Even more evidence for a gateway effect for e-cigs to cigarette smoking, this time from Germany

Matthis Morgenstern, Alina Nies, Michaela Goecke, Reiner Hanewinkel just published “E-Cigarettes and the Use of Conventional Cigarettes: A Cohort Study in 10th Grade Students in Germany” that shows that never smoking 10^th grade students (age 15-16 years old) who start nicotine use with e-cigarettes are about twice as likely to be smoking cigarettes 6 months later.  In addition, consistent with all the other earlier studies, the effect is bigger in kids at lower risk of starting nicotine use with cigarettes. 

There are now so many of these gateway studies that I have lost count.  The amazing thing is the consistency of findings.  All show a gateway effect for e-cigarettes with the odds of subsequent smoking increased by a factor of 2-3, except for England, where the odds increase by a factor of 12.

Here is the abstract:

Background: In 2015, 12.1% of 12– to 17-year-olds in Germany had reportedly already tried e-cigarette smoking at least once. We carried out a study of the “gateway” hypothesis, according to which the use of e-cigarettes can motivate adolescents to start smoking conventional cigarettes.

Methods: During the 2015/2016 school year, 2186 tenth-graders in the German states of Lower Saxony and Schleswig-Holstein who had never smoked conventional cigarettes before took part in a survey over a 6-month period (mean age 15.5 years, standard deviation 0.65; 53.6% female).

Results: 14.3% of the survey population (313 adolescents) said at the start of the survey period that they had already tried e-cigarettes at least once. By the end of the survey period, 12.3% (268) of those who had never smoked before had begun to experiment with conventional cigarettes. The risk of beginning such experimentation was 2.2 times higher among e-cigarette users. This association remained (relative risk = 2.18 [1.65; 2.83]) after statistical control for age, sex, state, immigrant background, type of school, socioeconomic status, various personality traits (sensation-seeking, impulsivity, anxiety, hopelessness, extraversion, agreeableness, conscientiousness, neuroticism, openness), and the use of alcohol, cannabis, and other illicit drugs. Further analysis revealed that the association between the use of e-cigarettes and the onset of conventional cigarette smoking was stronger among adolescents with low sensation-seeking scores and without any experience of alcohol intoxication.

Conclusion: Among adolescents who have never smoked, experimentation with conventional cigarettes is more common in those who have used e-cigarettes. This effect seems to be stronger among adolescents who, in general, have a lower risk of starting to smoke. The 6-month observation period of this study is too short to allow any inference regarding a connection between e-cigarette use and the development of tobacco dependence.

The citation for the paper is  Morgenstern M, Nies A, Goecke M, Hanewinkel R: E-cigarettes and the use of conventional cigarettes—a cohort study in 10th grade students in Germany.  Dtsch Arztebl Int 2018; 115: 243–8. DOI: 10.3238/arztebl.2018.0243  and it is available here.