Public Release: 

E-cigarettes may recruit lower risk teens to nicotine use

The Geisel School of Medicine at Dartmouth

Researchers at the Norris Cotton Cancer Center and University of Hawaii Cancer Center find that one-third of Hawaiian adolescents have tried e-cigarettes, half of whom have never used another tobacco product.

"This is a markedly different pattern of use compared to their peers in the continental U.S., where teen e-cigarette use is less than half that rate and e-cigarette users are mainly also cigarette smokers (dual-users)," reported James D. Sargent, MD, a pediatrician at Dartmouth Hitchcock's Norris Cotton Cancer Center in a paper published December 15, 2014 in the journal Pediatrics.

The investigators assessed risk status for three groups (non-users, e-cigarette-only users, and dual-users) on variables that predict future use of cigarettes, and found the e-cigarette-only users to have risk that was in between the never-smokers and dual-users. "The concern is that e-cigarette advertising is recruiting intermediate risk adolescents to nicotine use--kids who would not otherwise have started smoking," said Sargent. "These are kids who might go on to smoke cigarettes, which are much better at delivering nicotine than e-cigarettes."

Sargent added, "If this pattern of use is adopted by adolescents in the continental U.S., we could be in for an epidemic of teen tobacco use in this country that could greatly reduce the overall benefits to public health of e-cigarettes."

Researchers from Dartmouth and the University of Hawaii Cancer Center collaborated in the 2013 survey-based study of 1,941 adolescents aged 14-15 years old in public and private schools in Hawaii. Statistical analysis examined risk and protective variables across a spectrum of use, comparing never-smokers with e-cigarette-only users and e-cigarette-only users with dual-users.

Risk factors for smoking cigarettes include protective variables such as parental support and academic involvement, in addition to risk factors including peer smoking and sensation seeking. On almost all of those measures, e-cigarette users ranked somewhere between the never-smokers and the dual-users.

Cigarettes are highly taxed in Hawaii and e-cigarettes, with their potent combination of lower cost and kid-friendly flavors such as mango and pineapple, may be more attractive to teens. Thomas Wills, PhD, of the UH Cancer Center commented with concern on specifics of e-cigarettes, which are widely available in Hawaii, noting "The marketing is very aggressive here." He added that manufacturers place ads in venues such as movie theaters where adolescents socialize, as well as on radio and television.

Sargent and collaborators were so concerned about the findings that they submitted them to the FDA docket to inform proposed regulations on e-cigarettes. They note that flavoring, packaging, and marketing of e-cigarettes is not regulated, and that manufacturers' opportunities to target adolescents are wide open, absent FDA regulation of these products.


Sargent's collaborators include TA Willis, R Knight, RJ Williams, and I Pagano, all from the University of Hawaii Cancer Center, Honolulu, HI.

The National Cancer Institute grant RO1 CA 153154 funded the study.

About Norris Cotton Cancer Center at Dartmouth-Hitchcock

Norris Cotton Cancer Center combines advanced cancer research at Dartmouth and the Geisel School of Medicine with patient centered cancer care provided at Dartmouth-Hitchcock Medical Center in Lebanon, NH, at Dartmouth-Hitchcock regional locations in Manchester, Nashua, and Keene, NH, and St. Johnsbury, VT, and at 12 partner hospitals throughout New Hampshire and Vermont. It is one of 41 centers nationwide to earn the National Cancer Institute's "Comprehensive Cancer Center" designation. Learn more about Norris Cotton Cancer Center research, programs, and clinical trials online at

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