5.13.1 Confectionery cigarettes
Chocolate, sugar and bubblegum sticks made to look like cigarettes and cigars have been sold for many decades, often in packaging closely resembling that of real tobacco products.1 Probably the most widely recognised Australian confectionery cigarettes were ‘Fags’: white sugar sticks with one tip dyed red to simulate a lit cigarette.
Having young children accustomed to playing with the cigarette-like lollies in facsimile brand packaging provides obvious benefits for tobacco manufacturers.1 Although the tobacco companies publicly distanced themselves from confectionery cigarettes from the 1960s, they failed to pursue trademark infringements by confectionery companies.1
Research from the US in the 1990s found that children who bought confectionery cigarettes were almost four times more likely to have tried real cigarettes. This effect remained significant after parental smoking status was taken into consideration. Children liked confectionery cigarettes and tended to see them as illicit or mature pleasures, and to use them as props to imitate smoking behaviour.2 Research from the US has shown that adults who used confectionery cigarettes in childhood were about twice as likely to take up smoking, than adults who did not consume the lollies.3 Greater use of confectionery cigarettes was associated with a higher likelihood of becoming a smoker, irrespective of potential socio-demographic confounding factors.3
Confectionery cigarettes remain available in some parts of the world4 but are no longer legally sold in most states and territories in Australia. Interestingly however, the cigarette-shaped lollies sold as Fags in Australia continue to be sold but with a rebranding of the name from ‘Fags’ to ‘Fads’.
5.13.2 Flavoured cigarettes
Proliferation of flavoured brands has been attributed to the tobacco industry’s need to attract and retain young smokers in an increasingly challenging regulatory environment.5,6 Fruit and confectionary flavoured tobacco products that may appeal to children were effectively banned from sale in Australia in the late 2000s and the role of added cigarette flavourings in fostering smoking initiation was highlighted in partial guidelines adopted by the WHO Framework Convention on Tobacco Control (WHO FCTC) Conference of the Parties in November 2010.7 See Section 19.4.3 for the latest information. However, flavoured capsule cigarettes, flavoured roll-your-own (RYO) and pipe tobacco products continue to be available on the Australian market along with flavoured cigarettes papers for use with RYO tobacco—see Chapter 12, Section 12.8 for greater detail.
Analysis of tobacco industry documents suggests that companies have used flavourings to mask the harshness of tobacco smoke and improve palatability of tobacco products. This is particularly important for new tobacco users.7 Studies on the popularity of mainstream flavoured brands in the US (such as those produced by the major tobacco companies RJ Reynolds and Brown & Williamson) have shown that flavoured cigarettes are primarily used by younger people,5 and that college-age non-smokers, experimenters and smokers are more likely to have positive expectancies of flavoured variants of cigarettes compared with regular cigarettes.8 This confirms what the tobacco industry has long understood: that younger novice smokers are much more likely to be attracted to novelty flavoured tobacco products than older or established smokers.6
Flavoured tobacco products, including menthol and flavour capsule cigarettes, are discussed in greater detail in Chapter 10, Section 10.8.4
Menthol flavoured tobacco products are popular among young people. In 2014, 51.7% of Australian past-month smokers aged 12 to 17 years old had smoked a menthol hybrid/dual flavoured cigarette.9 A 2019 garbology study of environmental contamination from tobacco product waste conducted across 12 public high schools in California found 620 combustible cigarette butts, of which, 42% were menthol.10 Examination of tobacco industry documents reveals that menthol has been, and continues to be, essential to the tobacco industry’s strategy for recruiting and retaining young smokers.11 Moreover, these documents show how tobacco companies have analysed the concomitant effect of controlling menthol levels and increasing brand sales among specific groups.12 While adult menthol users prefer stronger levels of menthol sensation, brands with milder levels of menthol are also available and these appear to be more attractive to adolescent and young adult smokers.12 Investigators conducted independent laboratory tests on menthol brands and analysed data on menthol brand use from a nationally representative US health survey. They found evidence that the industry manipulated cigarette menthol levels and introduced new menthol brands to gain market share, especially among young people.12
