Concerns raised about increased e-cigarette use in teenagers

“E-cigarettes: Many teenagers trying them, survey concludes,” BBC News reports after a survey of around 16,000 English teenagers found one in five teens had tried an e-cigarette.

The concern is that rather than using e-cigarettes as a device to stop smoking, teenagers with no history of smoking could be using e-cigarettes because of their novelty value. This hypothesis seems to be borne out by the survey finding that 16% of teen e-cig users said they had never smoked conventional cigarettes.

While e-cigarettes are undoubtedly far safer than cigarettes, this does not mean they are 100% safe. Nicotine is a powerful substance and it is unclear what long-term effects it may have, especially on a teenage brain and nervous system that is still developing.

The study also found a strong association between alcohol misuse, such as binge drinking, and access to e-cigarettes. Other experts fear e-cigs could act as a potential gateway to smoking among children.

From 2016, the Medicines and Healthcare Products Regulatory Agency (MHRA) is expected to license e-cigarettes as a medicine in the UK, so they should become an age-restricted product.

One limitation of the study, however, is that it relied on self-reporting, so it is prone to selection bias. This makes its findings less reliable.

One final message you may want to convey to your children is that a nicotine addiction brings no useful benefits, but it can be expensive (especially for a teenager) and its long-term effects are unclear. 

Where did the story come from?

The study was carried out by researchers from Liverpool John Moores University, Public Health Wales, Health Equalities Group, and Trading Standards North West.

It was published in the peer-reviewed journal BMC Public Health. BMC Public Health is an open-access journal, so the study is free to read online.

It was covered broadly accurately in the papers, although reports focused on the number of non-smokers who had reportedly used e-cigarettes.

This raised fears in the press that the devices may become a gateway drug to tobacco, rather than concerns about the number of young smokers who reported using them.

The study’s limitations, such as the issue of selection bias (which could either lead to an over- or underestimation of the true figure) and the fact the sample may not be representative of England, were not discussed.  

What kind of research was this?

This was a cross-sectional survey of more than 16,000 school students in northwest England looking at reported use of e-cigarettes, conventional smoking, alcohol consumption and other factors.

The authors say that while e-cigarettes are marketed as a healthier alternative to tobacco, they contain the addictive drug nicotine.

The battery-powered devices, which can be bought online and in some pubs, chemists and newsagents, deliver a hit of addictive nicotine and emit water vapour to mimic the feeling and look of smoking.

The vapour is considered potentially less harmful than cigarette smoke and is free of some of its damaging substances, such as tar. 

What did the research involve?

The researchers used a cross-sectional survey of 16,193 school students aged 14 to 17 in northwest England. This is part of a biennial survey conducted in partnership with Trading Standards, whose remit includes enforcing regulations on the sale of age-restricted products in the UK.

The survey includes detailed questions on:

• age
• gender
• alcohol use (drinking frequency, binge drinking frequency, drink types consumed, drinking location, drinking to get drunk)
• smoking behaviours (smoking status, age of first smoking)
• how alcohol and tobacco were accessed
• parental smoking
• involvement in violence when drunk

In 2013, the survey included a question about e-cigarettes for the first time, asking students if they had ever tried or bought them.

The questionnaire was given to students by teachers during normal school lessons between January and April 2013. Students completed the questionnaire themselves voluntarily and anonymously. The researchers excluded questionnaires where data was incomplete or spoiled.

The researchers also collected information on deprivation using both home and school postcodes and assigning participants to five different groups (or quintiles). They used standard statistical methods to analyse associations between e-cigarette access and other factors. 

What were the basic results?

The main findings are summarised below:

• one in five children (19.2%) who responded said they had “accessed” e-cigarettes
• over one-third (35.8%) of those who reported accessing e-cigarettes were regular smokers, 11.6% smoked when drinking, 13.6% were ex-smokers, and 23.3% had tried smoking but didn’t like it
• 15.8% of teenagers who accessed e-cigarettes had never smoked conventional cigarettes
• e-cigarette access was also associated with being male, having parents or guardians that smoke, and students’ alcohol use
• compared with non-drinkers, teenagers who drank alcohol at least weekly and binge drank were more likely to have accessed e-cigarettes (adjusted odds ratio [AOR] 1.89)
• the link between e-cigarettes and alcohol was particularly strong among those who had never smoked tobacco (AOR 4.59)
• among drinkers, e-cigarette access was related to drinking to get drunk, alcohol-related violence, consumption of spirits, self-purchase of alcohol from shops or supermarkets, and accessing alcohol by recruiting adult proxy purchasers outside shops  

How did the researchers interpret the results?

The researchers say their findings suggest e-cigarettes are being accessed by teenagers more for experimentation and as a recreational drug, rather than for help with smoking cessation.

There is an urgent need for controls on the promotion and sale of e-cigarettes to children, the researchers argue, although they also point out that those most likely to obtain e-cigarettes may already be familiar with “illicit methods” of accessing age-restricted substances. 

Conclusion

As the authors point out, this cross-sectional survey had a number of limitations:

• it did not record how frequently e-cigarettes were reportedly accessed
• it cannot tell us whether children who reported both conventional smoking and e-cigarette access had accessed e-cigarettes before or after using conventional cigarettes
• it is possible that, as the questionnaire was voluntary, it suffered from selection bias, with only certain students completing it
• students may have under- or over-reported their smoking and drinking behaviours

The survey should not be considered representative of all 14- to 17-year-olds in England or in the northwest. However, the finding that one in five children reported having access to e-cigarettes, and that many of them are non-smokers, is a clear cause for concern.

From 2016, the Medicines and Healthcare Products Regulatory Agency (MHRA) is expected to license e-cigarettes as a medicine in the UK. This should bring them in line with nicotine patches and gum, and allow the agency to apply rules around the purity of the nicotine in e-cigarettes, for example.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

E-cigarettes: Many teenagers trying them, survey concludes. BBC News, March 31 2015

Four in 10 teenage e-cigarette users would not have smoked, warn health experts. The Daily Telegraph, March 31 2015

Are teenagers trying e-cigarettes as a trendy novelty? ITV News, March 31 2015

E-cigarettes: why are young people vaping? Channel 4 News, March 31 2015

One in five teens have tried e-cigs: Fears youngsters will move on to real cigarettes after getting taste for nicotine. Mail Online, March 31 2015

Links To Science

Hughes K, Bellis MA, Hardcastle KA, et al. Associations between e-cigarette access and smoking and drinking behaviours in teenagers. BMC Public Health. Published online March 31 2015