Tobacco Gateway Report Omits Important Information

Here we go again.  Another federally funded study from the University of California, San Francisco, claims that “Nonsmoking adolescents who use e-cigarettes, smokeless tobacco or tobacco water pipes are more likely to start smoking conventional cigarettes within a year.” (UCSF press release here)  Researchers analyzed data on some 10,400 teens enrolled in the Population Assessment of Tobacco and Health (PATH) Survey in 2013-2014, then followed up with the subjects one year later.

“We found that teens who experimented with tobacco in any form were at greater risk of future smoking,” said senior author Dr. Benjamin W. Chaffee; his study appears in JAMA Pediatrics.

The researchers report that teens who had ever used e-cigarettes, hookah, other combustible products or smokeless tobacco at the baseline survey were two or three times as likely to be smoking cigarettes (in the past-30 days) one year later than those who had not tried any tobacco product.  Those who had tried two or more products were 3.8 times more likely to be smoking.

The authors used a sophisticated analysis to arrive at these results, but news stories describing this as evidence of a gateway to teen smoking (examples here and here) are inaccurate.

Chaffee and his colleagues, including anti-tobacco crusader Stanton Glantz, omitted information that is critical to putting their findings in perspective.  Although teens trying other tobacco products were more likely to smoke, the majority of new smokers after one year came from the group that had not tried tobacco at baseline.  I offer the following calculations based on obscure information in the published article.

Odds Ratios (ORs) And Numbers of Teens Smoking Cigarettes After One Year, According to Ever Tobacco Status at Baseline
Ever Tobacco Status- Baseline (n)	Odds Ratios	Number Smoking At One Year (%)
Never tobacco use (9,058)	Referent	175 (79.9)
E-cigarettes (255)	2.12	11 (5.0)
Hookah (189)	2.15	8 (3.7)
Other combustible (114)	3.08	7 (3.2)
Smokeless tobacco (93)	1.53	3 (1.4)
Two or more products (200)	3.81	15 (6.8)
All (9,909)		219 (100)

After one year, 219 teens had smoked a cigarette in the past 30 days, and 175 of those (80%) had never used any tobacco product at baseline.  Even though the odds of smoking were higher among youth who had tried other products, the number of smokers contributed by each of these groups was minuscule.  (While actual survey numbers may vary slightly, the relative contributions of the groups will not change.)

The Chaffee article emphasizes odds ratios but omits or obscures important contextual information.  While teens who try one tobacco product are more likely to try another, the dominant gateway in the PATH survey was from no previous tobacco use to cigarettes.

No underage tobacco initiation is acceptable; neither is misdirection by researchers.

Nicotine, Smokeless Tobacco & Tourette Syndrome

A man with Tourette Syndrome, a nerve disorder developing in childhood and involving muscle tics (repetitive involuntary movement) and voice problems (here), recently posted online his experience with smokeless tobacco.  Diagnosed at age six, he was treated unsuccessfully with numerous drugs.  At ten, he experimented with dipping and discovered that it controlled his symptoms.  His doctor “was not happy that i was dipping but he under stood [sic] and told me the reason for that [alleviation of symptoms] was the nicotine…”  The doctor prescribed nicotine lozenges, which worked.  Later, the man resumed dipping.

Youth initiation of tobacco use is wrong, but this individual’s experience is worth noting.  Tourette is a challenging and frustrating disorder for which medicines are not always effective.

A search of the medical and scientific literature reveals that nicotine has been used with mixed results to treat the symptoms of Tourette, mainly as a supplement to other medicines (here, here, here, here, here, and here ).  Researchers have primarily tested nicotine gum and patches, which deliver very low, non-addictive doses.  These medicines have been shown to be less than ideal quit-smoking aids (here); perhaps their low nicotine levels limited their effectiveness with Tourette as well.  Moist snuff, in contrast, delivers a higher dose of nicotine for several hours, which may account for the symptom relief in the case described above.   

There is growing evidence that tobacco and nicotine may play a role in preventing and/or managing nerve disorders such as Parkinson’s disease, multiple sclerosis and Alzheimer’s disease (here).  Unfortunately, nicotine and smoke-free tobacco have been so demonized by prohibitionists that researchers are reluctant to fully investigate the benefits of these products.

High School Seniors’ Tobacco Use Pales in Comparison to Alcohol

Smoking by teens has declined to record-low levels, according to the latest University of Michigan annual Monitoring the Future Study, which examines youth tobacco, alcohol and drug use in 2012 (data tables here).  The figure at left, which shows the percentage of high school seniors using alcohol, marijuana, cigarettes and smokeless tobacco in the past 30 days over the period 1975-2012, is highly informative. 

Cigarette use continued a long-term decline, reaching 17%, the lowest prevalence since the survey’s introduction in 1975.  Cigarette use was lower than marijuana use (23%) for the fourth consecutive year.  Smokeless tobacco use among boys declined for the third consecutive year to 13.5%; use among girls was 1.6%. 

As I noted in 2009, (here), anti-tobacco forces have a brilliant strategy for dealing with tobacco use research: If it’s good, take credit; if it’s bad, blame the industry.  In a press release, the Campaign for Tobacco Free Kids did a little of both.  It implied that the gains were attributable to FDA regulation and tax increases, but it claimed that “…the tobacco industry still spends $8.5 billion a year — nearly $1 million every hour — to market its deadly and addictive products …that entice youth.”

If the tobacco industry is responsible for youth smoking, which industry is responsible for marijuana use?

For high school seniors, alcohol is by far the drug of choice.  While alcohol prevalence declined substantially from over 70% around 1980, it remains far too high.  In 2012, more than 40% of high school seniors had an alcoholic drink in the past 30 days; 28% of them had been drunk.  This is astounding, given that the legal age to consume alcohol is 21 years.  It is especially worrisome when considering how many teens and young adults die in auto accidents.  With the exception of the elderly, this age group (15-24 years) has by far the highest death rates from auto accidents.  It comprises 14% of the U.S. population but accounts for 27% of auto deaths (2,498 in 2009).

Any use of drugs among children is a problem that should concern every American. We need to better understand the social and behavioral reasons why children experiment with and adopt substance use, in order to develop prevention strategies.  But we need to prioritize limited resources based on the relative impact of each substance on children’s health. Cigarettes and smokeless tobacco should not be ignored, but the MTF survey documents that alcohol is the major threat.