Nicholas I. Goldenson, BA1Adam M. Leventhal, PhD1,2Matthew D. Stone, BA1et al

Key Points

Question  Is the use of electronic cigarettes with higher nicotine concentrations prospectively associated with greater frequency and intensity of combustible cigarette smoking and vaping in adolescents?

Findings  In this cohort study of 181 adolescent electronic cigarette users, use of electronic cigarettes with higher nicotine concentrations at baseline was associated with greater levels of combustible cigarette and electronic cigarette use in the past 30 days at the 6-month follow-up and greater intensity of daily use after controlling for baseline use.

Meaning  Use of electronic cigarettes with higher nicotine concentrations may contribute to the progression to smoking and vaping at higher levels of frequency and intensity among youths.


Importance  Research indicates that electronic cigarette (e-cigarette) use (vaping) among adolescents is associated with the initiation and progression of combustible cigarette smoking. The reasons for this association are unknown.

Objective  To evaluate whether use of e-cigarettes with higher nicotine concentrations is associated with subsequent increases in the frequency and intensity of combustible cigarette smoking and vaping.

Design, Setting, and Participants  In this prospective cohort study involving students from 10 high schools in the Los Angeles, California, metropolitan area, surveys were administered during 10th grade in the spring (baseline) and 11th grade in the fall (6-month follow-up) of 2015 to students who reported using e-cigarettes within the past 30 days and the nicotine concentration level they used at baseline.

Exposures  Self-report of baseline e-cigarette nicotine concentration of none (0 mg/mL), low (1-5 mg/mL), medium (6-17 mg/mL), or high (≥18 mg/mL) typically used during the past 30 days.

Main Outcomes and Measures  Frequency of combustible cigarette smoking and e-cigarette use within the past 30 days (0 days [none], 1-2 days [infrequent], or ≥3 days [frequent]) and daily intensity of smoking and vaping (number of cigarettes smoked per day, number of vaping episodes per day, and number of puffs per vaping episode) at the 6-month follow-up.

Results  The analytic sample included 181 students (96 boys [53.0%] and 85 girls [47.0%]; mean [SD] age, 16.1 [0.4] years). Each successive increase in nicotine concentration (none to low, low to medium, and medium to high) vaped was associated with a 2.26 (95% CI, 1.28-3.98) increase in the odds of frequent (vs no) smoking and a 1.65 (95% CI, 1.09-2.51) increase in the odds of frequent (vs no) vaping at follow-up after adjustment for baseline frequency of smoking and vaping and other relevant covariates. Use of e-cigarettes with high (vs no) nicotine concentration was associated with a greater number of cigarettes smoked per day at follow-up (adjusted rate ratio [RR], 7.03; 95% CI, 6.11-7.95). An association with a significantly greater number of vaping episodes per day was found with use of low (adjusted RR, 3.32; 95% CI, 2.61-4.03), medium (adjusted RR, 3.32; 95% CI, 2.54-4.10), and high (adjusted RR, 2.44; 95% CI, 1.63-3.24) nicotine concentrations (vs no nicotine) at baseline. Similar results were found for the number of puffs per vaping episode for low (adjusted RR, 2.05; 95% CI, 1.41-2.70), medium (adjusted RR, 3.39; 95% CI, 2.66-4.11), and high (adjusted RR, 2.23; 95% CI, 1.42-3.03) nicotine concentrations.

Conclusions and Relevance  The results of this study provide preliminary evidence that use of e-cigarettes with higher nicotine concentrations by youths may increase subsequent frequency and intensity of smoking and vaping.


Good study, adequate sample size.  Essentially, the “bottom line”  is that vaping frequently and at high concentrations is a marker for progression to more frequent and higher rates of smoking and continued vaping at high doses.

Nicotine has been labeled the most addictive substance on earth and for good reason.
At the same time, I’ve had experience in my practice that folks who are motivated to quit, if they SWITCH (not alternate) to exclusive vaping with a desire to quit smoking, they have a better cessation rate than if they stick to cigarettes.

Tobacco has about 700 toxins and additives in it.  Vape liquid (unflavored) has about 7 toxins.  The toxins inhibit the proper formation of cartilage and collagen. provides information on supplements that can be taken to speed repair of cartilage and collagen.  Degradation of these substances is a significant factor in osteoarthritis and spinal disc disease.  Repairing those tissues generally helps relieve the pain associated with inflammation and damage (ongoing for tobacco users, which is stressed in my practice) to those tissues.  The supplements only work on those who abstain from tobacco–vaping seems to be OK though.  We all have the “blueprint” (DNA) for health cartilage and collagen.  Our bodies have repair mechanisms that work if we don’t poison them.  When is the last time you saw a 2 year old at the playground limping around with a cane?  I have had great personal and practice success with the above link at the doses described, using ALL of the supplements (an orchestra or band sounds better than a solo musician, they all need to work TOGETHER, in harmony).

There’s a LOT to be said for proper patient education!

Dr. Raymond Oenbrink
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