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Is there really a youth vaping “epidemic” in the US, and if so, how much of a bad thing is it? Is it concerning enough to justify draconian restrictions (such as flavour bans) on novel nicotine products that apply across the board and not just to under-age vapers?
This debate – or to put it more honestly, dispute – goes to the heart of US perceptions of and policy on tobacco harm reduction. But it has been clouded by the (lack of) distinction between nicotine and smoking, and also by the sometimes awkward way in which the Centers for Disease Control and Prevention (CDC), operator of some of the most important surveys of nicotine consumption habits in the US, presents its data.
Now, a new study sheds some welcome and thought-provoking light on the CDC data, which ought to not only encourage a more positive view of vaping itself but also help to forestall undue panic about the arrival of nicotine pouches and heated tobacco. For unless you buy into the view that all forms of nicotine consumption are similarly harmful (and vaping is therefore no better than smoking), it’s difficult to deny that the figures imply the e-cigarette has been a positive for the health of US youth.
Reporting smoking and vaping rates together
Entitled “Joint smoking–vaping prevalence rates among American youth and young adults 2011-2022”, the analysis of the CDC’s data was published in Harm Reduction Journal and written by Brad Rodu – a professor of medicine at the University of Louisville in Kentucky and a mainstay of the tobacco harm reduction conference circuit – along with colleague Nantaporn Plurphanswat, a health economist.
It draws on data from the National Health Interview Survey (NHIS) and National Youth Tobacco Survey (NYTS), conducted by the CDC, which have been amassing data on smoking and vaping rates in the US for a decade or more. (The NYTS started covering vaping in 2011, the NHIS a little later, in 2014.)
So some of the data has been out there for a long time. But what the CDC has not done, according to Rodu and Plurphanswat, is report smoking and vaping rates together – something that would have helped answer questions about whether vaping helps smokers to quit or encourages young people to take it up. Their paper also points out that keeping the data sets separate tends to obscure dual use and lead to “erroneous overestimates of nicotine use” (since some individuals who both smoke and vape will be treated as two distinct people – one a smoker, the other a vaper).
To remedy this, Rodu and Plurphanswat have combined 2011-2022 data from both surveys, covering an age range that runs all the way from high schoolers (about 13 to 17) up to 44-year-olds. Importantly, the NHIS survey included a question to establish whether respondents were former smokers, allowing the researchers to see what proportion of adults had quit at a given time.
Smoking goes down as vaping goes up among US high schoolers
Some of the results should be required reading for anyone involved in US policy on youth nicotine usage. And the first trend that Rodu and Plurphanswat highlight will already be familiar to many in the harm reduction field, though it has received much less attention in the broader world: the rise of vaping among US high school students correlates directly with a decline in smoking.
In 2011, nearly 16% of high schoolers were smoking (a small number of them vaping as well); over the following decade this evaporated to less than 2% (the majority of whom were also vaping). Exclusive vaping of course also increased in this period; though after hitting a high in 2019, it too began to decline.
Nicotine use itself did not drop off dramatically over the decade – the proportion of high schoolers consuming it through either vapes or cigarettes in 2022 was only a little lower than in 2011 – but smoking had been almost entirely replaced by vaping.
Turning then to a slightly older age group, the “emerging young adults” aged 18 to 20, Rodu and Plurphanswat highlight a similar pattern, although now there are also some individuals in the “vape former smoke” category – presumably, people who gave up smoking by adopting e-cigarettes, though the researchers are rightly careful to point out that this data does not prove that.
And as we move to still older groups (25- to 34-year-olds, then 35- to 44-year-olds) the drop-off in smoking rates is less pronounced than in the younger groups, though by the end of the study period the “vape former smoke” category is especially well-established in these groups.
Dual use may be easier than quitting nicotine completely
What are the takeaways from all this?
What we are seeing (and this is my conclusion, not necessarily that of Rodu and Plurphanswat) is that vaping has most likely helped to hammer high school and “emerging young adult” smoking into near non-existence. (“Most likely helped to hammer”, not “hammered”, because there may well be other factors – but suggesting that vaping was not partly causal is even less plausible than claiming it was the only cause.) It also seems to have helped reduce smoking rates among older groups, although not to the same extent.
Equally interesting, alongside this, is that among all age groups the total proportion of nicotine users has not changed nearly as much as the composition of their consumption. In other words, whatever the causal factors are, moving between different nicotine delivery mechanisms may be much easier than giving it up entirely.
An important perspective on CDC figures
Finally, Rodu has also noted, in a separate blog, the “extraordinary one-year increase” in the quit ratio for “emerging young adults” in 2023 – a year beyond the period studied by the main paper. The quit ratio is essentially the percentage of those who have ever smoked who have now quit, so if 100 people in your sample have smoked at some point in their life but 40 of them have since given up, the quit ratio is 40%.
In 2023, the quit ratio for “emerging young adults” rose from 53% to 73% – meaning that a substantial majority of those aged 18 to 20 who had ever smoked had already given up. Combine this with a high schooler smoking rate of about 2% (for 2022) and it’s easy to see that if both the smoking rate and the quit ratio continue at the same levels, most high school smoking will not carry on beyond the age of 20 anyway, potentially pointing to a huge decrease in overall adult smoking levels in the long term. A decrease that would, indeed, take the US to what most countries define as “smoke-free” status.
If this is what happens in a vaping “epidemic”, some would argue that perhaps we should have more of them. As always, though, convincing sceptics takes a lot more than just pointing at the data; and it may also be that the data emerging from youth use of nicotine pouches (and heated tobacco, if it takes off) will look quite different.
So the important points made eloquently by Rodu and Plurphanswat are not enough for harm reductionists to win the battle. But they do, at least, give an important perspective on CDC figures that have too often been used to make the opposite argument.
– Barnaby Page TobaccoIntelligence staff
Photo: AI-generated
