Worldwide research shows that e-cigarettes, originally designed as a smoking cessation aid, are increasingly being used by teenagers who have never smoked cigarettes, creating a new problem in the fight against tobacco smoking.
Also known as “vapes,” electronic cigarette (e-cigarette) use is rapidly increasing among adolescents and young adults, raising concerns about the subsequent uptake of conventional tobacco cigarette smoking.
While e-cigarette use (vaping) has led to a decline in young people smoking conventional cigarettes, recent studies show that ever or current e-cigarette use increases the risk of commencing cigarette smoking three- to four-fold, and that rates of dual use (both cigarette smoking and e-cigarette use) are also on the rise. Originally designed as a smoking cessation aid, e-cigarettes are increasingly being used by teenagers who have never smoked cigarettes, creating a new problem in the fight against tobacco smoking. This relationship between vapes and conventional smoking raises red flags for insurers that offer non-smoker rates to e-cigarette users and have priced their products accordingly.
The World Health Organization (WHO) estimates that there are 984 million smokers worldwide, relatively unchanged since 2000.1 Worldwide, cigarette smoking is the single largest risk factor for early mortality and number of years lived with ill-health.2 There are around 8 million premature deaths globally each year from smoking-related diseases, with 11% of cardiovascular deaths worldwide associated with smoking.3 Despite the reduction in cigarette smoking by adolescents, there are still an estimated 11.3% of boys and 6.1% of girls who smoke cigarettes.4
The e-cigarette market is now 20 years old. E-cigarettes were first manufactured in 2003 as a product to assist in quitting cigarette smoking. E-cigarettes produce an aerosol that is formed by heating an e-liquid, a solution which is vaporized and then inhaled by the user. Vapes can be refillable or single-use disposables, and come in multiple flavor options, including tobacco, menthol, and fruit-flavored varieties.
Studies now show that many adolescents and young adults commence vaping without ever trying conventional cigarettes, defeating the original intended purpose of e-cigarettes.
According to a global meta-analysis of studies published between 2010 and 2020, lifetime (ever use) and current prevalence of vaping was 23% and 11%; 22% and 12% for men, and 16% and 8% for women, respectively. Current prevalence of vaping in ever smokers was 39%, and in current smokers was 43%. Lifetime prevalence of vaping in America, Europe, Asia, and Oceania was 24%, 26%, 16% and 25% respectively, and current prevalence was 10%, 14%, 11% and 6% respectively.5
Data from the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey (16–19-year-olds from Canada, England, and the U.S.) showed that smoking prevalence was 6.2% in August 2019, 8.5% in February 2020, and 7.9% in February 2021, while vaping prevalence was 7.7% in August 2019, 9.4% in February 2020, and 9.1% in February 2021.6
In the U.S., prevalence of e-cigarette use by 18-29 year olds increased from 8.8% to 10.2% between 2019 and 2021, with prevalence in never smokers increasing from 4.9% in 2019 to 6.4% in 2021.7 E-cigarettes have been the most used tobacco product by U.S. youths since 2014. The U.S. National Youth Tobacco Survey 2011-2018 reported that current e-cigarette use among high school students increased from 1.5% in 2011, to 16% in 2015, to 20.8% by 2018.8
Australian data from 2019 shows that vaping, unrelated to the purpose of quitting smoking, is more common in younger age groups up to the age of 24 – 15.5% are never smokers, 31.5% are past smokers, and 53% are dual users. The most common use of e-cigarettes is in conjunction with smoking conventional cigarettes.9 Recent data on current vaping and smoking in the Australian population shows a marked increase in vaping rates, as well as dual use, particularly in those aged under 35 years. Data showed that 34% of current vapers were under the age of 25, compared to 16% who were current smokers.10
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In New Zealand, figures from 2019 show that 10% of students aged 13-18 years vaped at least monthly, while 6% vaped weekly. More than 80% of ever vapers stated they were nonsmokers when they started using e-cigarettes, while 49% of regular vapers had never used conventional cigarettes.11
