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      Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis

      systematic-review

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          Abstract

          Objective

          The aim of this review was to investigate whether e-cigarette use compared with non-use in young non-smokers is associated with subsequent cigarette smoking.

          Data sources

          PubMed, Embase, Web of Science, Wiley Cochrane Library databases, and the 2018 Society for Research on Nicotine and Tobacco and Society for Behavioural Medicine conference abstracts.

          Study selection

          All studies of young people (up to age 30 years) with a measure of e-cigarette use prior to smoking and an outcome measure of smoking where an OR could be calculated were included (excluding reviews and animal studies).

          Data extraction

          Independent extraction was completed by multiple authors using a preprepared extraction form.

          Data synthesis

          Of 9199 results, 17 studies were included in the meta-analysis. There was strong evidence for an association between e-cigarette use among non-smokers and later smoking (OR: 4.59, 95% CI: 3.60 to 5.85) when the results were meta-analysed in a random-effects model. However, there was high heterogeneity ( I 2 =88%).

          Conclusions

          Although the association between e-cigarette use among non-smokers and subsequent smoking appears strong, the available evidence is limited by the reliance on self-report measures of smoking history without biochemical verification. None of the studies included negative controls which would provide stronger evidence for whether the association may be causal. Much of the evidence also failed to consider the nicotine content of e-liquids used by non-smokers meaning it is difficult to make conclusions about whether nicotine is the mechanism driving this association.

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          Most cited references38

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          A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy

          E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments.
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            Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis.

            The public health implications of e-cigarettes depend, in part, on whether e-cigarette use affects the risk of cigarette smoking.
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              Risk and Rationality in Adolescent Decision Making: Implications for Theory, Practice, and Public Policy.

