Smoking trends don’t show whether ecigs are “working”. Ever. So quit it!

by Carl V Phillips

Live by the sword….

A new study by Goniewicz et al. found that smoking and e-cigarette trialing[*] are both up in Poland. They conclude based on that (yes, just on that — my sentence fully sums up their results), “Observed parallel increase in e-cigarette use and smoking prevalence does not support the idea that e-cigarettes are displacing tobacco cigarettes in this population.” It turns out that simple sentence is wrong in its details (the trend was not remotely parallel) while right in its conclusion. But that is only because the conclusion is basically always true: There is no conceivable data from population usage trends that could either support or deny the conclusion that e-cigarettes are displacing cigarettes.

[*Important aside: The definition of “current smoker” in research is typically “have taken at least one puff in the last 30 days”. That is not a terrible simplification when the goal is to study smoking among adults. Most adults who have smoked once in the last 30 days are smokers by any reasonable definition; smoking is usually an established habit that is either done frequently or avoided entirely. It becomes rather more tenuous when we are talking about kids, because they are much more likely to dabble in such behaviors, so someone who has taken a puff recently may well not be a smoker by any natural definition. Still, there is a pretty decent chance he is because, again, it tends to be an established-or-never type behavior.

This contrasts sharply with e-cigarette usage, especially among kids. Survey designers have inappropriately copy-and-pasted the smoking question without learning enough to understand it is not a measure of the same phenomenon. Someone who has taken one puff on an e-cigarette in the last 30 days may be a vaper by any natural definition. Or she may be a smoker who keeps a cigalike in her purse and puffs on it once a week to relieve some of her suffering when she is trapped in a smoke-free venue for a long period. Or she may be transitioning off of cigarettes. Or she may not use any tobacco product and have approximately zero probability of ever doing so, but recently saw someone using an e-cigarette and asked to try a puff. The latter would seldom happen with a cigarette among adults. The contrast is that e-cigarettes are novel, interesting, and not unpleasant for nonusers to try, and informed people know that poses no more risk than trying a sip of someone’s coffee. We have all seen a nonuser sample an e-cigarette countless times. With kids — typically having more interest in novelty and broader social lives — that is going to happen much more.

Moreover the newness means that someone who takes a few puffs in their entire life, just to make the rational and normal human choice to try out the experience, is reasonably likely to have done it in the 30 days before the survey, unlike with cigarettes. Thus, to describe someone who has tried an e-cigarette in the last 30 days as “a current user” is clearly misleading.]

Back to the causal analysis of population data.

A disturbingly common trend among e-cigarette advocates is to claim that because smoking prevalence is going down where vaping prevalence or e-cigarette trialing is going up, it cannot be that e-cigarettes are a “gateway” to smoking. (I expect to be releasing a paper that covers that point within a few days.) Some take it even further and claim that because smoking rates are going down — as they have been for fifty years — it must be caused by e-cigarette use. This is wrong for the same reason that Goniewicz et al. are wrong: It is impossible, in such data, to sort out the effects of e-cigarettes from the many factors influencing smoking rates. Could e-cigarettes be a gateway to smoking, but smoking still decreases when vaping increases? Yes. Could it be that e-cigarettes do not actually reduce smoking, but smoking rates still go down? Yes. Could it be that e-cigarettes are making a big dent in would-be smoking, but smoking is still going up? Yes.

These are obviously not equally plausible claims. We have lots of evidence that shows that e-cigarettes are causing smoking cessation. But the population smoking prevalence tells us almost nothing. All those claims are equally wrong when the population prevalence data is cited as their basis, and for basically the same reasons.

Returning to Goniewicz paper itself, I have to chuckle at the first line of their press release, “Use of electronic cigarettes (e-cigarettes) has more than tripled among students in Poland, according to….” I wonder if they realize that any increasing trend that started at zero allows you to say “increased by a factor of X” where X is any positive number — you just have to pick the right starting and ending point. Ok, strictly speaking, because those numbers are quantum (the number of users must be a positive integer), you can only get X as high as the total number of users and you can only get a (large) finite subset of the rational numbers below it. Still, wouldn’t saying “…has increased 1000-fold…” be a much more impressive misleading statement? I wonder why they did not try that. (As long as I am enjoying math geek humor, I responded to a recent claim that e-cigarette use had doubled in the last decade with “[1] Inf”.)

