Clinical Edge

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Traditional Cigarette Initiation After E-Cigarette Use

Am J Med; 2017 Dec 10; Primack, Shensa, et al

Nearly half of young adults initiated traditional cigarette smoking at 18 months after baseline electronic cigarette (e-cigarette) use, a recent study found. The prospective cohort study used sampling frames representing 97% of the US population to recruit a nationally-representative sample of never-smoking young adults aged 18 to 30 years. The main outcome measure was initiation of traditional cigarette smoking between baseline (March 2013) and 18-month follow-up. Researchers found:

  • Baseline surveys were completed by 1,506 never-smoking young adults, of whom 915 (∼61%) completed follow-up.
  • 2.5% of the represented population of never-smokers used e-cigarettes at baseline.
  • Cigarette smoking was initiated by 47.7% of e-cigarette users and 10.2% of non-users.
  • In multivariable models, e-cigarette use at baseline was independently associated with initiation of smoking at 18 months (adjusted odds ratio, 6.8).


Primack BA, Shensa A, Sidani JE, et al. Initiation of traditional cigarette smoking after electronic cigarette use among tobacco-naïve US young adults. [Published online ahead of print December 10, 2017]. Am J Med. doi:10.1016/j.amjmed.2017.11.005.


Electronic cigarette (e-cigarette) use has increased rapidly among youth and young adults over the last 5 years from near negligible use to now more common than regular cigarette use. In 2014, the prevalence of past 30-day use was higher for e-cigarettes than regular cigarettes (13% vs 9%).1 E-cigarettes are perceived as safer than regular cigarettes and are therefore attractive to many non-smokers. An open question has been whether the use of e-cigarettes, and subsequent nicotine addiction that may develop, may lead to cigarette use. This study shows that in a nationally representative sample, e-cigarettes serve as a “gateway” to the use of regular cigarette use. The 5-fold increase in likelihood to go on to smoking cigarettes is large, and the clear message is that we should be discouraging nicotine use in all it forms. —Neil Skolnik, MD

  1. Arrazola RA, Singh T, Corey CG, et al. Tobacco use among middle and high school students—United States, 2011–2014. Vol 64. Atlanta; 2015. Accessed April 24, 2017.

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