In 2013, the Tobacco Policy Review Group published Tobacco Free Ireland, a report which set a target for Ireland to reduce smoking prevalence to less than 5% by 2025. The report identified tobacco-related harm reduction as a key issue for consideration. Since e-cigarettes’ launch in the European Union (EU) in 2006 and in the United States of America (USA) in 2007, research on their potential benefits in terms of tobacco-related harm reduction, and on the public health harms of e-cigarettes, has grown. The systematic evidence review reported in this piece outlines what is known to date about using e-cigarette and initiation of smoking tobacco cigarettes among teenagers. There are two sister reviews: the first maps the harms and benefits of e-cigarettes [McCarthy 2020] and the second presents a systematic review of e-cigarettes role in smoking cessation [Quigley 2020]. These reviews are one of the inputs to the Irish governments policy and clinical guidelines on e-cigarettes.

Our systematic review published in BMC Public Health found that e-cigarette use among teenagers in Europe and North America was associated with starting tobacco cigarette smoking. Based on nine primary studies’ adjusted odds ratios, our meta-analysis calculated a three to six times higher odds of starting tobacco cigarette smoking for teenagers who had ever used e-cigarettes at baseline. These findings identify an important health-related harm and are supported by four other systematic reviews. [Soneji 2017; Glasser 2019; Khouja 2019; Aladeokin and Haighton 2019] Three of these reviews were among young adults [Soneji 2017; Glasser 2019; Khouja 2019] and one was in teenagers living in the UK [Aladeokin and Haighton 2019]. These findings are important because the prevalence of e-cigarette use is increasing in Europe and North America. For example, the prevalence of e-cigarette use among teenagers in the USA increased from 1.5% in 2011 to 20.8% in 2018 [Cullen 2018] and in Ireland ever use is 22% [Költő 2020]. Additionally, there is a danger that society will not be able to protect achievements in declining tobacco cigarette initiation among teenagers.

The study provides added support for urgent response by policymakers to stop their use by teenagers to decrease direct harms in this susceptible population group.

Given the availability and usage of e-cigarettes, this study provides added support for urgent response by policymakers to stop their use by teenagers to decrease direct harms in this susceptible population group. The study presented in this paper was conducted as part of broader program of evidence reviews to inform and support public health policy in Ireland, which included mapping of the harms and benefits of e-cigarettes (and their e-liquids) [McCarthy 2020] and a systematic review of e-cigarettes role in smoking cessation [Quigley 2020]. We found that e-cigarettes (and their e-liquids) lead to acute harms such as poisoning, lung injury, and burns and blast injuries, a finding aligned with six other systematic reviews [Peruga 2020; National Academies of Sciences, Engineering, Medicine2018, Pisinger 2014; CADTH 2017; Byrne 2018; Bals 2019] and highlighted a need for continuing study using robust methods to measure the long-term health impacts of their use as these are not yet known.

Children and adolescents require the same protection from e-cigarettes as conventional tobacco cigarettes

Children and adolescents require the same protection from e-cigarettes as conventional tobacco cigarettes through a well-enforced regulatory regime of measures including age restriction on purchase, control of availability through licensing outlets, limits to product visibility and attractiveness, and appropriate pricing through taxation.

References

Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018, 67:1276-1277; doi: 10.15585/mmwr.mm6745a5.

Költő A, Gavin A, Molcho M, Kelly C, Walker L, Nic Gabhainn S. The Irish Health Behaviour in School-aged Children (HBSC) Study 2018. Dublin, Ireland: Department of Health & Galway Health Promotion Research Centre, National University of Ireland, Galway; 2020. Available from: https://doi.org/10.13025/zvwm-rp65

Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, Yang J, Primack BA, Andrews JA, Miech RA et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr 2017, 171(8):788-797; doi: 10.1001/jamapediatrics.2017.1488.

Glasser A, Abudayyeh H, Cantrell J, Niaura R. Patterns of e-cigarette use among youth and young adults: Review of the impact of e-cigarettes on cigarette smoking. Nicotine Tob Res 2019, 21(10):1320-1330; doi: 10.1093/ntr/nty103.

Khouja JN, Suddell SF, Peters SE, Taylor AE, Munafò MR. Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis. Tob Control 2020:tobaccocontrol-2019-055433; doi: 10.1136/tobaccocontrol-2019-055433.

Aladeokin A, Haighton C. Is adolescent e-cigarette use associated with smoking in the United Kingdom? A systematic review with meta-analysis. Tob Prev Cessat 2019, 5(April):15; doi: 10.18332/tpc/108553.

Quigley JM, Woods B, Thompson J, Bryden PA, Scott DA. PRM209 – Confronting heterogeneity: Using systematic review effectively for meta-analysis. Value Health 2013, 16(7):A612; doi: 10.1016/j.jval.2013.08.1763.

McCarthy A, Lee C, O’Brien D, Long J. Harms and benefits of e-cigarettes and heat-not-burn tobacco products: A literature map. Dublin, Ireland: Health Research Board,; 2020; 461pp. Available from: https://www.hrb.ie/publications/publication/harms-and-benefits-of-e-cigarettes-and-heat-not-burn-tobacco-products-a-literature-map/returnPage/1/

Peruga A, World Health Organization Regional Office for Europe. Electronic nicotine and non-nicotine delivery systems: a brief. Copenhagan: WHO Regional Office for Europe. ; 2020; 20pp. Available from: http://www.euro.who.int/en/health-topics/disease-prevention/tobacco/publications/2020/electronic-nicotine-and-non-nicotine-delivery-systems-a-brief-2020

National Academies of Sciences, Engineering, Medicine. Public health consequences of e-cigarettes. Washington DC, USA: The National Academies Press; 2018; 774pp. Available from: https://dx.doi.org/10.17226/24952

Scientific Committee on Health, Environmental and Emerging Risks (SCHEER),. Request for a scientific opinion on electronic cigarettes. European Commission,; 2020: 2pp. Available from: https://ec.europa.eu/health/sites/health/files/scientific_committees/scheer/docs/scheer_q_013.pdf

Pisinger C, Døssing M. A systematic review of health effects of electronic cigarettes. Prev Med 2014, 69:248-260; doi: 10.1016/j.ypmed.2014.10.009.

Canadian Agency for Drugs and Technologies in Health (CADTH). Electronic cigarettes for the reduction or cessation of smoking: Clinical utility, safety, and guidelines. Ottawa, Canada: Canadian Agency for Drugs and Technologies in Health (CADTH),; 2017. Available from: https://cadth.ca/electronic-cigarettes-reduction-or-cessation-smoking-clinical-utility-safety-and-guidelines-0

Byrne S, Brindal E, Williams G, Anastasiou K, Tonkin A, Battams S, Riley MD. E-cigarettes, smoking and health: A literature review update. Australia: Commonwealth Scientific and Industrial Research Organisation (CSIRO) 2018; 394pp. Available from: https://www.csiro.au/en/Research/BF/Areas/Nutrition-and-health/Public-health-and-wellbeing/Case-studies/E-cigarettes-report

Bals R, Boyd J, Esposito S, Foronjy R, Hiemstra PS, Jimenez-Ruiz CA, Katsaounou P, Lindberg A, Metz C, Schober W et al. Electronic cigarettes: A task force report from the European Respiratory Society. Eur Resp J 2019, 53(2):1801151; doi: 10.1183/13993003.01151-2018.