Myth: Alternative nicotine products are a gateway to smoking

Is the use of reduced-risk nicotine products like vapes, snus, nicotine pouches, etc., a gateway to smoking combustible tobacco? Can the use of these products be a gateway to an addiction to illicit substances and criminal activity to support that addiction?

Is it possible for reduced-risk products to be a gateway away from smoking?

Your Safer Nicotine Wiki (SNW) team explores the answers to those questions below.

The Gateway Hypothesis

Science Hygiene

Nicotine - Retracted Studies, Papers, and Articles

• For commentaries on papers indicating the possibility of a gateway effect, please see the "Gateway" section of the Retractions SNW page.

Papers

2024: The “Gateway” hypothesis: evaluation of evidence and alternative explanations

• Conclusion: "Evidence offered in support of the gateway hypothesis does not establish that ENDS use causes youth to also smoke cigarettes. Instead, this evidence is better interpreted as resulting from a common liability to use both ENDS and cigarettes. Population-level trends are inconsistent with the gateway hypothesis, and instead are consistent with (but do not prove) ENDS displacing cigarettes. Policies based on misinterpreting a causal gateway effect may be ineffective at best, and risk the negative unintended consequence of increased cigarette smoking."
  • Citation: Selya, A. The “Gateway” hypothesis: evaluation of evidence and alternative explanations. Harm Reduct J 21, 113 (2024). https://doi.org/10.1186/s12954-024-01034-6
    • Acknowledgment: The author thanks Joe Gitchell, Sooyong Kim, and Saul Shiffman, all of Pinney Associates, Inc. for their feedback on an early draft of this manuscript, and Floe Foxon and Sooyong Kim for assistance with manuscript formatting. Through Pinney Associates, Inc., AS provides consulting services on tobacco harm reduction to Juul Labs, Inc. (JLI). JLI partially supported the preparation of this manuscript, and reviewed and commented on a near-final version. After the initial submission of this manuscript, AS also began individually providing consulting services on behavioral science to the Center of Excellence for the Acceleration of Harm Reduction (CoEHAR) through ECLAT Srl, which received funding from the Foundation for a Smoke-Free World (FSFW). Neither CoEHAR nor FSFW had any role in, or oversight of, this commentary.

2015: Gateway Effects: Why the Cited Evidence Does Not Support Their Existence for Low-Risk Tobacco Products (and What Evidence Would)

• "Searching for some signal of a gateway effect amidst overwhelming confounding and reverse causation requires more rigorous methods than are typical in public health epidemiology. This generalizes to any attempt to use cross-sectional data to sort out causation in a particular direction from confounding or reverse causation. When seeking epidemiologic associations where confounding is minimal or relatively simple in its causes, the typical methods used in the field are still far from optimal, but the empirical results might still be basically useful. That is not the case in this context. While it might never be possible to convincingly demonstrate a gateway effect given the challenges, and statistical analyses have no hope of detecting a tiny effect, there are clearly better and worse ways to pursue the question."
  • Citation: Phillips CV. Gateway Effects: Why the Cited Evidence Does Not Support Their Existence for Low-Risk Tobacco Products (and What Evidence Would). International Journal of Environmental Research and Public Health. 2015; 12(5):5439-5464. https://doi.org/10.3390/ijerph120505439
    • Acknowledgment: The author’s work on this paper was supported by CASAA. CASAA is a public health NGO that represents the interests of consumers; it is dedicated to protecting consumers’ access to THR products and to promoting THR. Some of the research incorporated here, though not the creation of this paper itself, took place in 2014 when the author was the recipient of an unrestricted grant from British American Tobacco for support of his research. The author is the recipient of grant (unrestricted except for the general subject matter) from Imperial Tobacco Group for research on peer review in the health sciences; that topic is tangential to the main analysis, but some observations address it.

Resources

2023: Summary of Gateway Studies - Mendelsohn

• "There is a longitudinal association between adolescent vaping and smoking initiation. However after adjusting for covariates (common risk factors eg demographic characteristics, use of other psychoactive substances, perceived peer cigarette use, risk-taking, socially maladaptive behaviors, attitude toward smoking, and parental education using propensity scoring), the association reduces substantially or disappears completely."

2016: How not to be duped by gateway effect claims

• "Sometimes studies appear that can create the appearance of the discovery of a ‘gateway effect’ – the idea that vaping causes young people to progress to smoking...Here is an eight-point guide to evaluating such studies and the politically motivated claims that often go with them."

Smokeless Products (Excludes Vaping)

2019: Snus: a compelling harm reduction alternative to cigarettes

• "A review of the evidence [106] which examined gateway effects in Sweden suggested that snus appeared to lead users away from smoking rather than towards it and is an important reason why Sweden has the lowest rates of tobacco-related disease in Europe."
  • Citation: Clarke, E., Thompson, K., Weaver, S. et al. Snus: a compelling harm reduction alternative to cigarettes. Harm Reduct J 16, 62 (2019). https://doi.org/10.1186/s12954-019-0335-1
    • Acknowledgement: The review was funded by Imperial Brands Plc. EC, SW, JT and GOC are employees of Imperial Brands Plc. KT is an employee of Elucid8 Holdings Ltd and is acting as an independent scientific consultant to Imperial Brands Plc. KT is a former employee of Gallaher Ltd and Japan Tobacco International UK Ltd.

Evaluates Two or More Reduced-Risk Products

2015: Which Nicotine Products Are Gateways to Regular Use?