Flavour capsule cigarettes were reported in 2018 as the fastest growing segment of the combustible cigarette market. 13,14 First introduced in Japan in 2007, flavour capsule cigarettes feature a crushable capsule embedded in or near the filter of a combustible cigarette, which, when squeezed, releases concentrated flavouring.15 Menthol is the most commonly employed flavour for capsule cigarettes, providing a cooling, smoothing and anaesthetic effect on mucus membranes, masking the irritating effects of cigarette smoke. 15 Popular flavours reported globally include fruit, mint variations and beverage/cocktail flavours such as green tea and mojito.13 Researchers suggest flavour capsule cigarettes appeal particularly to young people as they reduce the initial harshness of smoking and may imply reduced risk.16
Speculation that flavour capsule cigarettes have been positioned by the tobacco industry as a starter product, is backed by research showing use of flavour capsule cigarettes to be highest among young adults, and associated with later onset of smoking.15 One study, conducted in New Zealand, concluded that flavour capsule cigarettes appealed more to non-smokers and non-daily smokers, than they did to daily smokers. This finding, in combination with flavour capsule cigarettes’ appeal to young people, means this product is positioned to recruit non-smokers and potentially increase overall smoking prevalence, especially among young people.16
The tobacco industry has consistently denied that packaging influences the uptake of smoking among young people, however industry documents clearly show that systematic and extensive research has been carried out by these tobacco companies to ensure that cigarette packaging appeals to selected target groups, including women and young people.17-20 Innovation in package design has been used by the tobacco industry as a way to communicate with consumers during increasing limitations on traditional tobacco advertising and promotion, especially in countries such as Australia.20,21 Elements of pack design engineered by tobacco companies to appeal to consumers include colour, imagery and logos; product descriptors and wording including typeface; pack shape, size and material as well as method of opening and seal.17,22 Evidence from internal tobacco industry documents detailing consumer research and marketing plans show that slim, rounded, oval and booklet shaped packs were found to be particularly appealing to young people. 20 In a 2009 UK study, children as young as 11 years old reported misperceptions of health risk based on pack design and wording. Brands considered to be less dangerous were also perceived as more appealing and chosen as the preferred brand if trying smoking.23 See Section 10.8 Trends in products and packaging for a detailed discussion about innovations in product and packaging design.
There is a growing body of research showing the effectiveness of health warnings for reducing the appeal of tobacco packaging and discouraging the uptake of smoking, especially among young people.24-32 Plain packaging has been shown to have great effect on reducing the appeal of tobacco packaging for young people and discouraging smoking uptake.33-39 For a detailed discussion on both health warnings and plain packaging, see InDepth 12A Health warnings and InDepth 11A Packaging as promotion: Evidence for and effects of plain packaging.
Packaging has also been altered to accommodate different quantities of cigarettes, with smaller packs being of particular appeal to young people. As mentioned in Section 5.12, the tobacco industry has been shown to target starters, new users and younger users through small pack size offerings, in both factory made packs and roll-your-own pouch sizes, based on young and new smokers’ lower consumption rates, their preference for cheaper per-pack prices, as well as smaller packs being easier to conceal.40, 41 In 1985 and early 1986 Philip Morris launched its popular brands Alpine and Peter Jackson in packs of 15. Dubbed ‘kiddie packs’ by health advocates, the cost of small packs was about half the price of other larger pack sizes at the time. South Australian research conducted soon after their introduction showed that the smaller packets were especially popular among young teenage smokers.42 While smaller packs of cigarettes were subsequently banned, ‘splittable’ packs, whereby a packet of 20 cigarettes could be separated along a perforated line to make two smaller packs, similar in dimensions to an ‘iPod’, were launched by British American Tobacco Australia in 2006.43 Since then, legislation has been introduced in Australia specifying minimum numbers of cigarettes per package and elements of pack design, which is intended to counter packaging that appeals to young users (see Section 5.23). See also, Section 10.8.1.1 Conveying value for money through the pack.
5.13.4 Other products
Alternative tobacco product use, such as waterpipe, otherwise known as hookah or shisha, is popular among adolescents in Western countries.44 Waterpipe smoking is particularly appealing to young people as they are used in social gatherings, come in various flavours, and can be used to perform smoke tricks.45 Use of waterpipe has been shown to be a novel risk factor for never smokers to initiate combustible cigarette smoking as well as a predictor of subsequent initiation of other tobacco products and e-cigarettes among young people.46,47 Research has found adolescents and young adults underestimate and discount the long-term risks associated with waterpipe.45 For information about the health effects of waterpipe smoking see Chapter 3, Section 3.27.5.
