Gateway or common liability? A systematic review and meta-analysis of studies of adolescent e-cigarette use and future smoking initiation

Background and aims: Studies have consistently found a longitudinal association between e-cigarette use (vaping) and cigarette smoking. Many have interpreted such association as causal. This systematic review and meta-analysis evaluated the plausibility of a causal interpretation by (1) estimating the effect of adolescent vaping on smoking initiation, adjusted for study quality characteristics, (2) evaluating the sufficiency of adjustment for confounding based on the social development model (SDM) and the social ecological model (SEM) and E-value analyses and (3) investigating sample attrition and publication bias.

Methods: Systematic review and meta-analysis of longitudinal studies that examined the association between e-cigarette use at baseline and smoking at follow-up. Participants were non-smokers aged < 18 at baseline.

Results: Meta-analysis of 11 studies showed a significant longitudinal association between vaping and smoking [adjusted odds ratio (aOR) = 2.93, 95% confidence interval (CI) = 2.22, 3.87]. Studies with sample sizes < 1000 had a significantly higher odds ratio (OR = 6.68, 95% CI = 3.63, 12.31) than studies with sample sizes > 1000 (OR = 2.49, 95% CI = 1.97, 3.15). Overall, the attrition rate was very high (median = 30%). All but one study reported results from complete sample analysis, despite those dropping out having higher risk profiles. Only two studies comprehensively adjusted for confounding. The median E-value was 2.90, indicating that the estimates were not robust against unmeasured confounding.

Conclusions: There is a longitudinal association between adolescent vaping and smoking initiation; however, the evidence is limited by publication bias, high sample attrition and inadequate adjustment for potential confounders.