• "Though this finding should be interpreted with caution, it potentially indicates that current ETPs are not necessarily strong gateways to regular tobacco use." (Note: ETP=Emergining Tobacco Products such as dissolvables, snus, and electronic cigarettes).
  • Citation: Meier EM, Tackett AP, Miller MB, Grant DM, Wagener TL. Which nicotine products are gateways to regular use? First-tried tobacco and current use in college students. Am J Prev Med. 2015 Jan;48(1 Suppl 1):S86-93. doi: 10.1016/j.amepre.2014.09.018. PMID: 25528714.
    • Acknowledgement: Publication of this article was supported by the Oklahoma Tobacco Research Center (OTRC), with funding from the Oklahoma Tobacco Settlement Endowment Trust (TSET).

Vaping Nicotine

2024: Increased e-cigarette use prevalence is associated with decreased smoking prevalence among US adults

• Nationally representative population-level data on tobacco product use by US adults continue to support the existence of an association between increasing prevalence of e-cigarette use and decreasing prevalence of cigarette smoking, i.e., possible substitution between cigarettes and e-cigarettes.
  • Citation: Foxon F, Selya A, Gitchell J, Shiffman S. Increased e-cigarette use prevalence is associated with decreased smoking prevalence among US adults. Harm Reduct J. 2024 Jul 18;21(1):136. doi: 10.1186/s12954-024-01056-0. PMID: 39026245; PMCID: PMC11256395.
    • Acknowledgment: Through PinneyAssociates, FF, AS, JG, and SS provide consulting services on tobacco harm reduction on an exclusive basis to Juul Labs Inc. The preparation of the previously-published version of this manuscript was funded by JLI, who reviewed and provided comments on a draft manuscript of the previously-published version. The present, updated version did not receive any funding or review from JLI, and was self-funded by PinneyAssociates. The content and the decision to publish are the responsibility of the authors. JG and SS also own interest in a novel nicotine gum that has neither been developed nor commercialized.

2023: Dramatic Reductions in Cigarette Smoking Prevalence among High School Youth from 1991 to 2022 Unlikely to Have Been Undermined by E-Cigarettes

• Conclusion: Healthy People’s 2030 goal for youth cigarette smoking, which uses the NYTS as its benchmark, has already been achieved and exceeded, years ahead of schedule. Concerns about a potential rise in adolescent cigarette use following the introduction of e-cigarettes to the U.S. market in the early 2010s are not supported by the data. In fact, the emergence of e-cigarettes has coincided with the most rapid declines in cigarette use over the past thirty years. It is important to recognize the possibility that had e-cigarettes not been available, changes in cigarette smoking prevalence among youth may have been different; this includes slower or faster declines. However, given the lack of a counterfactual, it is not possible to empirically evaluate this.
  • Citation: Delnevo CD, Villanti AC. Dramatic Reductions in Cigarette Smoking Prevalence among High School Youth from 1991 to 2022 Unlikely to Have Been Undermined by E-Cigarettes. International Journal of Environmental Research and Public Health. 2023; 20(19):6866. doi.org/10.3390/ijerph20196866
    • Acknowledgment: C.D.D. and A.C.V. were supported in part by a grant from the National Cancer Institute of the National Institutes of Health and the FDA Center for Tobacco Products (U54CA229973 and U01CA278695. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH, NCI or FDA.

2023: Effects of reduced-risk nicotine-delivery products on smoking prevalence and cigarette sales: an observational study

• "We detected some indications that alternative nicotine products are competing with cigarettes rather than promoting smoking and that regulations that allow their sales are associated with a reduction rather than an increase of smoking, but the findings are inconclusive because of insufficient data points and issues with the assumptions of the pre-specified statistical analyses."
  • Citation: Pesola F, Phillips-Waller A, Beard E, Shahab L, Sweanor D, Jarvis M & Hajek P. Effects of reduced-risk nicotine-delivery products on smoking prevalence and cigarette sales: an observational study. Public Health Res 2023;11(7)
    • Acknowledgment: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR129968) and will be published in full in Public Health Research; Vol. 11, No. 7. See the NIHR Journals Library website for further project information.

2023: e-Cigarette and Cigarette Use Among Youth: Gateway or Common Liability?

• "Collectively, concerns about a gateway effect and a potential increase in youth cigarette use following the introduction of e-cigarettes to the US market are not supported by the data. Moreover, future research and policy efforts should give more attention to the common liability theory and consider that in the context of a complex tobacco marketplace, increased diversity in the types of products, brands, and flavors fundamentally provides more opportunities for youths to experiment with tobacco and nicotine products."
  • Citation: Delnevo CD. e-Cigarette and Cigarette Use Among Youth: Gateway or Common Liability? JAMA Netw Open. 2023;6(3):e234890. doi:10.1001/jamanetworkopen.2023.4890
    • Acknowledgment: Dr Delnevo reported receiving grants from the National Cancer Institute and serving as the chair of the US Food and Drug Administration’s Tobacco Product Scientific Advisory Board outside the submitted work.

2023: Impact of e-cigarette experimentation and use on smoking behavior among adolescents aged 15–16 years in the Loire department, France

• "In our study, the low percentage of adolescents who reported using e-cigarettes before initiating smoking and the significant percentage of non-smokers who used nicotine-free e-cigarettes do not support the existence of a gateway effect. This is in line with many studies conducted in the school setting in which vaping was not a gateway to smoking."
  • Citation: Wamba A, Pourchez J, Masson J, Denis-Vatant C, Leclerc L, Nekaa M. Impact of e-cigarette experimentation and use on smoking behavior among adolescents aged 15-16 years in the Loire department, France. Tob Prev Cessat. 2023 Jun 22;9:21. doi: 10.18332/tpc/163416. PMID: 37363269; PMCID: PMC10286514.
    • Acknowledgment: This work was supported by a grant (AAP TABAC 2019) from the French National Cancer Institute (INCa) and French Public Health Research Institute (IReSP). Both funding agencies have no role in the study design, collection, analysis, or interpreting of the data, writing the manuscript, or the decision to submit the article for publication.