While some researchers argue that electronic cigarettes have the potential to be a useful cessation aid for smokers, there has been a dramatic increase in young non-smokers using these devices, particularly in the US 48,49, see 18B.6.1 Uptake among non-smokers and 18B.3 Extent of use. Since 2014, e-cigarettes have been the most popular tobacco product among young people in the US, having been used by 27.5% of high school students and 10.5% of middle school students in 2019. Among high school students who reported using e-cigarettes, more than one-third (34.2%) had used them on at least 20 of the past 30 days. Among students who reported ever having tried e-cigarettes, the three most common reasons for use were ‘I was curious about them’ (55.3%), ‘friend or family member used them’ (30.8%) and ‘they are available in flavors, such as mint, candy, fruit, or chocolate’ (22.4%). Among all students included in the survey, 28.2% perceived there to be no or little harm from intermittent e-cigarettes use, and 9.5% perceived there to be no or little harm from intermittent cigarette use.50
Furthermore, research has also shown that use of e-cigarettes by young non-smokers may act as a ‘gateway’ to tobacco smoking.51-53 Curiosity, willingness and intentions to smoke tobacco cigarettes were higher among users of e-cigarettes according to an Australian study examining e-cigarette use among young never (tobacco cigarette) smokers and its association with susceptibility for future tobacco cigarette use. This relationship remained significant even after controlling for numerous covariates, leading the researchers to conclude that even one or two puffs of an e-cigarette has the potential to increase susceptibility to combustible tobacco smoking among Australian young people. 54 See 18B.6.2 A ‘gateway effect’ to tobacco smoking.
Researchers have demonstrated how US electronic cigarette start-up Juul Labs Inc. specifically engineered its products in ways that make them both highly palatable and highly addictive.55 Their research showed Juul e-cigarettes were designed to emit a high-nicotine concentration aerosol in a protonated form—rather than freebase— meaning it is easily inhaled.55 Due to the products exceptionally high nicotine content—5% nicotine, compared to 1%–3% for other e-liquids—the product is extremely addictive.56 Juul also released flavours which were particularly appealing to young people, such as Crème brulee, Fruit medley and Mango.57 In addition, Juul adopted a marketing strategy which appeared to appeal directly to young non-smokers, including use of advertisements featuring attractive young models as well as social media and other media outlets frequented by young people. 57 In July, 2019 there was a two-part hearing in the US—Part I58 & Part II59—building on Congresses Economic and Consumer Policy Subcommittee’s investigation into Juul Labs Inc.’s role in what the FDA described as a youth nicotine addiction epidemic. The Subcommittee on Economic and Consumer Policy determined that Juul Labs Inc. had deliberately targeted children in order to become America’s largest seller of e-cigarettes. Specifically, the Subcommittee found:
•Juul deployed a sophisticated program to enter schools and convey its messaging directly to teenage children
•Juul targeted teenagers and children, as young as eight years old, in summer camps and public out-of-school programs
•Juul recruited thousands of online ‘influencers’ to market to teens.
The Subcommittee’s finding was based on approximately 55,000 non-public documents that the company produced to the Subcommittee and the Massachusetts Attorney General.
For more on electronic cigarettes see In Depth 18B Electronic cigarettes (e-cigarettes).
