes among Korean adolescents. Furthermore, the significant association between current e-cigarette use and higher levels of cigarette consumption compared with ever– and never–e-cigarette users suggests that e-cigarettes do not have a role in reducing harm among these teens, and in fact may be increasing harm.”
They also draw attention to the extremely small proportion (1.4 percent) of those surveyed had their first contact with nicotine coming in the form of an e-cigarette, but failed to draw attention to the fact that none of these people went on to become a regular smoker. They continually drive home the core points they want to get across, e-cig users smoke more cigarettes than non-users and are more likely to be current smokers than former smokers.
So, Are E-Cigs a Danger to Teens? Check the Methodology
As noted above, and as argued by Dr. Michael Siegel in his blog post about the study, the fact that this research is cross-sectional means that it can’t be used to draw cause-and-effect conclusions about the behavior of these teens. A longitudinal study would give that sort of information, and a recent example came to the opposite conclusion about dual use, finding that almost half of them quit within a year and the remainder reduced their cigarette consumption significantly.
So why does this piece of research seem to suggest that e-cigarette use increases cigarette consumption? Because this is only a single snapshot in time, it only actually shows that those who smoke more cigarettes are the ones who smoke more cigarettes. Given that e-cigarettes are a reduced harm option, it stands to reason that people who smoke more might be more concerned about their own health and thereby more likely to try to cut down through the use of e-cigs. The study itself shows that the e-cig users were more likely to have tried to quit in the past year.
However, for no reason whatsoever (aside from a pre-determined ideology) the researchers interpret the result in the opposite way. They think it’s because teens who use e-cigarettes go into some sort of nicotine-crazed frenzy and start to consume more cigarettes than ever before. They could be right, but it seems considerably more likely that the heavier smokers are more likely to want to stop or cut down. If this research had been longitudinal (or even if there’d been more questions), we might have an idea of whether these heavy-smoking dual users had decreased their consumption after starting to vape.
The same effective problem exists with the notion that e-cigarette users are more likely to be current smokers than former smokers, and therefore that e-cigarettes don’t help (or even hinder) quitting attempts. Since the definition of “former smoker” in this study is anybody who has ever taken as much as a puff on a single cigarette, it’s very easy to fall into this category. If you try a cigarette once and don’t like it, what interest will you have in e-cigarettes? None whatsoever. Whereas if you’re a current smoker, you’re likely to want to quit and therefore there’s a good chance you’ll give e-cigarettes a try. And given the lax definition of “current e-cig user” (as little as a single puff in the previous month), this is likely to include smoker’s who’ve had a puff of a friend’s e-cig out of sheer curiosity over the previous month, as well as the genuine regular users.
Because this data just represents a single point in time, the only information you get is, “at the time of the survey, regular smokers were more likely to have used e-cigs in the last 30 days than people who’d tried smoking at some point in their lives.” From this information, the researchers conclude that e-cigarette use somehow makes it less likely you’ll quit, a conclusion supported by no other research which doesn’t suffer from similarly crippling flaws. They don’t even mention the common-sense explanation for this: e-cigarettes are a product for smokers, and therefore smokers are more likely to have tried them than people who don’t smoke regularly.
Conclusion – E-Cigs Still Aren't A Gateway to Smoking
It’s clear that this research in no way supports the stated conclusion, thanks to its terrible design. In fact, the design is so awful it’s hard to imagine a single person with a PhD failing to spot the problems, much less three of them. It might not be a palatable conclusion, but it’s time to ask serious questions about the motivations of the people conducting these studies. They are either incompetent to the point of being unable to do their job, or are perfectly capable, yet have decided to use their knowledge to cynically construct a piece of research to support their pre-determined goal.
To end his blog post, Dr. Siegel questions why they even bother conducting the research if they are going to misrepresent the implications of their findings in such a grossly obvious (not to mention borderline malicious) fashion.
This is not science; this is propaganda. The real tragedy will be the coming references to this erroneous conclusion in the media, and the resulting misunderstanding among existing smokers. If just one smoker reads this research, decides e-cigs aren’t worth the “risk” of increasing their addiction, continues to smoke and later dies of lung cancer, would the researchers feel a pang of guilt? Would they be willing to admit to themselves that their desire to present a one-sided interpretation of some research has potentially prevented somebody from making a move that may just have saved their life? Perhaps they feel they’re doing the right thing, but from the outside it looks like an awfully thin ethical line to navigate.