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Comment & Response
August 2018

Noncigarette Tobacco Products—Gateway or Diversion?—Reply

Author Affiliations
  • 1Center for Tobacco Control Research and Education, Department of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
  • 2Center for Tobacco Control Research and Education, University of California, San Francisco
  • 3Center for Tobacco Control Research and Education, Department of Preventive and Restorative Dentistry, University of California, San Francisco
JAMA Pediatr. 2018;172(8):784-785. doi:10.1001/jamapediatrics.2018.1076

In Reply The declining prevalence of youth cigarette smoking in the United States has been a welcome and encouraging trend. However, contrary to the suggestion from Ip and Middlekauff, the available empirical evidence does not support attributing this achievement to the emerging popularity of tobacco in other forms.

Adolescent cigarette use has been in decline for 20 years, starting well before electronic cigarettes (e-cigarettes) became the most commonly used nicotine or tobacco product among middle and high school students. Before and during the time that e-cigarettes and hookah appeared in national surveys, proven tobacco control measures were taking effect across the country, including mass media campaigns, clean indoor air policies, rising cigarette excise taxes, and, more recently, an increasing number of jurisdictions rising the minimum tobacco purchase age to 21 years.1 Importantly, during this impressive downward trend, there was no acceleration in the decline of youth cigarette use after e-cigarettes emerged.2 In fact, when e-cigarette and hookah use spiked, the overall number of youths using any form of nicotine or tobacco increased.3

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