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. 2025 Jun;120(6):1090-1111.
doi: 10.1111/add.16773. Epub 2025 Jan 30.

Electronic cigarettes and subsequent cigarette smoking in young people: A systematic review

Rachna Begh  1 , Monserrat Conde  1 , Thomas R Fanshawe  1 , Dylan Kneale  2 , Lion Shahab  3 , Sufen Zhu  1 , Michael Pesko  4 , Jonathan Livingstone-Banks  1 , Nicola Lindson  1 , Nancy A Rigotti  5 , Kate Tudor  6 , Dimitra Kale  3 , Sarah E Jackson  3 , Karen Rees  7 , Jamie Hartmann-Boyce  8
Affiliations

Electronic cigarettes and subsequent cigarette smoking in young people: A systematic review

Rachna Begh et al. Addiction. 2025 Jun.

Abstract

Aims: To assess the evidence for a relationship between the use of e-cigarettes and subsequent smoking in young people (≤29 years), and whether this differs by demographic characteristics.

Methods: Systematic review with association direction plots (searches to April 2023). Screening, data extraction and critical appraisal followed Cochrane methods. Our primary outcome was the association between e-cigarette use, availability or both, and change in population rate of smoking in young people. The secondary outcomes were initiation, progression and cessation of smoking at individual level. We assessed certainty using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results: We included 126 studies. For our primary outcome, there was very low certainty evidence (limited by risk of bias and inconsistency) suggesting that e-cigarette use and availability were inversely associated with smoking in young people (i.e. as e-cigarettes became more available and/or used more widely, youth smoking rates went down or, conversely, as e-cigarettes were restricted, youth smoking rates went up). All secondary outcomes were judged to be very low certainty due to very serious risk of bias. Data consistently showed direct associations between vaping at baseline and smoking initiation (28 studies) and smoking progression (5 studies). The four studies contributing data on smoking cessation had mixed results, precluding drawing any conclusion on the direction of association. There was limited information to determine whether relationships varied by sociodemographic characteristics.

Conclusion: At an individual level, people who vape appear to be more likely to go on to smoke than people who do not vape; however, it is unclear if these behaviours are causally linked. Very low certainty evidence suggests that youth vaping and smoking could be inversely related.

Keywords: e‐cigarettes; gateway hypothesis; smoking; systematic review; young adults; youth.

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Conflict of interest statement

M.C.'s work is funded by Cancer Research UK under grant number PPRCTAGPJT\10 000. This was not deemed a conflict of interest. R.B., J.H., S.Z., R.N., J.L.B., K.R. and K.T. declare no competing interests. D.K. is an Associate Editor for Addiction and has no competing interests to declare. J.H.B. declares current funding from the Food and Drug Administration and the Truth Initiative on topics related to tobacco control and e‐cigarettes. C.N. is an Associate Editor at Addiction and the first author of an included study. C.N. was not involved in the screening, coding or quality appraisal of this study. N.L. is an Associate Editor for Addiction and has no competing interests to declare. S.C. is a Senior Editor at Addiction and the co‐author of an included study. S.C. was not involved in the screening, coding or quality appraisal of this study. S.J. is a Senior Editor at Addiction. L.S. is a HEFCE funded member of staff at University College London. He has received honoraria for talks, an unrestricted research grant and travel expenses to attend meetings and workshops from Pfizer and an honorarium to sit on advisory panel from Johnson and Johnson, both pharmaceutical companies that make smoking cessation products. He has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies. Other research has been funded by the Department of Health, UKRI, a community‐interested company (National Centre for Smoking Cessation) and charitable sources (Cancer Research UK, Yorkshire Cancer Research). He has never received personal fees or research funding of any kind from alcohol, electronic cigarette or tobacco companies. L.S. is the first author of an included study and was not involved in screening, data extraction, or appraisal of this study. M.P.'s research is supported by the National Institute on Drug Abuse of the National Institutes of Health under award number R01DA045016. M.P. declares current funding from the Food and Drug Administration, the American Cancer Society, University of Kentucky Institute for the Study of Free Enterprise, and Health Canada. M.P. is the first author and co‐author of included studies and was not involved in the screening, data extraction, or appraisal of these studies. T.R.F. receives funding from the National Institute for Health and care Research (NIHR) HealthTech Research Centre for Community Healthcare at Oxford Health NHS Foundation Trust and the NIHR Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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