Relevant news and research
For recent news items and research on this topic, click here. (Last updated October 2020)
1. Klein JD and Clair SS. Do candy cigarettes encourage young people to smoke? BMJ, 2000; 321(7257):362-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10926600
2. Klein J, Forehand B, Oliveri J, Patterson C, Kupersmidt J, et al. Candy cigarettes: do they encourage children's smoking? Pediatrics, 1992; 88:27–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1728016
3. Klein J, Thomas R, and Sutter E. History of childhood candy cigarette use is associated with tobacco smoking by adults. Preventive Medicine, 2007; 45(1):26–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17532370
4. Ferriman A. Chocolate cigarettes "recruit" children to smoking. BMJ, 2003; 326(7384):302. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12574033
5. Lewis MJ and Wackowski O. Dealing with an innovative industry: a look at flavored cigarettes promoted by mainstream brands. American Journal of Public Health, 2006; 96(2):244-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16380563
6. Carpenter C, Wayne G, Pauly J, Koh H, and Connolly G. New cigarette brands with flavors that appeal to youth: tobacco marketing strategies. Health Affairs, 2005; 24:1601–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16284034
7. FCTC/COP4(10). Partial guidelines for implementation of Articles 9 and 10 of the WHO Framework Convention on Tobacco Control (Regulation of the contents of tobacco products and Regulation of tobacco product disclosures). Geneva: World Health Organization, 2010. Available from: http://www.who.int/fctc/guidelines/Decisions9and10.pdf
8. Ashare R, Hawk LJ, Cummings K, O'Connor R, Fix B, et al. Smoking expectancies for flavored and non-flavored cigarettes among college students. Addictive Behaviors, 2007; 32:1252–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17030447
9. White V and Williams T. Australian secondary school students’ use of tobacco, alcohol, and over-the-counter and illicit substances in 2014. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2016. Available from: https://www.health.gov.au/sites/default/files/secondary-school-students-use-of-tobacco-alcohol-and-other-drugs-in-2014.pdf.
10. Mock J and Hendlin YH. Notes from the Field: Environmental Contamination from E-cigarette, Cigarette, Cigar, and Cannabis Products at 12 High Schools - San Francisco Bay Area, 2018-2019. MMWR; Morbidity and Mortality Weekly Report, 2019; 68(40):897-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31600185
11. van der Eijk Y, Lee JK, and P ML. How Menthol Is Key to the Tobacco Industry's Strategy of Recruiting and Retaining Young Smokers in Singapore. Journal of Adolescent Health, 2019; 64(3):347-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30392860
12. Kreslake JM, Wayne GF, Alpert HR, Koh HK, and Connolly GN. Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults. American Journal of Public Health, 2008; 98(9):1685-92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18633084
13. Moodie C, Thrasher JF, Cho YJ, Barnoya J, and Chaloupka FJ. Flavour capsule cigarettes continue to experience strong global growth. Tobacco Control, 2019; 28(5):595-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30368482
14. Haggart K, Hoek J, and Blank ML. Flavour Capsule Variants' Performance in a "Dark Market": Implications for Standardised Packaging. Nicotine and Tobacco Research, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30060215
15. Emond JA, Soneji S, Brunette MF, and Sargent JD. Flavour capsule cigarette use among US adult cigarette smokers. Tobacco Control, 2018; 27(6):650-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29363609
16. Hoek J, Gendall P, Eckert C, Louviere J, Blank ML, et al. Young adult susceptible non-smokers' and smokers' responses to capsule cigarettes. Tobacco Control, 2019; 28(5):498-505. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30282774
17. Wakefield M, Morley C, and Horan J. The cigarette pack as image: new evidence from tobacco industry documents. Tobacco Control, 2002; 11:i73–80. Available from: http://tobaccocontrol.bmj.com/cgi/reprint/11/suppl_1/i73.pdf
18. Hammond D, Doxey J, Daniel S, and Bansal-Travers M. Impact of female-oriented cigarette packaging in the United States. Nicotine and Tobacco Research, 2011; 13(7):579-88. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21486994
19. Doxey J and Hammond D. Deadly in pink: the impact of cigarette packaging among young women. Tobacco Control, 2011; 20(5):353–60. Available from: http://tobaccocontrol.bmj.com/content/20/5/353.short
20. Kotnowski K and Hammond D. The impact of cigarette pack shape, size and opening: evidence from tobacco company documents. Addiction, 2013; 108(9):1658-68. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23600674
21. Moodie C and Hastings GB. Making the pack the hero, tobacco industry response to marketing restrictions in the UK: findings from a long-term audit. International Journal of Mental Health and Addiction, 2011; 9(1):24–38. Available from: https://link.springer.com/article/10.1007/s11469-009-9247-8
22. Hammond D. "Plain packaging" regulations for tobacco products: the impact of standardizing the color and design of cigarette packs. Salud Publica de Mexico, 2010; 52 Suppl 2(suppl. 2):S226-32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21243193
23. Hammond D and Parkinson C. The impact of cigarette package design on perceptions of risk. Journal of Public Health, 2009; 31(3):345-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19636066
24. White V, Webster B, and Wakefield M. Do graphic health warning labels have an impact on adolescents' smoking-related beliefs and behaviours? Addiction, 2008; 103(9):1562–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18783508
25. Shanahan P and Elliott D. Evaluation of the effectiveness of the graphic health warnings on tobacco product packaging 2008. Canberra, Australia: Australian Government Department of Health and Ageing, 2009. Available from: http://webarchive.nla.gov.au/gov/20140801094931/http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-tobacco-eval-graphic-health-warnings-exec-sum.