Setting aside the innumeracy (and/or failure to notice they forgot to include the “in the last three years” or “among older teens” modifiers in their claim), the study found remarkably high rates in Poles, age 15-19. There are a few things that are quirky about the sampling methods and reasons to believe the populations sampled from 2010-11 and 2013-14 were not really the same, so I would not put too much stock in the exact numbers. That is something to keep in mind about most studies like this.

Smoking at least once in 30 days increased from 24% to 38%. It is really amazing what a sustained economic depression does to the use of all drugs by young people with no employment prospects.

The numbers for e-cigarette “current use” were 5.5% and 30%. That is the predictable trend, though the second figure is surprisingly high. Again, economic depression and all. Careful readers will have noticed that their describing that change as “more than tripled” is a bit odd. My three-year-old knows how to describe something as doubling or tripling but does not have the vocabulary for other multiples — maybe it was something like that.

Almost three-quarters of those who had recently tried an e-cigarette were also smokers, up from about 60%. This fits the downward trend in novelty I mentioned earlier: Over time, the portion of people who try an e-cigarette once or twice in their lives who have done that in the last 30 days will decrease, so more of them will be actual tobacco product users. From this we can conclude the trend is toward e-cigarettes being used almost exclusively by smokers and ex-smokers. Of course, the authors did not mention that obvious point nor, perhaps, even understand it. Also, it will probably surprise no one that they did not report the rate of former smoking among e-cigarette users, to avoid demonstrating that inconvenient fact.

The one good thing I can say about this paper is that they did not ramble on for pages about unrelated points, though the Discussion section is longer than either the Methods or Results, so that is still a fail. They discuss why their e-cigarette trialing rates were higher than those in another country where e-cigarettes are popular, the US. They nailed the obvious major source of the contrast (because the latter figures are based on ages 11-18), and yet go on to talk about other possible explanations.

So, what should the anti-THR liars have done with the main study result? If they were smart, they would have spun it (honestly) as a clear demonstration that it is invalid to use population-level trends to make claims about e-cigarettes helping people quit. After all, this is likely to be a rare or even unique case of smoking increasing in a population with a lot of e-cigarette use. Their best tactic would have been to use it as a demonstration that the many cases where smoking decreased while vaping increased do not provide evidence that e-cigarettes work.

That is both valid and tactical. It would be a serious mistake to get on record as saying “this shows that e-cigarettes are not causing cessation” — not just because it is a blatant lie, but because it provides a handy reference for everyone who wants to make the much more common opposite misleading statement.

Any guess what they did?

In an editorial accompanying the research paper, which is basically as long as the original paper, Dutra and Glantz wrote (…you can already guess where this is going…), “If adolescents were adopting e-cigarettes as alternatives to conventional cigarettes, conventional cigarette smoking…would have declined.” And a hearty thanks from everyone who wants to use declining smoking as evidence that e-cigarettes work to their pals Lauren and Stan. I cannot condone making arguments that are as bad as something Glantz would write, which that claim is. But if you are going to claim that declining smoking shows that people are adopting e-cigarettes as alternatives, be sure to cite Dutra and Glantz as agreeing with you.

I am not going to waste my time dissecting random rambles from Glantz. Down that path lies madness. But one point: The ellipses in the above quote stood for “…and dual use of e-cigarettes and cigarettes….” This is utter nonsense. There is not even a bad naive argument to be made that dual use should go down when e-cigarettes are substituted for smoking, and they do not even try to back that silly assertion. The reality, of course, is that dual use goes up sharply when substitution takes place because those engaging in partial substitution are necessarily dual users, while those transitioning off of cigarettes are also dual users during the transition period.

Ok, just one more, because if I am going to have to read Glantz we might as well get something useful from it:

Indeed, in its 2014 policy statement on e-cigarettes, the American Heart Association stated, “Among never smokers, 0.7% were currently users (past 30 days), which indicates that few never smokers who try e-cigarettes continue their use”. Results from Poland challenge this assumption (Table 1).

So apparently neither Dutra nor Glantz understands the difference between a simple observation about what is in a dataset and an assumption. Ok, we knew that. But if you look at their Table 1, in which they report a few other numbers based on the Goniewicz survey, they report that even for this population and its rather extreme numbers, only 2% of never-smokers tried an e-cigarette in the last 30 days, hardly a stunning contrast with the “assumption” they claim to deny.

