The gateway theory, a phrase that is commonly used in the drug world, claims that class B drugs inevitably lead to class A drugs. This is a very simplistic description, but when applied to vaping, the theory suggests that e-cigarettes lead to smoking.
Updated: 18th March 2020
Many people, including teenagers, believe that vaping is a way to stop smoking. However, when we dig a little deeper into teenage demographic, it isn’t as black and white as we would like.
To explore this theory further, we will be heavily relying on the work of Carl V Phillips, who has worked closely with CASAA for many years. We will also cover more recent research by Dr Lion Shahab et al, which addresses the common limitations using propensity score matching.
We will look at teen vaping, using the most recent research, to see if we are being fed a myopic view or if there is some truth to the theory that teens are using e-cigarettes as a gateway to smoking.
To answer this question we must explore how the gateway theory is developed, the many variables involved, and the magnitude of the gateway being discussed. We must also ask the question, “Why would someone go from vaping to smoking, when the vast anecdotal evidence is that vaping generally tastes better and is more enjoyable than smoking cigarettes?”
Why would someone choose to switch from a lower risk product to a higher risk one?
Let’s begin by looking at some baseline numbers. Here are the teen stats from the CDC:
Smoking Stats:
● Approximately 2 out of every 100 middle school students (2.2%) reported in 2016 that they smoked cigarettes in the past 30 days—a decrease from 4.3% in 2011.
● 8 out of every 100 high school students (8.0%) reported in 2016 that they smoked cigarettes in the past 30 days—a decrease from 15.8% in 2011.
Vaping Stats:
● About 4 out of every 100 middle school students (4.3%) reported in 2016 that they used electronic cigarettes in the past 30 days—an increase from 0.6% in 2011.
● About 11 out of every 100 high school students (11.3%) reported in 2016 that they used electronic cigarettes in the past 30 days—an increase from 1.5% in 2011.
Note: This could be a one-time only use of a tobacco product during a 30-day period, or it could be more frequent usage.
These figures show that more teens vape than smoke. They also show that there has been an increase in vaping and a decrease in smoking over the past 5 years.
To reiterate, smoking cigarettes is at an all-time low among students.
The fact that teens are vaping at all is what leads us to say that e-cigarettes are a gateway towards smoking. This statement is true for adults, as adults use vaping to transition from tobacco, or they dual use, but as many teens are not yet smoking, can we really say the same thing?
One thing that the stats don’t tell us is if these numbers are exclusive to vapers/smokers or is there some cross over? How many of them that use modern parlance are dual users?
The CDC state:
● In 2016, about 7 out of every 100 middle school students (7.2%) and about 20 out of every 100 high school students (20.2%) used some form of tobacco product.
BUT…. We don’t have all the information.
These studies generally do not account for confounding. Confounding variables, or third variables, are “variables that the researcher failed to control, or eliminate, damaging the internal validity of an experiment.”
The confounding variable here is that we do not know why some teens that vape move onto smoking.
Because again, why would someone do this?
We also do not know how effective the anti-smoking policies have been in lowering the teen smoking rate, nor do we know how effective e-cigarettes have been. Yes, there is information, but there are always variables. Could this be a perfect synchronicity where the timing is right, the environment is right, the availability of different products is right, and so smoking rates have decreased? We do not know.
Teenagers, unlike adults, have grown up with the knowledge and information that smoking is harmful. They have not seen cigarette advertising, and generally, this younger generation is more conservative than previous generations.
The argument here, as mentioned before, is that vaping is a gateway to smoking for teens. This can be seen in recent research with articles titled,
“High-nicotine e-cigs up chance teen will become a smoker”.
This headline is a simplistic way of inferring that e-cigarettes are a gateway to smoking.
This is what tobacco control does – they infer but they do not offer proof.
The study, published in the JAMA Paediatrics journal, was conducted with a group of 181 students. After 6 months of vaping, there was a follow-up study, and the results showed that those that vaped higher doses of nicotine were more likely to become smokers. The study found “that 43 percent of high school students who used high-nicotine e-cigarettes (18 milligrams per millilitre or more) at the start of the study were “frequent smokers” at the follow-up six months later, meaning they smoked traditional cigarettes at least three times in the past month. Only 10 percent of those who used low-strength e-cigarettes (1-5mg/mL of nicotine) and 6 percent of those who used nicotine-free e-cigarettes were frequent smokers at the follow-up.”
We are not dismissing these findings, though the participant group in the study was small. No teen under the age of 18 should be using tobacco products, whether that be cigarettes or e-cigarettes. We must look at this in context and through the lens of real life, and not just a clinical trial.
Can teen vaping be blamed for teen smoking?
We can easily say that some teens are seeking out risky behavior and that is why they smoke. But, can we prove that in these cases?