According to the U.K. independent public health charity Action on Smoking and Health (ASH), 8.3% of the adult population used nicotine vaping products in 2022 (up from 1.7% in 2012), of whom 65% vape only, and 35% vape as well as smoke cigarettes.1 ASH data showed that 8.6% of 11–18-year-olds in the U.K. use e-cigarettes.2
There is strong evidence that the use of e-cigarettes increases the risk of smoking conventional cigarettes in never smokers. The use of e-cigarettes is similar in habit to the use of conventional cigarettes – holding a cigarette, bringing the cigarette to the mouth, inhalation, and exhalation. In many cases, new users take up e-cigarettes for reasons other than quitting smoking, including general curiosity about the device. Flavored e-cigarettes make the product more attractive, providing a positive sensory experience and reinforcing reasons for use.12
Many e-cigarettes contain nicotine, exposing adolescents and young adults to potential nicotine dependence. Nicotine is also known to have adverse effects on the human brain, which continues to develop up to the age of 25. As e-cigarettes deliver nicotine more slowly than traditional cigarettes, users may be tempted to advance to more powerful nicotine delivery methods such as cigarettes, as well as experiment with other drugs. 13
Findings from multiple reviews show that e-cigarette use increases the risk of cigarette smoking. A 2021 meta-analysis of adolescents aged 13 to 19 years based in Europe and North America found that ever e-cigarette use was associated with four times higher odds (4.06) of commencing cigarette smoking.8 A 2022 global study found that e-cigarette use by young adults was associated with a three-fold increased risk of cigarette smoking.14
A separate pooled analysis of studies found that e-cigarette use in never smokers was associated with an over three-fold increased risk of ever smoking (OR 3.38).9
E-cigarette use is more prevalent among adolescents than adults. In 2018, 20.8% of U.S. high school students and 7.2% of middle school students were current e-cigarette users. Ever e-cigarette users had 5.6 times the odds of having ever smoked a conventional cigarette, and 4.5 times the odds of currently smoking conventional cigarettes compared to those who had never used e-cigarettes.15
Currently the long-term health impacts of e-cigarettes are largely unknown, but the WHO states that e-cigarettes should be strictly regulated to protect public health. A global review in 2022 of e-cigarette use and health outcomes found conclusive evidence that the use of e-cigarettes can cause respiratory disease, severe burns and injuries, poisoning, nicotine toxicity, increased airborne particulate matter, and seizures.9
There is strong evidence that never smokers who use e-cigarettes are on average around three times as likely to initiate cigarette smoking compared to those who do not use e-cigarettes.
The rate of smokers who use both e-cigarettes and conventional cigarettes is rising rapidly, compounding the health problem further. Dual users display poorer health scores and respiratory scores compared to cigarette smokers only. They have been found to have a 36% higher risk of cardiovascular disease compared to those who only smoke conventional cigarettes.16 Dual users were more likely to report breathing difficulties, chest pain, palpitations, coronary artery disease, arrhythmia, COPD, and asthma.17
Worldwide, at least 75 countries allow the sale and use of e-cigarettes, 36 countries ban the use of e-cigarettes, and 85 countries have no specific law or regulation regarding vaping.1 In response to the worrying increase in vaping by adolescents, other measures have been explored to curtail ever smoking, include banning flavored vapes and the sale of disposable vapes, regulating packaging and product availability, limiting nicotine concentration to a maximum of 20mg/mL, and restricting the sale of e-cigarettes to anyone under the age of 18.
E-cigarette use is a significant concern. Evidence shows that e-cigarette use can lead to conventional cigarette smoking, defeating the original purpose of e-cigarettes. Studies show that ever or current e-cigarette use increases the risk of commencing cigarette smoking three- to four-fold, and that rates of dual use are rising. Initial studies indicate the use of e-cigarettes negatively impacts health and is a gateway to tobacco smoking, particularly for adolescents and young adults. Insurers should be aware of the consequences of e-cigarette use, and how this may impact product pricing in the future.
