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Jim McManus | 26 January 2016

This morning saw a further paper , this time a longitudinal study, looking at young people in Hawai http://m.tobaccocontrol.bmj.com/content/early/2016/01/05/tobaccocontrol-2015-052705.

The paper concludes that "adolescents who use e-cigarettes are more likely to start smoking cigarettes. This result together with other findings suggests that policies restricting adolescents’ access to e-cigarettes may have a rationale from a public health standpoint. " Except, unfortunately, its methods don't justify those conclusions.

You can read for example here http://www.sciencemediacentre.org/expert-reaction-to-study-of-e-cigarette-use-and-cigarette-smoking-in-children/ and here http://www.sciencemediacentre.org/e-cigarette-use-and-cigarette-smoking-in-children/ There's a significant number of weaknesses in this paper. There's some useful stuff too especially in their press release. So we still don't have evidence that there is a gateway.

This paper, though, raises a number of issues for science around smoking and vaping and the health behaviour of young people generally.

  1. Every paper I have read which has set out to ask whether there is a gateway just does not have the right methods, or statistical power, or analysis of confounders, to ever answer this question. But we end up with papers making conclusions for policy on the assumption of gateway effects which are just not justified by their methods or results. That's not in the best interests of science, and it makes you wonder what the peer reviewers are doing letting these conclusions stand.
  2. The CDC earlier this year http://dailycaller.com/2016/01/08/cdc-admits-no-concrete-evidence-e-cigarettes-are-gateway-to-smoking/ said there was no real evidence of a gateway. We've had the same from the UK and elsewhere. It seems that some commentators are sustaining assertions of a gateway in spite of the lack of evidence. That obscures our vision of the real issue: how we help our young people be as healthy as possible for life.
  3. We seem to have some commentators in this field operating a sliding scale of standards as to what constitutes science. An entirely wrong application of the precautionary principle - "convince me this is entirely and absolutely safe before I act " on ecigarettes becomes an entirely unscientific "I'm going to believe there is a gateway until someone proves conclusively there isn't"aproach to young people. Commendable that we want to protect young people, but this wrongheaded seizing on studies with poor methods to claim policy conclusions that dont stack up is diverting us from the real work of improving and protecting the health of our young people.
  4. Much of this gateway debate seems to ignore the bad logic exposed repeatedly behind gateway theories for most substances http://www.sciencedirect.com/science/article/pii/S0277953614005334 Some people conclude there probably isn't a gateway. If there were, we'd have found it by now, they suggest. The history of gateway theory is much more about theory and panic than evidence. My own view is we should ditch gateway theory in favour of understanding behaviour and routes into and out of habit. Social factors, peer pressure, reward and a range of other things from biochemical to social levels need to be considered here. A gateway theory seems just a reductionist approach to a more complex set of phenomena. And reductionist theories in health behaviour usually turn out to have limited value.
  5. We now seem to be having a shift to people making the case for nicotine being bad and harmful in and of itself, and a gateway (where's the evidence?) way beyond what the evidence would suggest about harms of nicotine. Tobacco remains the lethal challenge, not nicotine. Tobacco is the mass scale killer. Not nicotine.
  6. Finally, a lot of this debate seems to be missing some of the fundamental context about young peoples' health. Recent brain science suggests adolescence as a time of hyperplasticity and this means we need to fundamentally rethink how we promote and protect the health of young people, who will in any case experiment. http://discovery.ucl.ac.uk/1468865/ http://www.nih.gov/news-events/news-releases/nih-launches-landmark-study-substance-use-adolescent-brain-development https://www.uclan.ac.uk/news/assets/darwin_day_poster_YS_2015.pdf Someone, somewhere, needs to articulate what a science of adolescent substance use means in the new world of brain science advances. We'll have to wait some time for NIH work recently announced but UCL is also doing significant work on this.

But there's another more worrying issue. Much of this debate seems to be rather badly informed by (or is just ignoring) our history of success (or do I mean failure) of stopping young people smoking. So let's restate the basics. Most smokers take it up before age 18. Study after study has shown repeated failure to prevent this systematically. In fact I can recall many more failed tools and projects to prevent young people taking up smoking than I can ever recall successful ones.

This is the real chalenge. I can understand why people might wel-intentionedly fear things like e cigarettes may lead young people more into smoking, but these good intentions are just distracting us from the real issues: a) there is just no convincing evidence of this and b) we are in danger of losing focus on how we get young people not to take up the lethal activity of tobaco smoking as a sustained habit.

Scotland has looked at how it does this recently http://www.youngscot.net/wp-content/uploads/2015/02/Youth-Comission-on-Smoking-Prevention.pdf as has NICE http://pathways.nice.org.uk/pathways/smoking/strategy-policy-and-commissioning-for-smoking-prevention-and-cessation and DECIPHER claim to have one of the more successful tools on this http://www.decipher-impact.com/ Tobacco remains the killer. Please, let's not forget that.

The challenge for us is to recognise young people experiment and then work out a public health policy around that. Much of the recent research shows young people are aware of electronic cigarettes. Some try them, some dont. Some come to them after smoking. Some try cigarettes. Others dont. So young people experiment. The key issue is how we help them avoid sustained use of tobacco.

If we really care about the health of young people, let's stop the hype and panic about gateways and ask ourselves the real questions:

Young people experiment. How do we help them do that as safely as possible on a whole range of things from driving to relationships to substances?

Some young people will experiment with tobacco. How do we help experimentation not turn into addiction and long term health problems?

Problematising nicotine (which we know is much more addictive when smoked with burnt tobacco anyway) and e-cigarettes in the absence of any real supporting evidence is just avoiding those questions.

Jim McManus
Director of Public Health at Hertfordshire County Council

Re-posted from Jim's LinkedIn article: https://www.linkedin.com/pulse/ecigarettes-gateway-smoking-young-people-still-evidence-jim-mcmanus