association between electronic nicotine delivery systems and electronic non-nicotine delivery systems with initiation of tobacco use in individuals aged < 20 years. a systematic review and meta-analysis.

Background
This systematic review described the association between electronic nicotine delivery systems
and electronic non-nicotine delivery systems (ENDS/ENNDS) use among non-smoking
children and adolescents aged <20 years with subsequent tobacco use.
Methods
We searched five electronic databases and the grey literature up to end of September 2020.
Prospective longitudinal studies that described the association between ENDS/ENNDS
use, and subsequent tobacco use in those aged < 20 years who were non-smokers at baseline
were included. The Joanna Briggs Institute Critical Appraisal Checklist was used to
assess risk of bias. Data were extracted by two reviewers and pooled using a randomeffects
meta-analysis. We generated unadjusted and adjusted risk ratios (ARRs) describing
associations between ENDS/ENNDS and tobacco use.
Findings
A total of 36 publications met the eligibility criteria, of which 25 were included in the systematic
review (23 in the meta-analysis) after exclusion of overlapping studies. Sixteen studies
had high to moderate risk of bias. Ever users of ENDS/ENNDS had over three times the risk
of ever cigarette use (ARR 3�01 (95% CI: 2�37, 3�82; p<0�001, I2: 82�3%), and current cigarette use had over two times the risk (ARR 2�56 (95% CI: 1�61, 4�07; p<0�001, I2:
77�3%) at follow up. Among current ENDS/ENNDS users, there was a significant association
with ever (ARR 2�63 (95% CI: 1�94, 3�57; p<0�001, I2: 21�2%)), but not current cigarette
use (ARR 1�88 (95% CI: 0�34, 10�30; p = 0�47, I2: 0%)) at follow up. For other tobacco use,
ARR ranged between 1�55 (95% CI 1�07, 2�23) and 8�32 (95% CI: 1�20, 57�04) for waterpipe
and pipes, respectively. Additionally, two studies examined the use of ENNDS (non-nicotine
devices) and found a pooled adjusted RR of 2�56 (95% CI: 0�47, 13�94, p = 0.035).
Conclusion
There is an urgent need for policies that regulate the availability, accessibility, and marketing
of ENDS/ENNDS to children and adolescents. Governments should also consider adopting
policies to prevent ENDS/ENNDS uptake and use in children and adolescents, up to and
including a ban for this group.

Yoong SL, hall a, Turon h, et al. association between electronic nicotine delivery systems and electronic non-nicotine delivery systems with initiation of tobacco use in individuals aged < 20 years. a systematic review and meta-analysis. PloS one. 2021;16(9):1. doi:10.1371/journal.pone.0256044