2022: United States public health officials need to correct e-cigarette health misinformation

• RE Gateway: "However, significant evidence now exists that this association between vaping and smoking is not causal, which is a source of confusion for the lay public and health-care professionals."
  • Citation: Pesko MF, Cummings KM, Douglas CE, Foulds J, Miller T, Rigotti NA, Warner KE. United States public health officials need to correct e-cigarette health misinformation. Addiction. 2023 May;118(5):785-788. doi: 10.1111/add.16097. Epub 2022 Dec 12. PMID: 36507802.
    • Acknowledgment: M.F.P. reports recent funding from the National Institutes of Health, Food and Drug Administration Center for Tobacco Products; American Cancer Society; Virginia Foundation for Healthy Youth; the University of Kentucky’s Institute for the Study of Free Enterprise; and Health Canada. N.A.R.'s research is primarily funded by the National Institutes of Health. She has also received research funding from and consulted with Achieve Life Sciences to evaluate an investigational smoking cessation medication. K.M.C. has served as a paid expert witness in litigation filed against cigarette manufacturers. J.F. has recently performed paid consulting for Johnson & Johnson pharmaceutical company on smoking cessation medicines and has received a research grant from the National Jewish Health (healthcare organization) on telephone smoking cessation counseling. His research on e-cigarettes is funded by the National Institutes of Health (NIDA). C.D. is a co-principal investigator for research conducted through the Center for the Assessment of Tobacco Regulations, which is funded by NIH/FDA. He is also an advisor to the Smoking Cessation Leadership Center at the University of California San Francisco relating to behavioral health and tobacco use. K.E.W.’s research is supported in part by a Tobacco Center of Regulatory Science grant to the University of Michigan and Georgetown University from the Food and Drug Administration and National Cancer Institute (award no. U54CA229974). T.M. is the acting Attorney General for the State of Iowa and is responsible for representing the state in any legal matters. The opinions expressed in this article are the authors’ own and do not necessarily reflect the views of any of the organizations and government agencies that have provided support to the authors.

2022: ASH brief for local authorities on youth vaping

• "There is NOT strong evidence that vaping is a gateway into smoking. Some who try vaping first may go on to smoke cigarettes, but this association works both ways and there are common risk factors for both behaviours; this does not prove that vaping caused subsequent smoking."

2022: Unpacking the Gateway Hypothesis of E-Cigarette Use: The Need for Triangulation of Individual- and Population-Level Data

• "Based on the current balance of evidence, using triangulated data from recent population-level cross-contextual comparisons, individual-level genetic analyses and modeling, we do believe, however, that causal claims about a strong gateway effect from e-cigarettes to smoking are unlikely to hold, while it remains too early to preclude other smaller or opposing effects."
  • Citation: Shahab L, Brown J, Boelen L, Beard E, West R, Munafò MR. Unpacking the Gateway Hypothesis of E-Cigarette Use: The Need for Triangulation of Individual- and Population-Level Data. Nicotine Tob Res. 2022 Jul 13;24(8):1315-1318. doi: 10.1093/ntr/ntac035. PMID: 35137222; PMCID: PMC9278819.
    • Acknowledgment: The salary of LS is Higher Education Funding Council for England (HEFCE) funded. JB’s and EB’s salaries are funded by Cancer Research UK (C1417/A22962). LB is an employee of Sandtable, Ltd. LS, EB, and JB are members of the SPECTRUM, a UK Prevention Research Partnership Consortium (MR/S037519/1). UKPRP is an initiative funded by the UK Research and Innovation Councils, the Department of Health and Social Care (England) and the UK devolved administrations, and leading health research charities. LS has received a research grant and honoraria for a talk and travel expenses from manufacturers of smoking cessation medications (Pfizer and Johnson & Johnson). JB and EB have received unrestricted research funding from Pfizer to study smoking cessation. RW reports grants and personal fees from companies that develop and manufacture smoking cessation medications, outside the submitted work. MRM has received unrestricted research funding fromPfizerandRusanto study smoking cessation.

2022: Association of quarterly prevalence of e-cigarette use with ever regular smoking among young adults in England: a time–series analysis between 2007 and 2018

• Conclusion:
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2022: Is Adolescent E-Cigarette Use Associated With Subsequent Smoking? A New Look

• "Adjusting for a full set of confounders, including adolescents’ sociodemographic characteristics, exposure to tobacco users, susceptibility to smoking, and behavioral risk factors, we found that the association of ever e-cigarette use with subsequent smoking decreases substantially and even becomes non-significant in some waves, using both past 12-month and past 30-day smoking as outcomes. We believe this is the first study to report any non-significant findings, likely the result of the more comprehensive set of risk factor variables we included. As we demonstrate with the use of four models, each adding significant risk factor variables (and in turn decreasing the aOR of e-cigarette use), inclusion of logical risk factors is important to interpreting the association between adolescent vaping and subsequent smoking."
  • Citation: Sun R, Mendez D, Warner KE. Is Adolescent E-Cigarette Use Associated With Subsequent Smoking? A New Look. Nicotine Tob Res. 2022 Mar 26;24(5):710-718. doi: 10.1093/ntr/ntab243. PMID: 34897507; PMCID: PMC8962683.
    • Acknowledgment: The authors received no specific funding for this work.

