Article Text

Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis
  1. Jasmine N Khouja1,2,3,
  2. Steph F Suddell1,3,4,
  3. Sarah E Peters5,
  4. Amy E Taylor2,4,
  5. Marcus R Munafò1,3
  1. 1 MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
  2. 2 Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
  3. 3 UK Centre for Tobacco and Alcohol Studies, School of Psychological Science, University of Bristol, Bristol, UK
  4. 4 NIHR Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  5. 5 Adapt (Study Rocket Ltd), London, UK
  1. Correspondence to Dr Jasmine N Khouja, MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 1TU, UK; jasmine.khouja{at}


Objective The aim of this review was to investigate whether e-cigarette use compared with non-use in young non-smokers is associated with subsequent cigarette smoking.

Data sources PubMed, Embase, Web of Science, Wiley Cochrane Library databases, and the 2018 Society for Research on Nicotine and Tobacco and Society for Behavioural Medicine conference abstracts.

Study selection All studies of young people (up to age 30 years) with a measure of e-cigarette use prior to smoking and an outcome measure of smoking where an OR could be calculated were included (excluding reviews and animal studies).

Data extraction Independent extraction was completed by multiple authors using a preprepared extraction form.

Data synthesis Of 9199 results, 17 studies were included in the meta-analysis. There was strong evidence for an association between e-cigarette use among non-smokers and later smoking (OR: 4.59, 95% CI: 3.60 to 5.85) when the results were meta-analysed in a random-effects model. However, there was high heterogeneity (I2 =88%).

Conclusions Although the association between e-cigarette use among non-smokers and subsequent smoking appears strong, the available evidence is limited by the reliance on self-report measures of smoking history without biochemical verification. None of the studies included negative controls which would provide stronger evidence for whether the association may be causal. Much of the evidence also failed to consider the nicotine content of e-liquids used by non-smokers meaning it is difficult to make conclusions about whether nicotine is the mechanism driving this association.

  • electronic nicotine delivery devices
  • addiction
  • co-substance use

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors JNK, AET and MRM: conceived and designed the study; interpreted the data; guarantors. JNK, SFS and SP: acquired and analysed the data. JNK: wrote the initial draft of the manuscript and all the authors were involved in preparing this manuscript and contributed to the revision of the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria were omitted.

  • Funding JNK, SFS and MRM: members of the UK Centre for Tobacco and Alcohol Studies, a UKCRC Public Health Research: Centre of Excellence. Funding from British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, and the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. This work was supported by the Medical Research Centre Integrative Epidemiology Unit at the University of Bristol [grant number MC_UU_0011/7]. This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

  • Competing interests MRM and AET report grants from Pfizer, outside the submitted work.

  • Patient consent for publication Not required.

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