26. Blanton H, Snyder LB, Strauts E, and Larson JG. Effect of graphic cigarette warnings on smoking intentions in young adults. PLoS ONE, 2014; 9(5):e96315. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24806481
27. White V, Bariola E, Faulkner A, Coomber K, and Wakefield M. Graphic Health Warnings on Cigarette Packs: How Long Before the Effects on Adolescents Wear Out? Nicotine and Tobacco Research, 2015; 17(7):776-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25239958
28. Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, et al. Pictorial cigarette pack warnings: a meta-analysis of experimental studies. Tobacco Control, 2016; 25(3):341-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25948713
29. Drovandi A, Teague PA, Glass B, and Malau-Aduli B. Australian School Student Perceptions of Effective Anti-tobacco Health Warnings. Front Public Health, 2018; 6:297. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30386764
30. Essence Communications. Evaluation of effectiveness of graphic health warnings on tobacco product packaging: An Evaluation Report. Prepared for the Department of Health, 2018. Available from: https://beta.health.gov.au/resources/publications/evaluation-of-effectiveness-of-graphic-health-warnings-on-tobacco-product-packaging.
31. Niederdeppe J, Kemp D, Jesch E, Scolere L, Greiner Safi A, et al. Using graphic warning labels to counter effects of social cues and brand imagery in cigarette advertising. Health Education Research, 2019; 34(1):38-49. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30358853
32. Francis DB, Mason N, Ross JC, and Noar SM. Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies. Tobacco Induced Diseases, 2019; 17:41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31516484
33. Scheffels J and Lund I. The impact of cigarette branding and plain packaging on perceptions of product appeal and risk among young adults in Norway: A between-subjects experimental survey. BMJ Open, 2013; 3(12):e003732. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24309171
34. Moodie C, Bauld L, Ford A, and Mackintosh AM. Young women smokers' response to using plain cigarette packaging: qualitative findings from a naturalistic study. BMC Public Health, 2014; 14:812. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25100245
35. White V, Williams T, and Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents' perceptions of cigarette packs and brands? Tobacco Control, 2015; 24(Suppl 2):ii42-ii9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28407611
36. Dunlop S, Perez D, Dessaix A, and Currow D. Australia's plain tobacco packs: anticipated and actual responses among adolescents and young adults 2010-2013. Tobacco Control, 2016. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27852891
37. El-Khoury Lesueur F, Bolze C, Gomajee R, White V, Melchior M, et al. Plain tobacco packaging, increased graphic health warnings and adolescents' perceptions and initiation of smoking: DePICT, a French nationwide study. Tobacco Control, 2019; 28(e1):e31-e6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30409812
38. Drovandi A, Teague PA, Glass B, and Malau-Aduli B. A systematic review of the perceptions of adolescents on graphic health warnings and plain packaging of cigarettes. Systematic Reviews 2019; 8(1):25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30654833
39. White VM, Guerin N, Williams T, and Wakefield MA. Long-term impact of plain packaging of cigarettes with larger graphic health warnings: findings from cross-sectional surveys of Australian adolescents between 2011 and 2017. Tobacco Control, 2019; 28(e1):e77-e84. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/28/e1/e77.full.pdf
40. Bayly M, Scollo MM, and Wakefield MA. Who uses rollies? Trends in product offerings, price and use of roll-your-own tobacco in Australia. Tobacco Control, 2019; 28(3):317-24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30030409
41. Persoskie A, Donaldson EA, and Ryant C. How tobacco companies have used package quantity for consumer targeting. Tobacco Control, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29853560
42. Wilson DH, Wakefield MA, Esterman A, and Baker CC. 15's: they fit in everywhere--especially the school bag: a survey of purchases of packets of 15 cigarettes by 14 and 15 year olds in South Australia. Community Health Studies, 1987; 11(suppl.1):i16–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3495401