But here is where the conspiracy gets really interesting. Recall how I mentioned that Goniewicz et al. fail to report what portion of the e-cigarette “users” were former smokers. They did not mention anything about former vs. never smoking in their results. So unless Dutra and Glantz were just making up numbers out of whole cloth (which seems unlikely — why commit that bright-line crime when it is so easy to get away with just lying about what the numbers mean), they were given access to data that was intentionally not shared with the readers of the original paper (nor the peer reviewers who signed off on it).

If only we could figure out what Goniewicz et al. did not tell us. Oh wait.

I thought it might take a bit of back calculating, but it turns out Dutra and Glantz accidentally provided new data that made it just a matter of simple subtraction. Of the population who puffed an e-cigarette in the last 30 days, from the 2013-2014 survey, 72% were smokers (reported by Goniewicz) and 21% were former smokers (and thus were probably using e-cigarettes for THR), with only 7% (reported by Glantz) being never smokers. The horror.

Of course, there is nothing terrible, nor even bad, about nonsmokers trying or even really using e-cigarettes. Some are would-be smokers who settled on a low-risk alternative instead (that number will grow steadily over time). Those who are would-be abstinent include a lot of people who will only try a few puffs ever, but happened to have done so just before the survey. But even if a would-be abstinent decides that using a low-risk product is better than being abstinent, where is the problem? They are making a rational consumption choice. Therein lies the fundamental problem with all of the rabid ranting from all these people.

33 responses to “Smoking trends don’t show whether ecigs are “working”. Ever. So quit it!

  1. If they were on the other hand engaged in a campaign to restrict ecigs then their tactic is the right one. They have produced a creditable paper which supports a position that can be used for this purpose. You assume they were doing a study to find out, when in fact they were doing a study to prove a point. Fair play for showing them their errors but as this kind of campaign is short term they might see it as worth the risk of their own petard hoisting them.

    • Carl V Phillips

      I was basing my tactical analysis on assuming their goal was anti-THR. By claiming that this one possibly unique example as informative in their favor, they set up claims about a hundred other examples to be used against them. I think they are simply no better at tactical thinking than they are at science, having relied entirely on a combination of overwhelming resource advantages and a captured credulous audience before. So much the better for us.

  2. Re the definition of “current smoker”: fully agreed. It’s a stupid definition, seemingly based heavily upon the addiction model from alcohol that would say “If you fell off the wagon and had one drink you’re back to being an ‘active’ alcoholic of roughly the same status as the drunk who’s continuing their 30 year roll in the gutter.”

    The Antis are still trying to recover from the blow their addiction model took when smoking behaviors changed so radically from only a small single-digit percentage of long-term smokers smoking less than a pack a week to a fairly significant double-digit percentage who do so. I don’t know the exact stats on that, but I think the pack-a-weeker or pack-a-monther types now make up close to a quarter of the regular smoking population. During the height of the “Let’s make sure we establish smoking as being a drug addiction” push of the Antis (mid-80s to mid-90s) the existence of “chippers” (a term I believe the Antis imported from heroin users specifically in order to buttress that addiction model in face of the behavior change) was portrayed as almost unknown: children would “try a few puffs” and almost inevitably become lifelong 20 to 50 per day addicts.

    – MJM

  3. You are saying that an anomalous 24%-38% hike in smoking rate which coincides with EC use doesn’t show causation because of possible unknown confoundings. Using this approach you can almost never prove anything.

    However, a 24%-38% smoking hike in just 3 years is seems even too extreme for a possible gateway effect (and is incongruous with international data). Thus, the spike is probably due to the fact that 40% of schools participating in the 2nd cross-sectional substituted 5 schools from the 1st one.

    • Carl V Phillips

      I am saying that, indeed, you can pretty much never make convincing claims about any particular causal agent by looking at population smoking prevalence. There is confounding and noise, as well as secular trends, and in this case quite possibly comparing two dissimilar populations and pretending they are the same population (which I guess you could technically call confounding, but that seems a bit too innocent). With so many variables in play, there is simply no way that one such observation can tell us much of anything about one of them. Anyone who thinks so is mostly just showing they should stay away from numbers and return to their pulpit. Scientists — as opposed to physicians, pundits, politicians, and liars (bit of redundancy in that list) — prefer to make multiple observations before concluding causation.

      • Where the secular trend in many countries is a constant drop in youth smoking and all of a sudden we see a massive spike of 24%-38%, than you cannot just attribute it to noise (and not even admit that there’s anything to warrant worry); noise is everywhere and you just don’t see such spikes.
        I already wrote in my previous comment that the spike must be due to differences in populations.

