Year: 2024
Type: preprint
Abstract: Background: Electronic nicotine delivery systems (ENDS) offer a substantial harm reduction opportunity for adults who smoke and are unlikely to quit in the near term. However, a major concern about ENDS is their use by non-smoking youth, and particularly whether ENDS are acting as a “gateway” that leads youth to later start smoking cigarettes. However, evidence for the gateway hypothesis can be interpreted in alternate ways, e.g. that youth who have certain characteristics were already predisposed to use both ENDS and cigarettes (“common liability” explanation). Aims: This Perspective provides an evaluation of the gateway hypothesis that is accessible by a lay audience. This paper first reviews and evaluates the evidence interpreted as supporting the gateway hypothesis. Important alternate explanations (i.e., common liability) are discussed, as are different types of evidence (i.e., population-level trends) that can help differentiate between these competing explanations. Overview: The evidence provided in support of the gateway hypothesis is the finding that youth who use ENDS are more likely to also smoke cigarettes. However, this evidence suffers from an important flaw: these studies fail to fully account for some youths’ pre-existing tendency to use tobacco products, and inappropriately interpret the results as ENDS use causing some youth to smoke. Common liability studies suggest that ENDS use does not, in and of itself, directly cause youth to later smoke cigarettes, beyond their pre-existing tendency to use tobacco. Population-level trends show that youth cigarette smoking declined faster after ENDS use became common, which contradicts the central prediction of the gateway hypothesis (i.e. that youth smoking would be more common following ENDS uptake, than what would otherwise be expected). Conclusion: Evidence offered in support of the gateway hypothesis does not establish that ENDS use causes youth to also smoke cigarettes. Instead, this evidence is better interpreted as resulting from a common liability to use both ENDS and cigarettes. Population-level trends are inconsistent with the gateway hypothesis, and instead are consistent with ENDS possibly displacing cigarettes among youth who already had a tendency to use tobacco products, though more research is needed to support this diversion hypothesis.
Author: Arielle Selya
Institution: Pinney Associates (United States)
Language: English
Subfield: Physiology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W4391432289