2021: High School Seniors Who Used E-Cigarettes May Have Otherwise Been Cigarette Smokers: Evidence From Monitoring the Future (United States, 2009–2018)

• Conclusion:
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2021: Association of genetic liability to smoking initiation with e-cigarette use in young adults: A cohort study

• Conclusion:
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2021: Trends in electronic cigarette use and conventional smoking: quantifying a possible 'diversion' effect among US adolescents

• Conclusion: "The current study uses simulation modeling to show that a net diversion effect is necessary to explain observed trends on US adolescent nicotine use. This is the first study to quantify the potential diversion effect of ECs, whereby they entirely prevent youth from using conventional smoking. This has important implications for the harm reduction potential of ECs. Future studies should extend this work by replicating findings in other settings, accounting for policy changes over time and incorporating forthcoming data on nicotine use trends."
  • Citation: Selya AS, Foxon F. Trends in electronic cigarette use and conventional smoking: quantifying a possible 'diversion' effect among US adolescents. Addiction. 2021 Jul;116(7):1848-1858. doi: 10.1111/add.15385. Epub 2021 Jan 19. PMID: 33394529; PMCID: PMC8172422.
    • Acknowledgment: This work was supported by the National Institute for General Medical Sciences (NIGMS) within the National Institutes of Health (NIH), grant number P20GM121341; by Direktoratet for internasjonalisering og kvalitetsutvikling i høgare utdanning (the Norwegian Agency for International Cooperation and Quality Enhancement in Higher Education; DIKU), grant number NNA‐2016/10023; and through a graduate research assistantship from the University of North Dakota (UND). This content is solely the work of the authors, and does not necessarily reflect the views of the NIH, NIGMS, DIKU or UND. The authors would also like to thank Dr Navid Ghaffarzadegan for feedback on an early version of the model. After this initial study was completed, both authors became affiliated with Pinney Associates, Inc., which provides consulting services on tobacco harm minimization to JUUL Labs, Inc. The content here precedes this conflict of interest, and as such neither JUUL nor Pinney Associates had any role in the conceptualization, design, analysis, interpretation or presentation of data, or in the decision to publish.

2021: Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study

• "In conclusion, this matched control analysis of NYTS data from 2014 to 2017 suggests that for adolescents initiation with e-cigarettes is associated with a reduced risk of subsequent cigarette smoking compared with initiators with other combustible and non-combustible tobacco products use, and propensity score matched adolescents without initial e-cigarette use. This suggests that, over the time period considered, e-cigarettes were unlikely to have acted as an important gateway towards cigarette smoking and may, in fact, have acted as a gateway away from smoking for vulnerable adolescents; this is consistent with the decrease in youth cigarette smoking prevalence over the same time period that youth e-cigarette use increased between 2014 and 2017.
• PDF of full paper
  • Citation: Shahab L, Beard E, Brown JAssociation of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control studyTobacco Control 2021;30:212-220.
    • Acknowledgment: This project is funded by Cancer Research UK (C1417/A22962). All authors are members of the UK Centre for Tobacco and Alcohol Studies (UKCTAS), funded under the auspices of the UK Clinical Research Collaboration (MR/K023195/1). LS has received a research grant and honoraria for a talk and travel expenses from manufacturers of smoking cessation medications (Pfizer and Johnson & Johnson). JB has received unrestricted research funding from Pfizer to study smoking cessation.

2020: Does the gateway theory justify a ban on nicotine vaping in Australia?

• Conclusion: The association between nicotine vaping and cigarette smoking provides weak support for a gateway hypothesis. 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. If there is a gateway effect, it is small at the population level because smoking prevalence has continued to decline despite an increased uptake of vaping in countries that allow it.
• PDF of full paper
  • Citation: Mendelsohn CP, Hall W. Does the gateway theory justify a ban on nicotine vaping in Australia? Int J Drug Policy. 2020 Apr;78:102712. doi: 10.1016/j.drugpo.2020.102712. Epub 2020 Mar 4. PMID: 32145594.
    • Acknowledgment: Colin Mendelsohn: I have received funding from Pfizer Australia, Johnson & Johnson Pacific and Perrigo Australia for teaching, consulting and conference expenses. I have never received payments from electronic cigarette or tobacco companies. I am a Board member of the Australian Tobacco Harm Reduction Association (ATHRA), a health promotion charity. ATHRA has received unconditional funding for establishment costs from small Australian vape businesses. Vape industry funding has not been accepted since March 2019.

2020: Trends in Tobacco Use Among Adolescents by Grade, Sex, and Race, 1991-2019

• This cross-sectional study suggests that, despite the increase in the prevalence of e-cigarette use among adolescents between 2011 and 2019, the prevalence of cigarette and smokeless tobacco use has decreased more rapidly during the same period compared with earlier years.
• Link to PDF on study page
  • Citation: Meza R, Jimenez-Mendoza E, Levy DT. Trends in Tobacco Use Among Adolescents by Grade, Sex, and Race, 1991-2019. JAMA Netw Open. 2020;3(12):e2027465. doi:10.1001/jamanetworkopen.2020.27465
    • Acknowledgement: Research reported in this publication was supported by award U54CA229974 from the National Cancer Institute of the National Institutes of Health and the US Food and Drug Administration Center for Tobacco Products.

2020: Electronic cigarettes, nicotine use trends and use initiation ages among US adolescents from 1999 to 2018

• Conclusion: "Electronic cigarettes may have offset conventional smoking among US adolescents between 2010 and 2018 by maintaining the total nicotine use prevalence and diverting them from more harmful conventional smoking. Additionally, electronic cigarette users appear to initiate at older ages relative to conventional smokers, which is associated with lower risk."
  • Citation: Foxon F, Selya AS. Electronic cigarettes, nicotine use trends and use initiation ages among US adolescents from 1999 to 2018. Addiction. 2020 Dec;115(12):2369-2378. doi: 10.1111/add.15099. Epub 2020 May 19. PMID: 32335976; PMCID: PMC7606254.
    • Acknowledgment: This work was supported by the National Institute of General Medical Sciences of the National Institutes of Health under grant number 1P20GM121341. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or NIGMS.