        • Carl V Phillips

          I don’t know too much about Poland. I know that in other places in the east of Europe, there have been all sorts of recent negative population happiness shocks — or, arguably, trends — and, as a result, negative health impacts. I am not inclined to rule out that either or both of real trends and artifacts of the data collection (intentional or not) contributed to this change.

        • “I know that in other places in the east of Europe, there have been all sorts of recent negative population happiness shocks — or, arguably, trends — and, as a result, negative health impacts.”
          If you happen to have any of those sources available, it would be really helpful in my fight against my country’s proposed EC prohibition law (Health Ministry official already referenced Polish study).

        • Carl V Phillips

          Just search the popular press and blogosphere — they are a better source for these than the ivory tower journals. Smoking and other drug use rates, suicides, etc. Greece, Russia, Hungary, etc.

  4. Table 1 in the Dutra/Glantz commentary also revealed (when compared with data provided by Goniewicz et al) that cigarette smokers were 28 times more likely than never smokers (57.4% vs 2%) to report “past month” use of an e-cig in 2013/14, which is consistent with all other published surveys of teen cigarette and e-cig use.

    While the 2% of never smokers is reported in Table 1, the 57.4% is obtained by dividing percentage of dual users by the percentage of smokers (.218/.30=.574).

    In fact, all of the many teen e-cig surveys (including those done by CDC) have found that cigarette smokers were at least 20 times more likely than never smokers to report “past month” use of an e-cig.

    And as you pointed out, Table 1 reported that 6.8% of “past month” users of an e-cig were never smokers, while Goniewicz reported that 72.4% were cigarette smokers (i.e. dual users). While it’s likely that the remaining 21% of “past month” e-cig users were “former smokers”, its possible that there was a fourth category for those who had smoked once or twice, but not in the past month.

    I wasn’t surprised that Goniewicz et al and Dutra/Glantz inappropriately compared (and touted) the 2013/14 survey data to incomparable 2010/11 survey data (as 12 of the 25 schools surveyed in were excluded from the other survey), rendering comparisons between the 2010/11 and 2013/14 surveys as invalid. I don’t know about Polish schools, but in the US, schools in low income/education districts have significantly higher smoking rates than schools in high income/education districts. By adding a half dozen low income/education school districts in the 2013/14 survey (that weren’t included in the 2010/11 survey), Goniewicz et al could easily skew the results so they could claim that both e-cig use and smoking rates increased, and then falsely imply that e-cigs are gateways to cigarettes.

    • Carl V Phillips

      I agree with those additional calculations. There was probably not another category in the division, though: Someone who smoked once or twice is generally included in the “never smoker” category, which is not unreasonable. There are always a few odd ones who qualify as both “never smoker” (have not consumed a cumulative total of 100 sticks) and “current smoker” (took a puff in the last 30 days), but other than that the categories — for what they are worth — break cleanly.

      Interesting point on the surveys. I noted they were differences and oddities, so not too much stock could be put into them. It could have been intentional. As I have written at length for years, epidemiology is so badly done and reported that it is trivial for dishonest researchers to cook results in their analysis and then hide that they did. If they control the data collection also, they can do further cooking there.

    • It’s important to point out that it’s not 2 percent of never smokers who use EC, but 2 percent of youth were never smokers and use EC.

      Thus, we cannot conclude that cigarette smokers were 28 times more likely than never smokers (57.4% vs 2%) to report “past month” use of an e-cig.

      • “40 current e-cigarette users who were never smokers of 1,970 adolescents” – that is of all adolescents in the study, not just never smokers.

  5. On several other issues raised in this post.

    Don’t know what was meant by the word “working” in the title of this post, but the enormous decline in youth/teen “past month” (as well as “daily”) cigarette smoking rates in the US, UK (and other countries where vaping has skyrocketed) demolishes and disproves the claim/hypothesis (repeated daily since 2009 by FDA, CDC, CTFK, ACS, AHA, ALA, AAP, news media) that e-cigs are a “gateway” for cigarette smoking.

    As Brad Rodu posted on his blog last week, the NSDUH found a 15% decline (from 6.6% to 5.6%) in “past month” cigarette smoking by adolescents (ages 12-17) from 2012 to 2013, and a 43% decline (from 9.9% to 5.6%) from 2007 to 2013 (as sales/vaping of e-cigs skyrocketed). (Figure 4.2 on page 49)

    Other DHHS surveys (NYTS, MTF) have found the same huge decline in teen smoking.

