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Gateway Drug

Does the gateway theory justify a ban on nicotine vaping in Australia?


•The evidence does not provide strong support for the hypothesis that vaping is a significant gateway to smoking in young people.

•Regular vaping by young never-smokers is rare.

•Most young people who use e-cigarettes have already smoked combustible cigarettes.

•A ban on nicotine vaping prevents adult smokers from accessing a potentially lifesaving alternative to smoking.

•A more nuanced regulatory policy could restrict young nonsmokers’ access to vaping while allowing access for adult smokers.


Australia bans the sale, possession and use of liquid nicotine for vaping. One of the major arguments used to justify Australia’s policy is that the availability of nicotine vaping products will lead a substantial number of young people who would otherwise not have smoked cigarettes to take up regular smoking (the gateway theory). In this article, we provide a critical analysis of the use of the gateway theory to justify Australian policy. We argue first that the evidence that vaping serves as a gateway to smoking is unconvincing. Smoking more often precedes vaping than vice versa, regular vaping by never-smokers is rare and the association is more plausibly explained by a common liability model. Second, we argue that even if the evidence were stronger it would not justify a ban on the sale of nicotine to adult smokers because there are other ways of preventing adolescent vaping that do not require a ban. We describe an alternative regulatory model for Australia that would address legitimate concerns about preventing adolescent uptake while allowing adult smokers to access these products for cessation or as an alternative to smoking cigarettes.

Online Pro-Tobacco Marketing Exposure Is Associated With Dual Tobacco Product Use Among Underage US Students



To understand the effect of pro-tobacco marketing on electronic cigarette and combustible cigarette dual use among US middle and high school students under 18 years of age.


Data were derived from the 2018 National Youth Tobacco Survey, an annual self-administered school-based cross-sectional survey.


The survey was administered in public and private middle and high schools across the United States.


The probability sample size was 15 238 middle and high school students with complete responses who were under 18 years of age during the study period.


The study measured self-reported exposure to online combustible and electronic cigarette advertisements, dual use of combustible and electronic cigarettes during the past 30 days, exposure to the Real Cost antitobacco campaign advertisements, and other sociodemographic factors (eg, race/ethnicity, gender, and grade).


Logistic regressions were used to measure pro-tobacco marketing exposure and dual use as a function of pro-tobacco marketing exposure.


Descriptive analyses show that 59.0% of respondents were exposed to pro-tobacco online marketing, and 2.9% were dual users. Dual users (odds ratio [OR] = 1.73) and high school students (OR = 1.43) were more likely to report exposure to online pro-tobacco marketing.


Findings indicate that a gap in electronic cigarette pro-tobacco marketing regulatory oversight may exist. Further policy action may be warranted to protect the public health of minors and other vulnerable populations who are most susceptible to pro-tobacco marketing.

Integrating Social Dynamics Into Modeling Cigarette and E-Cigarette Use



The use of electronic cigarettes (e-cigarette) offers potential to facilitate cigarette smoking cessation, yet potentially increases risk of cigarette smoking initiation. This relationship has been primarily modeled in mathematical ways that often do not represent real-world complexities, which could inform decisions regarding local prevention programs or policies. Aims. To develop a model of cigarette and e-cigarette use that combines current research on tobacco use and incorporates real-world geographic and demographic data. Method. We used a platform for developing agent-based models with demographic information representative of the population in Pennsylvania. We developed three models of cigarette and e-cigarette use. The primary outcome for each was the total number of users for cigarette, e-cigarette, and total nicotine. The first model applied current cigarette and e-cigarette data, the second tested the effect of implementing a program of e-cigarette education and policies, and the third considered a social contagion factor, where local schools functioned as a transmission vector. Results. The baseline and social contagion models found an overall decline in cigarette use but an increase in e-cigarette and total nicotine use. The education/policies model had declines in all categories. Sensitivity analysis suggested the importance of nuanced e-cigarette/cigarette interactions when modeling tobacco use.