2020: Does e-cigarette experimentation increase the transition to daily smoking among young ever-smokers in France?

• Conclusion:
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2019: Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check

• Conclusion:
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2019: E-cigarette use and onset of first cigarette smoking among adolescents: An empirical test of the ‘common liability’ theory

• Conclusion: "Findings from this study provide supportive evidence for the ‘common liability’ underlying observed associations between e-cigarette use and smoking onset."
  • Citation: Cheng HG, Largo EG, Gogova M. E-cigarette use and onset of first cigarette smoking among adolescents: An empirical test of the 'common liability' theory. F1000Res. 2019 Dec 13;8:2099. doi: 10.12688/f1000research.21377.3. PMID: 32724557; PMCID: PMC7366034.
    • Acknowledgment: The study is supported by Altria Client Services LLC. All authors are full-time employees of Altria Client Services LLC.

2019: The Relationship Between Electronic Cigarette Use and Conventional Cigarette Smoking Is Largely Attributable to Shared Risk Factors

• "Taken together, the current findings fail to support the gateway theory, which predicts that e-cigarettes will promote the initiation as well as continued21,31,42 and heavier43 smoking of conventional cigarettes."
  • Citation: Kim S, Selya AS. The Relationship Between Electronic Cigarette Use and Conventional Cigarette Smoking Is Largely Attributable to Shared Risk Factors. Nicotine Tob Res. 2020 Jun 12;22(7):1123-1130. doi: 10.1093/ntr/ntz157. PMID: 31680169; PMCID: PMC7291806.
    • Acknowledgment: This work was supported by an Early Career Grant Award to AS from the University of North Dakota, the National Institute on Drug Abuse (grant number L40 DA042431), and the National Institute for General Medical Sciences (grant number 1P20GM121341-01).

2019: The Impact of Electronic Cigarettes on Cigarette Smoking By Americans and Its Health and Economic Implications

• In this study, we examined the growing use of electronic cigarettes and its implications. The wide use of e-cigarettes is a very recent development, and issues regarding their long-term effects and significance cannot be fully analyzed at this time. Using CDC and other data covering the last decade, however, we examined the relationship between the recent sharp increase in e-cigarette use among Americans and the contemporaneous acceleration in the declining rate of cigarette smoking. We found that the sharp increase in e-cigarette use across many groups can explain as much as 70 percent of the accelerating decline in smoking rates. We also found no reasonable evidential basis for concerns that e-cigarettes are a gateway to cigarette smoking. We further found that e-cigarettes are highly effective in helping people stop smoking cigarettes.
• Finally, we analyzed the impact of the sharp increase in e-cigarette use and the accelerating decline in cigarette smoking on healthcare costs and economic productivity. We found that while e-cigarette users incur lower healthcare costs than cigarette smokers or ex-smokers, the longer lifespans of e-cigarette users and ex-smokers who used e-cigarettes to quit smoking result in higher lifetime healthcare costs. However, we also found that the value of the additional years of life associated with using e-cigarettes instead of smoking is much greater than the additional healthcare costs. Lastly, we found that the increase in e-cigarette use and the associated reduction in smoking rates results in large productivity benefits, mainly from lower rates of illness.
  • Citation:
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2019: Considerations related to vaping as a possible gateway into cigarette smoking: an analytical review

• "Data from five surveys in US/UK youths all show that, regardless of sex and age, smoking prevalence in 2014–2016 declined faster than predicted by the preceding trend, suggesting the absence of a substantial gateway effect."
  • Citation: Lee PN, Coombs KJ and Afolalu EF. Considerations related to vaping as a possible gateway into cigarette smoking: an analytical review [version 3; peer review: 2 approved]. F1000Research 2019, 7:1915 (https://doi.org/10.12688/f1000research.16928.3)
    • Acknowledgment: Competing interests: PNL and KJC consult for various tobacco companies. EFA is a current employee of Philip Morris International. Grant information: This work was supported by PMI R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, CH-2000 Neuchâtel, Switzerland.

Letters/Testimony

2021: Testimony in Netherlands pertaining to a potential flavour / flavor ban: Regulation of e-cigarette flavours – a response

• Signed by 24 experts from around the world
• Covers 12 key points, including the theory of a gateway effect

Articles/Blogs

• A collection of articles, press releases, Op-Eds, and blog posts about products being a gateway to smoking. Is there proof? How are concerns about gateway being used to influence policy?

2024: Study: Heated Tobacco Products Increase Smoking Cessation Chances; 99.4% of Users Switched from Traditional Cigarettes

• "They also affirmed that there is no evidence that heated tobacco products serve as a gateway to starting smoking."

2024: Why We Need World Vape Day More Than Ever

• (Talking about misinformation.) "Just since April, the following claims have earned community notes: People who vape have high levels of uranium in their urine; vaping causes seizures; vaping harms your lungs within days; vaping is a gateway to smoking, all nicotine products are extremely damaging to health; and vapes cannot be recycled."

2024: It’s Critically Important to Tell Women the Truth About Nicotine

• "Dire warnings based on debunked myths backed by questionable science continue to make headlines, claiming people who vape nicotine will get popcorn lung, COVID, or “EVALI.” Studies full of methodological flaws portray vaping as a “gateway” to smoking. Or claim that vaping causes cancer, liver disease, myocardial infarction, COPD, and other diseases. Experts are kept busy evaluating these studies and submitting critiques of some of the most egregious papers, and their work has led to some studies being retracted."

