Amid the moral panic over youth vaping and a widespread belief that it’s a “gateway” to cigarettes, youth smoking in the United States is at an all-time low. Yet very little is written about this. Why?
Professor Kenneth Warner, of the University of Michigan’s School of Public Health, asks that very question in his new paper, published by the American Journal of Public Health and titled: “Kids No Longer Smoke Cigarettes. Why Aren’t We Celebrating?”
He argues that one of the reasons we’re not shouting “one of the great public health triumphs” from “the mountaintops” is skewed public and professional perceptions of safer nicotine products.
Warner’s extensive research has concerned areas including economics and policy in relation to tobacco harm reduction, and he has over 300 professional publications and a host of research and tobacco control awards to his name. So his words carry weight.
When a 2020 national survey found that just 11 percent of respondents correctly believed nicotine vapes to be less harmful than cigarettes, as Warner noted in his article, “Anyone concerned about youth tobacco product use may consider the demise of smoking per se only a step in the right direction.”
Filter was able to ask Prof. Warner more about his latest publication and the circumstances it reflects.
“I suspect that a decade ago, we in the US would have been very pleased to see youth smoking drop to 5 percent. That figure is in the rear-view mirror.”
Kiran Sidhu: The title of your paper contains a blunt assertion which may surprise many: “Kids no longer smoke.” What is the basis for that claim?
Kenneth Warner: In 1997, more than a third of high school seniors (36.5 percent, to be exact) reported smoking cigarettes in the past 30 days. For 10th graders, the figure was 30.4 percent. Last year, 1.9 percent of high school students smoked in the past 30 days.
Even more dramatically, in 1997 fully a quarter of seniors (24.6 percent) smoked every single day. Last year, that figure had plummeted to 0.7 percent. That’s one of every 143 seniors.
With adolescent use of cigars having fallen dramatically as well, it seems quite safe to conclude that youth smoking has nearly ceased to exist. For perspective, those countries that have established tobacco endgame goals have defined “the end” as reaching 5 percent smoking prevalence. That’s for adults, but I suspect that a decade ago, we in the US would have been very pleased to see youth smoking drop to 5 percent.
That figure is in the rear-view mirror. The near-disappearance of youth smoking in our country is without doubt one of the greatest public health achievements of the present century.
KS: Is there a simple answer to your question of why we’re not celebrating it?
KW: There is no simple answer. I believe it involves people conflating nicotine use with smoking-produced disease. People—including physicians—incorrectly believe that nicotine is the source of smoking-caused diseases. Nicotine is the chemical that addicts people to cigarettes, with many other chemicals in cigarette smoke actually causing the diseases.
The incredible coverage of youth use of e-cigarettes—incredible both in its quantity and its “frightening” tone—is undoubtedly also a factor. As a consequence of the coverage, the public erroneously believes that e-cigarettes are as dangerous as, or more dangerous than, combustible cigarettes. Major authoritative sources agree that e-cigarettes are substantially less dangerous.
“We know that the rate of decline in youth smoking was at its fastest ever precisely during the period of vaping’s ascendancy.”
KS: When youth who were smoking were predominantly from marginalized backgrounds, did that make the decline less noticeable than if youth smoking had been concentrated in populations with louder voices?
KW: Yes, it is likely a factor, possibly an important one.
Unlike cigarette smoking, vaping has been engaged in by kids, many of them white, from families with higher levels of education and income. Their parents have a strong political voice and have used it effectively to create great awareness and concern about youth vaping.
KS: Your paper states that changing social norms have played a role in the decline of youth smoking. How much of a contribution would you say nicotine vapes have made to that decline, compared to social norms?
KW: No one can answer that fully. Youth smoking has been falling steadily since the mid-1960s, so e-cigarettes clearly weren’t a factor in the first half of the decline. That was more social norms and policies.
I suspect—but no one can prove—that e-cigarettes played a role in the disappearance of youth smoking since the mid-2010s. We do know that the rate of decline in youth smoking was at its fastest ever precisely during the period of vaping’s ascendancy.
KS: What would youth have done in a hypothetical world without vapes?
KW: We almost certainly would have seen a continued decline in youth smoking, but we have no way of knowing how far it would have gone. Would youth smoking have leveled off at 8 percent or 5 percent? There is no way of answering that counterfactual question.
Logic suggests that the decline in the most recent years—when the rate of decline accelerated—might have been slower without e-cigarettes.
“Who will produce and disseminate the truth? It would run contrary to the emphasis of educational efforts to date.”
KS: In your article you talk about people, including health professionals, incorrectly believing that vapes are as harmful as cigarettes—it’s one of the reasons, you say, why we’re not celebrating the near-disappearance of youth smoking. Why do you think this incorrect belief is so entrenched, and what’s the solution?
KW: Misconceptions about the dangers of vaping compared to those of smoking are widespread and of long standing. I wish I had a solution.
“Public education” is the simple answer, but who will produce and disseminate the truth? It would take an incredible public education campaign to correct the misimpression. It would run contrary to the emphasis of the educational efforts to date.
KS: Do you think regulations should make it comparatively easier for youth to access vapes than cigarettes, if they’re going to access one or the other?
I definitely favor age restrictions for youth. While it is conceivable that vaping has contributed to the rapid decline in smoking, as I discussed earlier, smoking is now largely gone. Vaping does run the risk of addicting a subset of kids to nicotine, which is certainly not desirable.
If you’re asking me whether I would rather see a kid vaping instead of smoking, the answer is yes. That adolescent’s risk of both addiction and eventual chronic disease would be less with vaping. But I’d much rather see them doing neither. Note that there are age restrictions on cigarettes, of course. If kids access cigarettes under those restrictions, they certainly could access e-cigarettes.
KS: With the younger generation smoking less and less, what impacts can we expect on our health systems in years to come?
People will live longer. There will be a reduced demand for cancer treatment and other chronic disease care during middle age and early senior years. But there may be a need for more care for the larger population of older people.
Photograph by Mathew MacQuarrie via Unsplash