              Crime, smoking, drug use, alcoholism, reckless driving, and many other unhealthy patterns of behavior that play out over a lifetime often debut during adolescence. Avoiding risks or buying time can set a different lifetime pattern. Changing unhealthy behaviors in adolescence would have a broad impact on society, reducing the burdens of disease, injury, human suffering, and associated economic costs. Any program designed to prevent or change such risky behaviors should be founded on a clear idea of what is normative (what behaviors, ideally, should the program foster?), descriptive (how are adolescents making decisions in the absence of the program?), and prescriptive (which practices can realistically move adolescent decisions closer to the normative ideal?). Normatively, decision processes should be evaluated for coherence (is the thinking process nonsensical, illogical, or self-contradictory?) and correspondence (are the outcomes of the decisions positive?). Behaviors that promote positive physical and mental health outcomes in modern society can be at odds with those selected for by evolution (e.g., early procreation). Healthy behaviors may also conflict with a decision maker's goals. Adolescents' goals are more likely to maximize immediate pleasure, and strict decision analysis implies that many kinds of unhealthy behavior, such as drinking and drug use, could be deemed rational. However, based on data showing developmental changes in goals, it is important for policy to promote positive long-term outcomes rather than adolescents' short-term goals. Developmental data also suggest that greater risk aversion is generally adaptive, and that decision processes that support this aversion are more advanced than those that support risk taking. A key question is whether adolescents are developmentally competent to make decisions about risks. In principle, barring temptations with high rewards and individual differences that reduce self-control (i.e., under ideal conditions), adolescents are capable of rational decision making to achieve their goals. In practice, much depends on the particular situation in which a decision is made. In the heat of passion, in the presence of peers, on the spur of the moment, in unfamiliar situations, when trading off risks and benefits favors bad long-term outcomes, and when behavioral inhibition is required for good outcomes, adolescents are likely to reason more poorly than adults do. Brain maturation in adolescence is incomplete. Impulsivity, sensation seeking, thrill seeking, depression, and other individual differences also contribute to risk taking that resists standard risk-reduction interventions, although some conditions such as depression can be effectively treated with other approaches. Major explanatory models of risky decision making can be roughly divided into (a) those, including health-belief models and the theory of planned behavior, that adhere to a "rational" behavioral decision-making framework that stresses deliberate, quantitative trading off of risks and benefits; and (b) those that emphasize nondeliberative reaction to the perceived gists or prototypes in the immediate decision environment. (A gist is a fuzzy mental representation of the general meaning of information or experience; a prototype is a mental representation of a standard or typical example of a category.) Although perceived risks and especially benefits predict behavioral intentions and risk-taking behavior, behavioral willingness is an even better predictor of susceptibility to risk taking-and has unique explanatory power-because adolescents are willing to do riskier things than they either intend or expect to do. Dual-process models, such as the prototype/willingness model and fuzzy-trace theory, identify two divergent paths to risk taking: a reasoned and a reactive route. Such models explain apparent contradictions in the literature, including different causes of risk taking for different individuals. Interventions to reduce risk taking must take into account the different causes of such behavior if they are to be effective. Longitudinal and experimental research are needed to disentangle opposing causal processes-particularly, those that produce positive versus negative relations between risk perceptions and behaviors. Counterintuitive findings that must be accommodated by any adequate theory of risk taking include the following: (a) Despite conventional wisdom, adolescents do not perceive themselves to be invulnerable, and perceived vulnerability declines with increasing age; (b) although the object of many interventions is to enhance the accuracy of risk perceptions, adolescents typically overestimate important risks, such as HIV and lung cancer; (c) despite increasing competence in reasoning, some biases in judgment and decision making grow with age, producing more "irrational" violations of coherence among adults than among adolescents and younger children. The latter occurs because of a known developmental increase in gist processing with age. One implication of these findings is that traditional interventions stressing accurate risk perceptions are apt to be ineffective or backfire because young people already feel vulnerable and overestimate their risk. In addition, research shows that experience is not a good teacher for children and younger adolescents, because they tend to learn little from negative outcomes (favoring the use of effective deterrents, such as monitoring and supervision), although learning from experience improves considerably with age. Experience in the absence of negative consequences may increase feelings of invulnerability and thus explain the decrease in risk perceptions from early to late adolescence, as exploration increases. Finally, novel interventions that discourage deliberate weighing of risks and benefits by adolescents may ultimately prove more effective and enduring. Mature adults apparently resist taking risks not out of any conscious deliberation or choice, but because they intuitively grasp the gists of risky situations, retrieve appropriate risk-avoidant values, and never proceed down the slippery slope of actually contemplating tradeoffs between risks and benefits.
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                Author and article information

                Journal
                Tob Control
                Tob Control
                tobaccocontrol
                tc
                Tobacco Control
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0964-4563
                1468-3318
                January 2021
                10 March 2020
                : 30
                : 1
                : 8-15
                Affiliations
                [1 ] departmentMRC Integrative Epidemiology Unit , University of Bristol , Bristol, UK
                [2 ] departmentDepartment of Population Health Sciences , Bristol Medical School, University of Bristol , Bristol, UK
                [3 ] departmentUK Centre for Tobacco and Alcohol Studies, School of Psychological Science , University of Bristol , Bristol, UK
                [4 ] NIHR Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust , Bristol, UK
                [5 ] Adapt (Study Rocket Ltd) , London, UK
                Author notes
                [Correspondence to ] Dr Jasmine N Khouja, MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 1TU, UK; jasmine.khouja@ 123456bristol.ac.uk
                Author information
                http://orcid.org/0000-0002-7944-2981
                Article
                tobaccocontrol-2019-055433
                10.1136/tobaccocontrol-2019-055433
                7803902
                32156694
                c348fbb4-61fd-4baf-86eb-892809cc9234
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

                History
                : 04 October 2019
                : 11 December 2019
                : 31 December 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000265, Medical Research Council;
                Award ID: MC_UU_0011/7
                Categories
                Review
                1506
                1507
                Custom metadata
                unlocked
                editors-choice
                free

                Public health
                electronic nicotine delivery devices,addiction,co-substance use
                Public health
                electronic nicotine delivery devices, addiction, co-substance use

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