43. Chapman S. Australia: British American Tobacco 'addresses' youth smoking. Tobacco Control, 2007; 16(1):2–3. Available from: http://tobaccocontrol.bmj.com/cgi/reprint/16/1/2-a
44. Penzes M, Foley KL, Balazs P, and Urban R. Patterns of alternative tobacco product experimentation among ever smoker adolescents. Central European Journal of Public Health, 2019; 27(1):3-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30927390
45. Cornacchione J, Wagoner KG, Wiseman KD, Kelley D, Noar SM, et al. Adolescent and Young Adult Perceptions of Hookah and Little Cigars/Cigarillos: Implications for Risk Messages. Journal of Health Communication, 2016; 21(7):818-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27337629
46. Case KR, Creamer MR, Cooper MR, Loukas A, and Perry CL. Hookah use as a predictor of other tobacco product use: A longitudinal analysis of Texas college students. Addictive Behaviors, 2018; 87:131-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30016762
47. Veeranki SP, Alzyoud S, Kheirallah KA, and Pbert L. Waterpipe Use and Susceptibility to Cigarette Smoking Among Never-Smoking Youth. American Journal of Preventive Medicine, 2015; 49(4):502-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26143951
48. Barrington-Trimis JL, Urman R, Leventhal AM, Gauderman WJ, Cruz TB, et al. E-cigarettes, Cigarettes, and the Prevalence of Adolescent Tobacco Use. Pediatrics, 2016; 138(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/27401102
49. Chaffee BW, Couch ET, and Gansky SA. Trends in characteristics and multi-product use among adolescents who use electronic cigarettes, United States 2011-2015. PLoS ONE, 2017; 12(5):e0177073. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28475634
50. Wang TW, Gentzke AS, Creamer MR, Cullen KA, Holder-Hayes E, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students - United States, 2019. MMWR Surveillance Summaries, 2019; 68(12):1-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31805035
51. Zhong J, Cao S, Gong W, Fei F, and Wang M. Electronic Cigarettes Use and Intention to Cigarette Smoking among Never-Smoking Adolescents and Young Adults: A Meta-Analysis. International Journal of Environmental Research and Public Health, 2016; 13(5). Available from: https://www.ncbi.nlm.nih.gov/pubmed/27153077
52. Chatterjee K, Alzghoul B, Innabi A, and Meena N. Is vaping a gateway to smoking: a review of the longitudinal studies. International Journal of Adolescent Medicine and Health, 2016; 30(3). Available from: https://www.ncbi.nlm.nih.gov/pubmed/27505084
53. National Academies of Sciences Engineering and Medicine. Public Health Consequences of E-Cigarettes. The National Academies Press, Washington, DC 2018. Available from: http://nationalacademies.org/hmd/Reports/2018/public-health-consequences-of-e-cigarettes.aspx.
54. Jongenelis MI, Jardine E, Kameron C, Rudaizky D, and Pettigrew S. E-cigarette use is associated with susceptibility to tobacco use among Australian young adults. International Journal of Drug Policy, 2019; 74:266-73. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31257041
55. Talih S, Salman R, El-Hage R, Karam E, Karaoghlanian N, et al. Characteristics and toxicant emissions of JUUL electronic cigarettes. Tobacco Control, 2019; 28(6):678-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30745326
56. Jackler RK and Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market. Tobacco Control, 2019; 28(6):623-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30733312
57. Vallone DM, Cuccia AF, Briggs J, Xiao H, Schillo BA, et al. Electronic Cigarette and JUUL Use Among Adolescents and Young Adults. JAMA Pediatrics, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31961395
58. No authors listed. Examining JUUL’s Role in the Youth Nicotine Epidemic: Part I. Committee on Oversight and Reform, 2019. Available from: https://oversight.house.gov/legislation/hearings/examining-juul-s-role-in-the-youth-nicotine-epidemic-part-i
59. No authors listed. Examining JUUL’s Role in the Youth Nicotine Epidemic: Part II. Committee on Oversight and Reform, 2019. Available from: https://oversight.house.gov/legislation/hearings/examining-juul-s-role-in-the-youth-nicotine-epidemic-part-ii