We do not know why some teens that started vaping have migrated to smoking. We cannot dismiss the fact that this is happening, but can we lay it squarely at the door of vaping?
Again, why would someone go from a lower risk product to a higher risk one? Is it really all about the nicotine?
We do not know whether these students would have taken up smoking if no alternative had been available. We do not have the full picture of why these teenagers moved to smoking. The e-cigarette makes up part of the picture. But we cannot from this small study, assess just how much of a part vaping played in this transition.
Updated: 18th August 2020
However, in March, an extensive piece of research was conducted by Dr Lion Shahab, Dr Emma Beard and Dr Jamie Brown, highly regarded UK tobacco control experts. The trio explained that they had suitably accounted for factors which could contribute towards the likelihood of future smoking, by using a technique called propensity score matching (PSM), which is more commonly used in medical treatment validation. The methodology is explained by the authors in great detail in the Tobacco Control journal.
The study compared the uptake of smoking after initiation with cigarettes, e-cigarettes, non-combustible tobacco products (Chewing tobacco, snuff etc.), and combustible non-cigarette products (pipes, cigars etc.).
The research concluded that e-cigarettes are not the significant gateway into smoking for youth populations of the USA, which is of course the good old-fashioned combustible cigarette, and that e-cigarettes are actually more likely to be a gateway out of smoking.
The concluding comments read:
“Less than 1% of US adolescents who use e-cigarettes first were established cigarette smokers. They were less likely to be smokers than adolescents who tried other combustible or non-combustible tobacco products first and propensity score matched adolescents without initial e-cigarette use.”
The research also showed that initiation with other non-combustible tobacco products and combustible non-cigarette products results in a significantly higher conversion from ever smokers to established smokers than that observed with e-cigarettes. The conversion from “ever smoked” to becoming an established smoker was 2.7% for those who used an e-cigarette first, compared to 9% that first tried a combustible cigarette. So, it appears not only that combustible cigarettes are the real gateway, but that having tried an e-cigarette may well provide a protective effect from occasional teen smoking becoming a lifelong habit.
In summary, while previous longitudinal studies may have correctly shown that around 25% of e-cigarette initiators go on to try a cigarette, this does not constitute a gateway, as experimenting with smoking is only a cause for concern if it leads to a continued smoking habit. With the correct matching and variables in place, Dr Lion Shahab et al have uncovered that this initiation with e-cigarettes very rarely leads to a continued smoking habit, and in fact reduces the likelihood of a continued smoking habit when compared with various other tobacco-related products.
It is very easy for us to point to the numbers. We have done at the start of the post, and indeed have done in the past. It is clear that 15.8% is a phenomenal drop in smoking rates in only 5 years. Yes, vaping rates are climbing, but at a much slower pace. On the surface, it appears that vaping is a gateway away from smoking.
Vaping is in a time of transition
But here’s another BUT…
We are in a time of transition.
Carl Philips thinks it’s too early to tell. We don’t know if vaping is a gateway to smoking for more than a small percentage of teen vapers. Vaping has not been around long enough for more in-depth statistics.
It would appear from the overall picture and history, that teens that are going to use tobacco products. They are going to use them regardless. But, many are opting to use e-cigarettes instead of tobacco. This would imply that smoking is a gateway out of vaping for those teens. Although some are unfortunately moving onto smoking.
We do not have the numbers to back up the gateway theory that vaping leads to smoking. All we have is a few teenagers that have done this, but what is the magnitude of this movement? Is it a few? Is it a stampede?
Vaping propaganda
Which raises the next question…
Are these few teenagers being used as propaganda? Is this the myopic view that anti-vaping and anti-tobacco groups want the world to see? Do they not want the world to see the truer picture? That e-cigarettes may just be a gateway away from tobacco for adults?
E-Cigarettes are an adult product. They have an age limit and are successfully helping millions of people transition away from tobacco. Phillips continues that opponents of THR have invoked
“the gateway claim in discussions about eliminating the products entirely (which would stop any gateway effect), but also about regulating where the products can be used (which would have no apparent effect on any gateway). They invoke the same claims when the discussion is about whether to encourage the use of low-risk alternatives among current smokers (which could not possibly create a gateway). This suggests the gateway is, to them, merely a rhetorical tactic, not a genuine concern.”
Could this be true? Could it all just be a ploy to harm e-cigarette companies? The article continues that,”Indeed, a leading anti-THR strategy is to claim that the low-risk products are much higher risk than they are, which, if believed, tends to increase, rather than decrease, any gateway effect because it tells anyone using those products that they might as well smoke.”
Could tobacco control be scoring an own goal here? We’ll leave that conclusion up to you.
News from: https://www.totallywicked-eliquid.co.uk/vaped/the-gateway-theory-and-teens-true-or-false/