Public health campaigns that focus on reducing youth e-cigarette usage can have a large effect. Social contagion should be strongly considered when studying e-cigarette spread. Conclusion. Targeted public health campaigns focused on reducing school prevalence of e-cigarette use may be particularly valuable.

Historical Perspective of Proactive and Reactive Regulations of E-cigarettes to Combat Nicotine Addiction


Cigarettes and electronic cigarettes (e-cigarettes) are major sources of exposure to nicotine, an addictive chemical. Although these products are being regulated by the Food and Drug Administration (FDA) under the Tobacco Control Act, specifications about the nicotine content in these products have not been established yet. In e-cigarettes, nicotine concentration ranges from 0 to > 50mg/mL, and the recent e-cigarette devices provide control to change nicotine flux for higher nicotine delivery. Due to the lack of robust regulations in manufacturing, distribution and marketing, e-cigarettes have already infiltrated the market with youth appealing flavors and devices. As a result, the country is facing a youth epidemic of e-cigarette use. The unregulated nicotine levels in both cigarettes and e-cigarettes can lead to repeated and overexposure of nicotine to youth which can lead to the addiction and detrimental effects on their cognitive functions. Over the past decade, the corrective measures being taken by the FDA for cigarette and e-cigarette regulations also should focus on nicotine exposure levels. Before it is too late to prevent youth from lifetime addiction to nicotine, it is important to address the issues of nicotine concentration, nicotine flux and the e-cigarette device regulations while offering adults with smoking disorder less harmful alternatives to cigarettes.

Response to Britton et al.

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A rational approach to e-cigarettes – challenging ERS policy on tobacco harm reduction

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E-cigarette Product Characteristics and Subsequent Frequency of Cigarette Smoking

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Psychological well-being and dual-use of cigarettes and e-cigarettes among high school students in Canada


•6.3% of Canadian middle and high school students were dual users of cigarettes and e-cigarettes.

•Three times more Canadian youth used e-cigarettes exclusively than used cigarettes exclusively.

•High-frequency dual-users had lower psychological well-being than low-frequency dual-users.

•High-frequency cigarette dual-users had higher autonomy scores than low-frequency dual-users.



Cigarette and e-cigarette use are prevalent among Canadian adolescents. Evidence shows psychiatric comorbidity with adolescent cigarette smoking, but little is known about psychological well-being among dual users of e-cigarettes and cigarettes. This study examined the association between dual-use status and psychological well-being among high school students.


We used the 2016–2017 Canadian Student Tobacco, Alcohol, and Drugs Survey. Scales of psychological well-being (relatedness, autonomy, competency, prosocial behavior, and social responsiveness) were derived from self-reported data. Dual-use status was categorized into non-users, cigarette-only smokers, e-cigarette-only users, and four types of dual-users. Multivariable linear regression models examined the association between dual-use and psychological well-being.


Among the participants, 6.3% were current dual-users, 4.1% were cigarette-only smokers, 12.6% were e-cigarette-only users, and 77.0% were non-users. Compared to non-users, relatedness and social responsiveness were lower for all users. When compared to e-cigarette users, most other users had lower relatedness (high-frequency dual-users [β=-6.05], high-frequency cigarette dual-users [β=-2.27], high-frequency e-cigarette dual-users: [β=-1.32], low-frequency dual-users [β=-1.91], and cigarette-only smokers [β=-1.66]) and social responsiveness. High-frequency dual-users had lower scores for relatedness and social responsiveness, while high-frequency cigarette dual-users had higher autonomy, compared to low-frequency dual-users.


Dual-users had poorer psychological well-being, which differed among dual-user sub-groups. This study highlights an opportunity for specialized programs to promote psychological well-being and reduce tobacco product use among adolescents.


The study is based on respondent self-report, and the use of cross-sectional data precludes us from determining the temporal order between dual-use and psychological well-being.

How E-Cigarettes Featured in a $42.5 Million South Florida Tobacco Verdict

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Tobacco insider Jeffrey Wigand on Juul