2023: Is vaping a gateway to smoking?

• "The gateway theory predicts that vaping will increase smoking rates in young people. However, we are seeing the opposite of this. In countries where vaping is readily available such as the UK, US and New Zealand, the decline in youth smoking rates has accelerated."

2023: French Parliament Unanimously Backs Disposable Vapes Ban

• “This clearly shows that large [youth] experimentation of vaping does not lead to a collective ‘gateway effect’ to smoking,” he said. “In contrast, vaping could have a diversion effect.”

2023: France to Ban Disposable Vapes This Year in “Dangerous” Move

• "But the now-familiar “gateway theory” is contradicted by large-scale evidence. As recent commentary in the International Journal of Drug Policy noted, if the theory accurately described the population-level relationship between youth vaping and smoking, you’d expect vaping increases to produce higher youth smoking rates. On the contrary, rises in youth vaping in the United States, the United Kingdom and New Zealand “have been accompanied by an accelerated decline in smoking.”

2023: The Slow-Moving Train Wreck of Australian Vaping Policy

• "A case study is how Health Minister Butler frames his proposed harsher crackdown on vaping as youth protection. Despite the evidence to the contrary, he repeatedly claims that “vaping is a gateway to smoking.” He states that, “Vaping is creating a whole new generation of nicotine dependency in our community,” when Australian studies show that among youth who don’t smoke, less than 2 percent vape nicotine weekly or more."

2023: With youth vaping hitting a 10-year low, policymakers should focus on harm-reduction

• "Youth vaping in the United States has hit a 10-year low, according to new data from the Centers for Disease Control and Prevention (CDC). The so-called youth vaping epidemic appears to be a thing of the past, with historical lows in youth smoking dispelling fears of a gateway effect."

2023: No “Epidemic,” But CDC Delivers New Dose of Youth-Vaping Alarmism

• "In “What Are the Health Risks of Vaping for Youth?” the CDC states that youth are more susceptible than adults to nicotine addiction, which “may put youth at a risk for addiction to other substances in the future”—a version of the “gateway theory” that simply isn’t supported by meaningful evidence."

2023: Venezuela Bans All Vape Products, in Latest Blow to THR in Latin America

• "In 2022, the board of Brazil’s National Health Regulatory Agency (ANVISA) unanimously decided to uphold the country’s vape ban. They justified this with a series of false claims, saying that vapes are not shown to reduce harm and are a “gateway” to cigarette smoking for young people."

2023: It’s Time to Change the Way We Look at Youth Vaping

• "Young people who try vaping are more likely to try smoking. But this simply tells us that people who are more likely to try nicotine products are also more likely to try other nicotine products. There is no evidence that vaping causes people to smoke if they would not otherwise have done so (the “gateway theory”)."

2023: Situation Looks “Dire,” Say Opponents of Oregon Vape Flavor Ban

• "In commentary published by the Journal of the American Medical Association in March, for example, the director of the Rutgers Center for Tobacco Studies, Cristine Delnevo, wrote that “concerns about a gateway effect and a potential increase in youth cigarette use following the introduction of e-cigarettes to the US market are not supported by the data.”

2023: Is Canada Turning the Corner on Tobacco Harm Reduction?

• "The justifications were a highly debatable belief that flavors increase youth vaping, and the notion, refuted by population-level data, that vaping is a “gateway” into cigarette smoking."

2023: Anti-Vaping Sensors and CCTV in Schools: Is the UK Joining In?

• “At the population level,” she concluded, “e-cigarettes do not appear to be a gateway to cigarette smoking.” ... "Yet in justifying the measures at Baxter College, Carpenter, like many international public health figures, cited this supposed “gateway” effect."

2023: Taiwan Is About to Ban the Use of Nicotine Vapes

• "...the government has listed many reasons for the ban—alleging that vaping is bad for health, causes “EVALI,” includes cannabis use, has “gateway” potential, leads to a youth epidemic, and so forth."

2022: The Half-Truth Initiative: How an Anti-Smoking Group Lost Its Way

• "For example, Truth claims that vaping is a gateway to smoking. “Young people who had ever used e-cigarettes had seven times higher odds of becoming smokers one year later compared with those who had never vaped,” it says. But other studies find that “vaping likely diverts more young people from smoking than encourages them to smoke,” according to a paper by 15 past SRNT presidents. That paper also notes that “smoking among young people has declined at its fastest rate ever during vaping’s ascendancy,” making the gateway claim highly unlikely."

2022: Researchers Expose the Pitiful Quality of Highly Cited Vaping Studies

• "Among others, the researchers debunked studies that claimed to demonstrate the so-called “gateway effect,” which has been widely used to scare the public into believing that vaping nicotine leads to combustible tobacco use. “The studies we analyzed lacked sound research methods, and as such, could not reliably establish causation or identify a gateway effect,” the authors wrote."

2022: End Vape Misinformation, Tobacco Control Experts Urge Surgeon General

• "Cliff Douglas, one of the coauthors and the director of the University of Michigan Tobacco Research Network, told Filter. “The surgeon general’s website implies, for example, that e-cigarette use causes young people to become smokers, but this is strongly contradicted by widely available evidence"...The authors argue, therefore, that Surgeon General Vivek Murthy has helped perpetuate the myth that vapes are a “gateway” to cigarettes. In fact, they’re a well-trodden path to smoking cessation."

