Exploring the gateway hypothesis of e-cigarettes and tobacco: a prospective replication study among adolescents in the Netherlands and Flanders
Open accessAbstract
Background: Studies demonstrated that adolescent e-cigarette use is associated with subsequent tobacco smoking, commonly referred to as the gateway effect . However, most studies only investigated gateways from e-cigarettes to tobacco smoking. This study replicates a cornerstone study revealing a positive association between both adolescent e-cigarette use and subsequent tobacco use; and tobacco and subsequent e-cigarette use in the Netherlands and Flanders. Design: The longitudinal design included baseline (n=2839) and 6-month (n=1276) and 12-month (n=1025) follow-up surveys among a school-based cohort (mean age: 13.62). Ten high schools were recruited as a convenience sample. The analyses involved (1) associations of baseline e-cigarette use and subsequent tobacco smoking among never smokers; (2) associations of e-cigarette use frequency at baseline and tobacco smoking frequency at follow-up; and (3) the association of baseline tobacco smoking and subsequent e-cigarette use among non-users of e-cigarettes. Findings: Consistent with prior findings, baseline e-cigarette use was associated with higher odds of tobacco smoking at 6-month (OR=1.89; 95% CI 1.05 to 3.37) and 12-month (OR=5.63; 95% CI 3.04 to 10.42) follow-ups. More frequent use of e-cigarettes at baseline was associated with more frequent smoking at follow-ups. Baseline tobacco smoking was associated with subsequent e-cigarette use (OR=3.10; 95% CI 1.58 to 6.06 at both follow-ups). Conclusion: Our study replicated the positive relation between e-cigarette use and tobacco smoking in both directions for adolescents. This may mean that the gateway works in two directions, that e-cigarette and tobacco use share common risk factors, or that both mechanisms apply.
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More adolescents are inclined to transition from vaping to conventional cigarettes, reversing a two-decade-long decline.
“Moreover, more adolescents are inclined to transition from vaping to conventional cigarettes, reversing a two-decade-long decline [166–169].”
From Adolescent nicotine exposure and persistent neurocircuitry changes: unveiling lifelong psychiatric risks (2025) · cites this paper as [168]
The Results and Discussion report that adolescents who had used e-cigarettes were more likely to start smoking combustible cigarettes than those who had not. The paper does not establish that this transition reversed a two-decade decline; its Introduction instead says adolescent tobacco use decreased during the last decade as e-cigarette use increased. Page numbers are unavailable in our copy. (LLM, conf=0.90)
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- Authors
- Martinelli, T., Candel, M. J. J. M., de Vries, H., Talhout, R., Knapen, V., van Schayck, C. P., & Nagelhout, G. E.
- Affiliations
- Tilburg University (NL)
- Maastricht University (NL)
- National Institute for Public Health and the Environment (NL)
- Corresponding author
- Martinelli, Thomas
- Venue
- Tobacco Control
- Publisher
- BMJ
- Published
- 2021-07-05
- Volume
- 32
- Issue
- 2
- Pages
- 170-178
- ISSN
- 0964-4563 (ISSN-L)
- 1468-3318
- PMC
- PMC9985733
- OpenAlex
- W3178295146
- Cited by
- 92
- References
- 72
- Citations by year
- 2026: 13 · 2025: 23 · 2024: 17 · 2023: 24 · 2022: 11 · 2021: 4
- FWCI
- 8.78
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Tobacco Control (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, cc-by)
- Research portal (Tilburg University) (submittedVersion, cc-by)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Rivm (National Institute for Public Health and the Environment) (submittedVersion, cc-by-nc)
- Rivm Repository (Netherlands National Institute for Public Health and the Environment) (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion, cc-by)
- Funders
- NWO (401.16.012)
- Topics
- Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Social Sciences › Sociology and Political Science › Impact of Technology on Adolescents
- Keywords
- gateway hypothesis, electronic cigarettes, smoking, adolescents, vaping, tobacco use, replication study, dual use, smoking initiation
- MeSH terms
- Vaping, Adolescent, Adolescent Behavior, Humans, Longitudinal Studies, Netherlands, Prospective Studies, Nicotiana, Electronic Nicotine Delivery Systems
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