    So while annual e-cig sales skyrocketed from $10 million to $2 billion, “past month” teen smoking rates declined 43%. And of course, the ANTZ (nor anyone else) still haven’t found even one nonsmoker (anywhere in the world) who began to vape and then proceeded to smoking cigarettes.

    The NSDUH also found that “past month” cigar use declined 46% (from 4.3% to 2.3%) from 2007 to 2013 (also in contrast to CDC’s false claims that flavored cigars have been addicting lots of teens to lobby for the FDA deeming reg).

    Regarding the issue of “past month use” being defined as “current use”, DHHS and other ANTZ have been intentionally using that latter term to deceitfully conflate “past month” usage rates with “daily” usage rates (because most of the public considers “current use” as “daily use”, and “current users” as “daily users”.

    Tom Frieden has taken this a step further to conflate “past month” and even “ever use” use with “daily addiction”, and other ANTZ have been doing the same to greatly exaggerate actual usage rates to confuse, scare and lobby for the FDA deeming regulation (by citing “ever use” and “past month” use data on teen use of e-cigs, cigars and hookah).

    Finally, while it is clear that Goniewicz shared his most important survey data with Glantz (but didn’t cite it in the study), perhaps Glantz was also involved in designing the 2012/13 survey (and maybe that’s why 4 schools in the 2010/11 survey were excluded from the 2012/13 survey, and why 8 new schools were added that just happened to have high smoking rates).

    I just don’t understand how the peer reviewers and the journal editor didn’t reject the study because of 12 school difference, and because the study focused primarily on comparing the two different survey findings from 2010 and 2014. Instead, the editor decided to publiish the junk science, invited a detailed commentary by Glantz, and then Glantz probably wrote Goniewicz press release and coordinated its timing with the journal editors.

    Unlike Glantz, CDC and other ANTZ (which issue press releases for nearly all of their junk studies on e-cigs), virtually none of the studies published by objective researchers and THR advocates are accompanied with a press release, so no news stories are written.

    • Carl V Phillips

      1. No. Population smoking statistics cannot rule out that there is a gateway. There can be some people who are caused to start smoking by e-cigarettes (or whatever) at the same time that there is a net decline in smoking. That is like saying that faulty airbags are not killing people because there is an overall decline in automobile mortality.

      2. It is definitely true that CDC and other ANTZ have intentionally used the misleading definition of “use” to mislead the public. I have written about that extensively here. However, I think it is still the case that the reason they were able to do that is that some clueless but not necessarily intentionally-dishonest people who were actually doing the work did not even understand that “tried a puff in the last 30 days” means something very different for ecigs than it does for smoking. I know how research is done. That rings true.

      3. You may be right that the gaming of the comparison was intentional and represented a conspiracy. I think you have a point that this should not have been accepted as a legitimate study without at least some argument by the authors that this was not hugely problematic. Also, you introduce the observation about press releases and such, which makes me think: Surely the headline of the press release, if the authors really believed their results, should have been “smoking is skyrocketing among Polish teens”. This certainly does point to the authors knowing their results were cooked. Perhaps that is worthy of another post.

  6. Pingback: Smoking trends don't show whether ecigs are &qu...

  7. I wrote the following comment elsewhere (under my real name).

    Previously you argued against the use of smoking trends as a measure of the gateway-effect by writing, “even though e-cigarette use is increasing, its absolute level is still very small among those at risk of becoming gateway cases.”

    Now, where absolute level among those at risk is not small, you use a different argument.

    • Carl V Phillips

      I would be rather surprised if I contradicted myself via different arguments (via single-word typo, well perhaps occasionally). The general point is that it is basically impossible to ever use data on the first derivative of smoking prevalence to say anything about gateway effects, one way or the other. Similarly, under any observed circumstance it is impossible to use it to make conclusions about THR effects. There is just far too much noise and there are secular trends that are not perfectly stable, both of which obscure any causation. (That “any observed” acknowledges the possibility that there might be such a rapid surge in THR product uptake somewhere that it would emerge from the noise in the smoking prevalence data.)

      It is possible to use the absolute level to say something about the effect of THR adoption prevalence. Certainly that is true in an extreme case like Sweden. You still could not get any traction on gateway (I say more about this in a paper I have coming out shortly).

