In the 1970s, a company called Swedish Match started advertising snus to Swedish men. Snus wasn’t a new product; the pouches of tobacco that users tuck into their cheeks or lips, where they slowly release nicotine, had been around since the 17th century. But snus had fallen out of fashion and been replaced by combustible cigarettes.
At the time, Sweden, like many other countries, had a smoking problem. Forty percent of men smoked. But as sales of snus picked up, smoking rates plummeted. By the year 2000, Sweden was the only industrialized nation to achieve the World Health Organization’s goal of reducing adult smoking to less than 20 percent.
Snus is a great example of a theory called harm reduction which argues that, rather than promoting public health policies that completely eliminate tobacco, addicted users should have access to products that give them the nicotine they crave, but that drastically reduce the health risks posed by cigarettes. Snus delivers a kick of nicotine, but releases chemicals without the dangers of combustion and tar, some of the major contributors to lung cancer.
Sound familiar? When e-cigarettes (also known as vapes) appeared in the mid-2000s, some researchers in the tobacco control community thought young smokers in the US might make a similar choice, causing overall smoking rates to decline. E-cigarettes create an aerosol by heating a nicotine-containing fluid. That aerosol can be inhaled and exhaled like the smoke from a regular cigarette, but it doesn’t contain the tar and many of the toxic chemicals that tobacco smoke does. While research suggests that these devices have their own dangers, including reducing the lungs’ ability to fight infections, a big cause for concern during the Covid-19 pandemic. But even with their risks, e-cigarette supporters believed these products could present a safer alternative to combustible cigarettes, just as snus did for the Swedes back in the 1970s and ’80s. “People were hoping that would happen here,” says John Pierce, a professor at UC San Diego who researchers cancer and tobacco.
But in a paper published in Pediatrics this month, Pierce and his colleagues show that isn’t happening after all. Instead, young people who experiment with e-cigarettes are three times more likely than ones who have never tried vaping to become daily cigarette smokers a few years later. And the more tobacco products young people experiment with, the greater that likelihood becomes. “We haven’t had this harm reduction thing,” Pierce says.
Pierce’s team analyzed data from the US Population Assessment of Tobacco and Health (PATH) study, a survey of nearly 50,000 Americans conducted annually by the National Institutes of Health and the Food and Drug Administration. They looked specifically at people ages 12 to 24 and tracked their responses over the four years between 2013 and 2017, following their use of tobacco products and their progression from occasional experimenters to daily users.
They found that just over 60 percent of respondents in this age group tried a tobacco product at some point and that 30 percent experimented with multiple products like e-cigarettes, hookahs, and cigarillos. Of all the young people in the study, those who experimented with many different products were 15 percentage points more likely to become daily cigarette smokers than those who had only tried one kind of tobacco product. And teenagers who experimented with e-cigarettes before age 18 were more likely to become daily smokers than those who tried vaping later in life. In other words, the theory that this new product would dissuade young people from using cigarettes didn’t hold up.