2022: Supreme Court Refuses to Block California’s Nicotine Flavor Ban

• " “Flavored tobacco products have hooked a new generation of young smokers at a time when tobacco is already the number one preventable killer in the United States,” the attorney general of California, Rob Bonta, said in a press statement. Vapes’ inclusion as “tobacco products” in US nomenclature means that he wrongly implied vaping is a “gateway” to smoking. And cigarette smoking is the number one cause of preventable death—not tobacco per se, which is also found in harm reduction products like snus or “heat-not-burn” devices. "

2022: California Votes to Ban Sales of Almost All Flavored Nicotine Products

• "Vaping nicotine, however, has in no way been established as a “gateway” to combustible cigarette use. Actually, the opposite looks to be true: A study published in JAMA Pediatrics by the Yale public health researcher Abigail Friedman showed that teenagers were more likely to start smoking than those in other US school districts after San Francisco’s flavored vape ban passed; another study by Brown’s Natasha Sokol and Harvard’s Justin Feldman, which appeared in Nicotine & Tobacco Research, suggested that youth who do vape are typically those who would have been smoking were vapes unavailable."

2022: How to Respond Sensibly to an Increase in Youth Vaping

• "The ASH briefing went on to firmly refute myths that had been promoted by garish headlines. It stated categorically that, “Disposable vapes DO NOT contain as much or more nicotine as a packet of 20 cigarettes.” It added that, “There is NOT strong evidence that vaping is a gateway into smoking,” with no evidence for the “gateway hypothesis.” And it asserted, correctly, that “An outbreak of serious respiratory disease (known as ‘EVALI’) in the US in 2019 WAS NOT caused by vaping nicotine.” "

2022: Why Aren’t We Celebrating the End of Teenage Smoking?

• "I believe this raises serious questions about the motivations of health “experts” who continue to insist that teen vaping is a gateway to smoking, that we’re in the midst of a teen vaping epidemic, and that a “whole new generation” is now “addicted to nicotine.” All of those claims bear an uncanny resemblance to 1930s Reefer Madness."

2021: Canada’s Proposed Nicotine Cap for Vapes Earns Sharp Criticism

• "However, the researchers also determined that in Canada, unlike in the US, there had also been a significant uptick in youth smoking—lending credence to an often-debunked and challenged theory of a “gateway” from vapes to combustible cigarettes. The problem was—as Clive Bates, a public health consultant and the former director of Action on Smoking and Health in the UK noted at the time—the BMJ paper’s figures were wrong. Almost exactly a year later, the journal issued a correction, seemingly hidden in a statistical supplement. Nonetheless, the controversial paper—critiqued in tobacco control and harm reduction circles—has apparently made an impact."

2020: Study: Vaping Looks Like a Gateway Out of—Not Into—Smoking

• “Just like sugar substitutes help people to reduce their sugar intake, e-cigarettes help people to quit smoking,” Chaplia continued. “We don’t blame sugar substitutes for increased sugar consumption, yet doing so for e-cigarettes seems to be acceptable.”

2020: Dismantling NY Mag’s Disgraceful Hit-Job on Vaping

• "Myers warns, “We now know conclusively that kids who start using e-cigarettes are far more likely to go onto smoke cigarettes.” Actually, the idea that e-cigarettes are a gateway to smoking has been conclusively debunked."

2019: Unfounded E-Cigarette Panic Puts Public Health at Risk

• "More important, the latest CDC data reveal nothing about underage smoking, which is the single most important data point in evaluating the harms or benefits of teenage vaping. Since the introduction of e-cigarettes to the U.S. market, adolescent use of cigarettes has more than halved, from 15.8 percent in 2011 to 7.6 percent in 2017. Rather than e-cigarettes acting as a gateway to smoking, as is assumed by government and advocacy groups, this indicates that teenage e-cigarette use is more likely diverting would-be smokers toward a less harmful means of nicotine consumption and potentially away from nicotine consumption altogether."

2019: Addicted to fear, the FDA is hurtling toward a historic mistake

• "In essence, the FDA is planning a massive regulatory onslaught against products that are significantly safer than cigarettes based on an unproven hypothesis and an alleged gateway that is as poorly defined as it is elusive."

2019: New Zealand Government Initiative Shows Welcome Support for Tobacco Harm Reduction

• "Salesa and the website challenge popular criticisms of vaping. While recognizing that vaping products are “not harmless to health,” but instead simply “much less harmful than smoking,” Salesa rejects the idea, popular in the United States, that providing tobacco harm reduction information will encourage young people to take up vaping. “Some people worry that vaping might be a ‘gateway’ to smoking for young people, but there is no clear evidence for this.” "

2019: Prohibition and Misinformation: Australia’s Tobacco Harm Reduction Fail

• "Queensland Health also makes the claim—familiar to US observers—that vaping is a “gateway” for young people to start smoking. This has not been borne out by international experience."

2019: FDA Cherry Picks Science in “Magic” Anti-Vaping Campaign

• "On July 22, the US Food and Drug Administration announced the launch of two new videos promoting the message that vaping is a “gateway” to smoking. It’s part of the agency’s ongoing youth-vaping prevention campaign, “The Real Cost,” that has repeatedly leaned on fear-mongering...It alludes to the findings of one study from February 2019 that observed, “prior e-cigarette use was associated with more than four times the odds of ever cigarette use.” ... The researchers also noted that they “cannot establish causal relations or rule out the possibility of residual confounding by underlying risk-taking propensities,” and thus their findings “should be interpreted with caution.” "

2018: Expert Debunks Vaping ‘Gateway’ Myth, Ripping ‘Bad Science In Service Of Bad Theories’

• " A leading expert in the field of tobacco harm reduction is criticizing a wave of recent studies claiming electronic cigarettes are a “gateway” to smoking as “bad science in service of bad theories.” "

2018: The War on Nicotine Pits Prejudice Against Public Health

• "This nicotine war carries eerie echoes from the ruinous war on illegal drugs. Taking several pages out of the “Reefer Madness” playbook, the tobacco control establishment’s “Vaper Madness” deploys tactics including: specious protect-the-children arguments, “gateway” claims, unfounded exaggerations of risks, and junk science."