      I am not sure what your last sentence means. In this population, as will all others previously observed, the number of never-smokers “using” e-cigarettes is very low. If 5% of them, or even 50% of them to propose an absurd hypothesis, were caused to become smokers because of their ecig use, it would be invisible in the smoking prevalence data.

      • Regarding my last sentence, I don’t think the number of never smoking EC users are not really important here. The significant rise in smoking was not for ever but “current” use.
        Thus, those at risk are those who ever used both EC and tobacco cigarettes (62.1% tried EC, of them subtract the 7.1% never-smokers). Of course, among these many would have become current-smokers regardless of EC, others are ex-smokers, and some only tried EC once.

        • Carl V Phillips

          Ok, I am still not sure I am fully getting that, but let me try: Smokers are not at risk of becoming gateway cases because nothing can cause them to become smokers. (They are at risk of becoming THR cases, of course.) Yes, it is true that former smokers are at risk of ecigs causing them to become smokers again, which could be defined as a gateway case (though it might be called something different), but that does not seem to be what anyone claims. (This is all about parsing the claims with the data since there is nothing other than unsubstantiated claims in that whole space.)

          So, someone who tried smoking but is not a smoker is at risk. But so is someone who never tried smoking. To be at risk of being a gateway case, of course, he needs to use ecigs (I would have to say more than just tried — it is even more absurd to claim that one puff on an ecig caused smoking than to say real use of an ecig caused smoking).

          So this comes out to less than 1% of the population even in this extreme case. Imagine, absurdly, that half of all ecig users in this population were caused to start smoking each year. That would be 0.5% of the population. Yet the error in measuring smoking rates (and everything suggests that it was an error) was in the order of 10 percentage points of the population. The hypothetical signal is swamped by the noise alone, regardless of other trends.

          So, even making an absurd assumptions, there is no way that would show up in the smoking prevalence data, and thus gateway cannot be meaningfully supported nor disputed based on that data.

      • Of the 55% who tried both products,
        – subtract 15 who would’ve been part of the 24% “current” smokers in the first survey.
        – subtract 2 for quitters who use EC
        = 38%
        – in Poland EC got little negative publicity (see link below), so maybe most of those who tried EC continue to experiment with them.
        – a portion of those take a cigarettes about once a month as a result.

  8. The final survey has a bias towards a higher current-smoking rate. The 1st survey took place from September to June and the 2nd survey took place from October to January.
    It may be that the likelihood of smoking in the last 30 days among occasional smokers is very higher after New Year’s partying.

    • Carl V Phillips

      Interesting. I suspect that is swamped by other biases from the sampling (I hope to write another post about that), but it is probably not zero. I will mention it. (Of course, there might be summertime partying in the first survey. I know rather little about how and when Polish teens party.)

  9. From this Google translated article article it sounds like the spike in tobacco smoking results contrasts popular belief:

    After reporting study results the author writes:
    “So much science, and how the practice? Just a few years ago in junior high and high schools students-nikotyniści (nicotine?) long breaks hid in bathrooms or exhibition within the walls of the school… Today, though tobacco in schools survived, it is no longer “trendi”.

    “Here you do not even need polls. The best thing about the scale of telling educators. – Only from the previous school year began this watch. Has developed a fashion e-smoking and getting more students came to school with these devices. Although the statute is non-smoking, unlike ordinary cigarette smokers are hard to catch, such as hand – says Ewa Kolasinska, director of the Gymnasium Defenders of Lwow in Poznan.”

  10. Just found another huge discrepancy in the Goniewicz et al study.
    Per my comment at
    Goniewicz’ 2010/11 survey actually found a 37.1% smoking rate (not the 23.9% claimed by Goniewicz in his most recent study).

    “Among surveyed Polish youths, e-cigarettes were the fourth most common source of nicotine after tobacco cigarettes (37.1%; 95% CI: 36.2–37.9), waterpipes (22.2%; 95% CI: 21.5–23.0), and snuff (16.9%; 95% CI: 16.2–17.5) (Fig 1).”

    In a nutshell, Goniewicz et al cherry picked two regions of Poland (for their 2013/14 survey) whose 2010/11 survey data differed sharply from overall national survey data (in addition to changing many schools within those 2 regions for their so-called followup survey).

    Have to go now, but tomorrow I’ll point out why the huge decline in smoking rates among teens disproves the false claim that e-cigs are a gateway to cigarette smoking.

