Article Text

Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check
  1. David T Levy1,
  2. Kenneth E Warner2,
  3. K Michael Cummings3,
  4. David Hammond4,
  5. Charlene Kuo1,
  6. Geoffrey T Fong5,
  7. James F Thrasher6,
  8. Maciej Lukasz Goniewicz7,
  9. Ron Borland8
  1. 1 Cancer Prevention and Control, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
  2. 2 Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
  3. 3 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4 School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  5. 5 Department of Psychology, School of Public Health and Health Systems, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  6. 6 Health Promotion, Education, and Behavior, School of Public Health, University of South Carolina, Columbia, South Carolina, USA
  7. 7 Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
  8. 8 Nigel Gray Distinguished Fellow in Cancer Prevention, Cancer Council Victoria, Carlton, Victoria, Australia
  1. Correspondence to Dr. David T Levy, Cancer Prevention and Control, Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC 20007, USA; dl777{at}


Background The 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA.

Methods Using publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent.

Results There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent.

Conclusions The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping’s ascendance.

  • electronic nicotine delivery devices
  • surveillance and monitoring
  • harm reduction

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors DTL wrote the original manuscript, conducted the empirical analysis and revised the manuscript. CK helped write the original manuscript, conduct empirical analyses and edit the paper. The other authors all took an active role in developing the original ideas for the study, critiquing the analysis, extensive editing of the manuscript and revising the manuscript.

  • Funding RB, KMC, GTF, MLG, DH, DTL and JFT received funding from the National Cancer Institute under grant P01CA200512.

  • Competing interests MLG was a member of the National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems who wrote the report. The report was funded by the Food and Drug Administration (FDA), but the FDA was not involved in the drafting or review of the NASEM Report or this manuscript. The policy implications written in this manuscript are the views of the authors and do not necessarily represent the views of the other members of the Committee, the NASEM or the FDA. MLG also received a research grant and served as an advisory board member to pharmaceutical companies that manufacture smoking cessation medications. KMC and DH have served as an expert witness in litigation against the cigarette industry.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data are all published. The authors will make these data available to all who request it.