2017: Vaping Study Sinks Claims E-Cigarettes Are Hooking Teens On Tobacco

• The hysteria over vaping allegedly serving as a gateway to smoking for teens is unfounded and goes against scientific evidence, according to a new study.

2017: Feds Owe the Public 'Corrective Statements' on Vaping

• "In the U.S., by contrast, former Surgeon General Vivek Murthy's 2016 report on youth vaping raised a range of concerns, including the risk of a “gateway” effect whereby teen vapers allegedly progressed to smoking. That would be a grave concern if it were happening – but it’s not."

2017: Huffington Post author claims vaping could be gateway to drugs and crime

• "E-cigarettes are under fire for being a possible gateway to a life of crime and crippling addiction to hard drugs in one of the most lurid attacks on the products yet."
• “E-cigs can easily become a gateway to trying and developing an addiction to more serious drugs,” warns Sudip Bose, a physician, in an article for the Huffington Post. “Addiction correlates to crime. People need to feed their habit, they break into homes to steal things to resell, they commit robberies on the streets, all to get money to feed their addiction.”
• "The jump from experimenting with e-cigarettes, to nicotine addiction, to hard drugs and crime stretches Bose’s credibility to a breaking point: There is precisely zero evidence for any gateway effect of e-cigarettes on drugs or crime, and none is cited in the article."
• "Not only that, but there is no evidence that vaping acts as a gateway to regular tobacco smoking despite the best efforts of some anti-e-cigarette campaigners."

2017: Merchants Of Doubt: How Public Health Uses Tobacco Tactics Against E-Cigarettes

• "Several years of the background noise of claim and counterclaim has contaminated the public's understanding of relative risk and harm reduction. Constant panics of teen vaping and unproven "gateway" effects take prominence in media coverage over the potential benefits of smokers switching to vaping."

2017: Vaping Is Not a Gateway to Smoking, New Study Shows

• "But far from being the smoking gun finally proving e-cigarettes are a gateway to their tobacco-filled rivals, the study itself finds there is still absolutely no evidence of a gateway effect from vaping to regular cigarette use."

2016: New CDC Report on E-Cigarettes Shatters Gateway Myth, Suggests Shift from Hazardous Smoking to Much Safer Vaping among Youth

• "However, today's CDC report reveals that something very different appears to be occurring. It appears that rather than serving as a gateway toward cigarette smoking, e-cigarettes may actually be acting as a diversion away from cigarettes."

2015: World Lung Foundation Disseminates Conclusion that E-Cigarettes are a Gateway to Smoking Based on a Bogus Study

• "More importantly, nowhere in the study does it conclude that e-cigarettes are a gateway to smoking."
• "However, the most embarrassing and irresponsible behavior in this story is that of the World Lung Foundation, which disseminated the conclusion that e-cigarettes are a gateway to smoking based on the barely comprehensible quote of a single kid in Fife."

2015: 2014 Anti-Smoking Myth of the Year Award Goes to CDC, Dr. Stan Glantz, and Dr. Michael Fiore

• "...for publicly spreading the myths that electronic cigarettes have been found to be a gateway to smoking..."

2014: New Study Refutes Claim that Electronic Cigarettes are a Gateway to Smoking

• "This study found only three students, in a sample of 1,300, who had initiated nicotine use with e-cigarettes and progressed to smoking...These findings refute the claim that electronic cigarettes are a gateway to smoking. "

2014: Glantz Tells Public There is No Question that E-Cigarettes are a Gateway to Smoking, But Today's Monitoring the Future Data Show the Opposite

• "It is clear that experimentation with electronic cigarettes among youth has increased dramatically from 2011 to 2014. But despite this dramatic increase, the prevalence of current smoking among youth decreased dramatically. And the sharpest decline in smoking occurred concurrently with the largest increase in electronic cigarette use."

2014: Columbia Scientists Claim that E-Cigarettes May Be Gateway to Illicit Drug Use and Addiction

• "There is no justification for drawing this sweeping conclusion based solely on studies of mouse brains, without a shred of clinical or epidemiologic evidence that suggests e-cigarettes serve as a gateway to smoking or illicit drug addiction."

2014: Spurred On By CDC/Glantz Propaganda, Two U.S. Senators Claim that Electronic Cigarettes are a Gateway to Smoking

• "The assertions by the CDC, by Stan Glantz, by Senator Blumenthal, and by Senator Schumer are completely unsubstantiated by actual scientific data. In fact, there is no scientific evidence to support the conclusion that they have all disseminated to the public: that electronic cigarettes are a gateway to smoking."

2013: Cambridge Public Health Department Follows the CDC's Lead, Claims that Electronic Cigarettes are a Gateway to a Lifetime of Tobacco Use

• "There is, in fact, no evidence that electronic cigarettes serve as a gateway to a lifelong tobacco habit. In fact, there is not even any evidence that electronic cigarettes serve as a gateway to a short-lived tobacco habit. The only study to examine this hypothesis found that electronic cigarettes are not currently serving as a gateway to cigarette smoking among young people."

2013: E-Cigarettes May Not Be Gateway to Smoking: Study

• "It didn't seem as though it really proved to be a gateway to anything," said Wagener, who presented his findings at a meeting of the American Association for Cancer Research, in National Harbor, Md."