To the Editor While Watkins et al1 offer substantial evidence that, in young people, noncigarette tobacco product use is associated with future conventional cigarette use,1 we would argue that interpretation of the same evidence, paradoxically, can lead to the opposite conclusion: ie, the increase in noncigarette tobacco product use actually decreases future conventional cigarette use. Evidence supports that fact that more youths use noncigarette tobacco products now compared with 10 years ago.2,3 Whereas extrapolation from the Watkins et al argument1 would lead one to predict that the increased noncigarette tobacco product use is associated with a corresponding increase in conventional cigarette use, surprisingly, just the opposite is reported.3 The number of youths who smoke conventional cigarettes has never been lower than the present; furthermore, the steepest decline in conventional cigarette smoking occurred during the period of the greatest uptick in noncigarette tobacco product use.3 Interestingly, from 2011 to 2015, the composition within the classification of a “noncigarette tobacco product” changed dramatically. Electronic cigarettes (e-cigarettes) entered the market and use soared from 1.5% to 16%, making e-cigarettes the greatest source of noncigarette tobacco product use.3 Also increasing was the use of hookahs (4.1% to 7.2%).3 During this period, conventional cigarette smoking plummeted from 15.8% to 9.3%. Use of other noncigarette tobacco products, including cigars (11.6% to 8.6%), smokeless tobacco (7.9% to 6.0%), pipe tobacco (4.0% to 1.0%), and bidis (2.0% to 0.6%), also declined.3 Although e-cigarettes’ sudden appearance and boom within the high school student population does seem alarming, it can be concluded that e-cigarettes have played a part in displacing other tobacco products, including conventional cigarettes, in youthful experimentation. While it is true that the minority of youths who do become conventional cigarette smokers have experimented with noncigarette tobacco products, often more than one kind, they remain a minority.1
Ip M, Middlekauff HR. Noncigarette Tobacco Products—Gateway or Diversion? JAMA Pediatr. 2018;172(8):784. doi:10.1001/jamapediatrics.2018.1073
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