E-cigarette marketing to teens significantly increases smoking rates


E-cigarette marketing targeted at adolescents plays a significant role in the uptake of e-cigarette use, as well as the use of traditional cigarettes.

Despite 2 decades of restrictions on cigarette marketing, these ads still effectively target young persons and have a significant impact on their uptake of cigarettes. E-cigarette marketing, which is allowed on television and has a heavy presence on social media, is a particular concern, according to a new study published in JAMA Pediatrics.

The study sought to address how much advertising plays a role in adolescents and young adults trying tobacco. The researchers found that advertisements had a significant impact on those aged 12 to 17 years who had never used tobacco-progressing to trying it within a year.

“Tobacco product advertising is effective at undermining the commitment of underaged adolescents not to use tobacco products,” says John P. Pierce, PhD, professor emeritus in the Department of Family Medicine and Public Health, Moores University of California San Diego Cancer Center, La Jolla, California, and lead author of the study. “Further, advertising for e-cigarettes can cross over and get young people to start smoking cigarettes.”

The research team used the Population Assessment of Tobacco and Health (PATH) Study at wave 1 (from 2013 to 2014) and 1-year follow-up at wave 2 (from 2014 to 2015). The assessment was conducted using never tobacco users aged 12 to 24 years. Nearly 11,000 assessments were completed, and the study notes that receptivity to tobacco advertising at wave 1 was high for those aged 12 to 14 years, but highest in the aged-18-to-21-years group. E-cigarette ads had the most impact, according to the report.

The research team notes that 12- to 17-year-olds susceptible to use a particular tobacco product in wave 1 were very likely to have used that product by the wave 2 assessment. The research team also noted differences in patterns between conventional and e-cigarette ads and use.

“Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2,” the study notes.

Eighty-two percent of adult smokers in the United States tried their first cigarette before age 18 years, according to the report, and 93% before the age of 21 years. Within 4 years of trying that first cigarette, 30% to 50% of teenagers became regular users and developed long-term dependence on cigarettes, the study notes. Regulations on cigarette marketing were put into place in 1998 and are believed to have contributed to a steady decline in high school seniors who started to smoke cigarettes, from 65% at that time to 28% by 2016. Marketing of other tobacco products, such as e-cigarettes, has grown, however, and is contributing to uptake in these products as well as traditional cigarettes, according to the study data.

To undertake the study, researchers showed each subject 20 ads from 4 different product categories, randomly selected from all tobacco ads used in the year prior to the survey. These ads included those used in print mail, direct mail, and television formats. Participants were asked if they had seen the ad in the prior year and whether they liked the ad. Their receptivity was ranked and follow-up assessments were done at a year to determine the smoking status of the participant.

Although tobacco advertisements are regulated, there are e-cigarette ads on television, and Pierce says 44% of children aged 12 to 14 years can recall these ads.

“The industry is spending a fortune on social media exposure of kids. This is below the radar of many adults,” Pierce says. “One concern is that all the great work done in the past 25 years that has led to a major reduction in smoking initiation among adolescents appears to be at risk as e-cigarettes, in particular, are addicting a new generation to nicotine with many later converting to cigarettes.”

For all the participants in every age group, receptivity was highest to e-cigarettes, followed by cigarettes, smokeless tobacco, and cigars. This pattern continued to age 21 years, according to the report, with 27.5% of those aged 18 to 21 years having a moderate to high receptivity to ads compared with 9.7% of 12- to 14-year-olds. In participants with any receptivity at all, 67.2% were receptive to e-cigarette ads and 57.1% were receptive to cigarette ads.

Pierce says more research is needed to figure out why e-cigarette marketing leads to uptake of traditional cigarettes, but says the study reinforces the fact that tobacco marketing continues to be a big factor in tobacco use in youths.
Pierce says pediatricians have busy visits, but they must find a way to work in a discussion on tobacco use. Pediatricians should ask parents and patients these 2 simple questions during visits, he says:

1. “Can you recall any advertising for a tobacco product?

2. “Is there any tobacco advertisement that you like or catches your attention?”

Emphasize the addictiveness of nicotine even after only a few puffs, Pierce adds. “Warn the parents that there is a big risk of future use in that child.”


1. Pierce JP, Sargent JD. Portnoy DB, et al. Association between receptivity to tobacco advertising and progression to tobacco use in youth and young adults in the PATH study. JAMA Pediatrics. March 26, 2018. Epub ahead of print.

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