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expert reaction to study on e-cigarette use by teenagers

A new study in the journal BMC Public Health surveyed over 16,000 14-17 year-olds in North West England and asked participants about their alcohol and tobacco-related behaviors. The authors report that one in five had used e-cigarettes, and that they observed a link between alcohol consumption and the likelihood of e-cigarette access.


Dr Michael Bloomfield, NIHR Academic Clinical Fellow and Honorary Clinical Lecture in Psychiatry, University College London, said:

“This new study adds to existing studies reporting growth in e-cigarette use in young people.  Whilst e-cigarettes may be less harmful than tobacco cigarettes, there is concern that despite progress in controlling tobacco use, young people continue to develop an avoidable addiction.

“More research is needed into the effects of nicotine addiction on the adolescent brain, given converging evidence from other drugs of addiction that exposure during this key developmental period can have lasting effects on the brain extending into adulthood.”


Prof. Marcus Munafo, Professor of Biological Psychology, MRC Integrative Epidemiology Unit, UK Centre for Tobacco and Alcohol Studies, University of Bristol, said:

“This study builds on what we already know – young people who have not smoked are experimenting with electronic cigarettes. There are a number of percentages referenced which can be a bit confusing. To clarify, from the figures presented it seems that less than 3% of the 16,193 youth sampled fell into the category of never having smoked but having accessed an e-cigarette. Of the 61.2% (9,699) of teenagers who reported never having previously smoked conventional cigarettes, 4.9% of them (475) had accessed e-cigarettes. These figures have been calculated from Table 1 and may be subject to a degree of rounding error. The results from this study are broadly consistent with previous large, representative surveys in the UK.

“Critically, these previous surveys have shown that while some young people are experimenting with electronic cigarettes, progression to regular use is rare. Product labels already indicate that electronic cigarettes are not for sale to under-18s, and in 2014 the UK government indicated that legislation will be brought forward to prohibit the sale of electronic cigarettes to under-18s.

“To describe electronic cigarette use as “a new drug use option” and part of “at-risk teenagers’ substance using repertoires” is unnecessarily alarmist, given the evidence that regular use among never smokers is negligible, the lack of evidence that electronic cigarette use acts as a gateway to tobacco use, and the likely low level of harm associated with electronic cigarette use.”


Prof. Robert West, Professor of Health Psychology, Department of Epidemiology and Public Health, University College London, said:

“This is a relatively large survey of one region in the UK. The key problem is not so much about the methods used as the interpretation of the findings. This study shows exactly the same as all the other studies. The data to date show that lots of young people are trying e-cigarettes, mostly smokers, but that almost no non-smokers continue to use them.

“The kinds of young people who try e-cigarettes are pretty much the same people as those who try smoking. The conclusion that we should try to prevent young people from using e-cigarettes is pretty obvious but this does not follow from the study.”


Prof. Martin McKee, Professor of European Public Health, London School of Hygiene and Tropical Medicine, said:

“The rapid increase in sales of electronic cigarettes, driven by massive marketing campaigns, have left health policy makers struggling to know how best to respond. There are still very many unanswered questions about them, some of the most important relating to their adoption by adolescents.

“The authors have analysed data from over 16,000 young people attending schools in the North-West of England, gathering information about not only their use of electronic cigarettes but also smoking and hazardous drinking.  The study has many strengths, including its very large size, the ability to determine which young people were living in rich and poor areas, and the careful and detailed analysis undertaken. Its weakness, common to all studies undertaken on electronic cigarettes so far, is that it could not follow up individual children to determine what happens to young people who have not previously smoked but who are using electronic cigarettes. We also don’t know if there are any young people who were regular users but have managed to wean themselves off them, an important piece of information given concerns about their long term use.

“Even so, the findings are very important. They show a very rapid increase in uptake of electronic cigarettes among young people, with one in five having used them. They also show that there are more young people who are using them but who have never previously smoked, who, it is feared, may subsequently graduate to smoking, than there are ex-smokers using them. Crucially, their use is most common among young people with other forms of hazardous behaviour, such as binge drinking, suggesting that they are simply being added to the portfolio of dangerous or addictive substances that these often vulnerable young people are using.

“This paper adds to the rapidly growing body of evidence raising concerns about the aggressive marketing of electronic cigarettes in those countries where it is still permitted. The paper’s most important contribution is to show how, despite often being promoted as cessation aids, these products really are being used as just another recreational drug. That finding must inform debates on how they should be regulated.”


Prof. Linda Bauld, Professor of Health Policy, University of Stirling, said:

“There are now at least 37 peer-reviewed published studies reporting use of electronic cigarettes amongst young people in different parts of the world. This study adds to that literature by reporting on use from one region in England, where a large sample was asked about e-cigarettes alongside tobacco and alcohol consumption. Its findings are consistent with surveys in other countries.

“What this study shows, as others have done, is that a significant proportion of young people are trying electronic cigarettes, including non-smokers. This underscores the need for age-of-sale restrictions of the kind that will soon be introduced in England.

“However, while the study asks questions about frequency and amount of tobacco and alcohol use, for e-cigarettes it only asks whether a young person has ever tried or purchased an e-cigarette. This ignores a key question, which is whether young people are regularly using e-cigarettes.  Other surveys have so far found that progressing from ever trying an e-cigarette to regular use amongst non-smoking children is very rare or entirely absent, suggesting that, to date, e-cigarettes are not responsible for creating a ‘new generation’ of nicotine addicts, despite what some commentators have claimed.”


‘Associations between e-cigarette access and smoking and drinking behaviours in teenagers’ by Hughes et al. published in BMC Public Health at 01:00 UK time on Tuesday 31st March.


All our previous output on this subject can be seen at this weblink:


Declared interests:

Dr Michael Bloomfield: None declared

Prof. Robert West: I have not and will not accept any kind of funds, payments or hospitality from companies that make e-cigarettes because of the risk of being perceived as tainted on that count. I undertake research and consultancy for companies that manufacture smoking cessation medications and licensed nicotine replacement products. My salary is funded by Cancer Research UK

Prof. Marcus Munafo: I receive research funding from companies that manufacture smoking cessation medications and licensed nicotine replacement products.

Prof. Martin McKee: None declared

Prof. Linda Bauld: I chaired the NICE programme development group on tobacco harm reduction.  NICE guidance on tobacco harm reduction was published in 2013.

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