  11. Following up on my previous comment, it appears that there is some confusion between the “gateway effect” at the individual level versus at the population level.

    Based upon the several “gateway” studies by Kozlowski and O’Conner a decade ago on smokeless tobacco and cigarettes, as well as the 2009 NSDUH report by SAMHSA at
    that found
    “Among persons who had used both smokeless tobacco and cigarettes in their lifetime, 31.8 percent started using smokeless tobacco first, 65.5 percent started using cigarettes first, and 2.7 percent initiated use of smokeless tobacco and cigarettes at about the same time,” its been my understanding that a “gateway effect” at the population level can only occur if more half of cigarette smokers first used smokeless tobacco (or e-cigs) before smoking cigarettes (or vice versa).

    Since the evidence consistently finds that the vast majority of e-cig users smoked cigarettes before using e-cigs, and virtually all cigarette smokers smoked cigarettes before using e-cigs, e-cigs cannot be a gateway to cigarettes, while it is clear (to any objective person) that e-cigs are gateways away from cigarettes (at the population level).

    The huge decline in US teen cigarette smoking rates (i.e. 43% decline from 2007 to 2013), along with the huge increase in e-cig usage rates during that same time period, it is impossible for e-cigs to be a gateway to cigarette smoking (and this will become even more obvious when 2014 and future e-cig use and cigarette smoking data become available).

    • Carl V Phillips

      Confusion indeed.

      As with all population-level phenomena, they actually only exist at the individual level. The population effect is merely the sum or rate of all the individual effects. If there are no individual cases, then there is nothing in the population. If there is one individual case, then there is something in the population. (However, population-level statistics are unlikely to be able to distinguish those.)

      “its been my understanding that a “gateway effect” at the population level can only occur if more half of cigarette smokers first used smokeless tobacco (or e-cigs) before smoking cigarettes (or vice versa).” — No, nothing remotely resembling that is true. You may have been confused by the Kozlowski and O’Conner papers because, as I recall, they dance around the gateway without ever really defining it or recognizing that they were not really assessing it, but some other things that were sort of in the same neighborhood.

      A gateway to smoking occurs if someone who would have been a nonsmoker is caused to be a smoker instead due to use of some other product. If there is one or more people for whom that is true, then the gateway is occurring, though perhaps merely to an extent that we do not really care about. It has nothing to do with proportions and is not determined by the order of actions, only causation.

      (Thus, of course, the conclusions that followed from the quoted statement are wrong.)

  12. if cigarettes are a gateway to e-cigs for 99% of e-cig users, and if e-cigs are a gateway to cigarettes for 1% of e-cig users, I (and most others) would consider that as convincing evidence that e-cigs are not a gateway to cigarettes (at the population level).

    I never like the term gateway, especially because its primarily cited by tobacco and drug harm reduction opponents (most of whom are prohibitionists) to demonize low risk products, and to confuse and scare the public.

    So we need to more effectively confront and refute those false claims.

    • Carl V Phillips

      Gateway is not a bad term, so long as it is clearly defined (which means, in particular, that it is about causation of smoking where it would not otherwise occur, not mere precedence). The concept traces back to cannabis prohibition and drug prohibitionism in general, and is definitely a tool of the prohibitionists — almost always in the form of completely unsupported claims. But that does not make it invalid as a concept. (And it is not proper to use it to refer to transitioning in the low-risk direction. That is like the ANTZ game of trying to redefine THR to mean abstinence. The word describes a legitimate concept, and we should not play word games to try to pretend otherwise.)

      A gateway exists if anyone is caused to become a smoker by her use of e-cigarettes. You can certainly argue that a few gateway cases is not an adequate reason to take steps that might interfere with a whole lot of THR. I certainly would. But there would be a gateway effect in that scenario you cite, even if only crazy people would deny that it is a small price to pay for the benefits.

  13. Data showing decline in Polish youth smoking from (bellow age 24) ’11-’13

    Click to access report_2013.pdf

    p. 249

  14. Pingback: New Survey Finds Reduced Youth Smoking as E-Cigs Rise in Popularity »

  15. Robert Mrówczyński

    I requested the authors to show the actual text of the survey in Polish schools. The answer was: “we will publish the text of survey in approx. 6 months”. Means we can expect the publication in April 2015.

  16. Pingback: New Survey Finds Reduced Youth Smoking as E-Cigs Rise in Popularity

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