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The 2009 Tobacco Control Act requires the U.S. Food and Drug Administration (FDA) to make tobacco-related regulatory decisions using a population-level Public Health Standard. This article proposes a thought experiment to assist the FDA in determining how it implements this standard: if the FDA had possessed the authority to regulate tobacco in 1990, would it have been able to accurately determine that the sale of "low-tar" cigarettes did not meet the requirements of the Public Health Standard? To answer this question, we analyzed scientific publications and internal tobacco industry documents gathered in a systematic search to inform previous work examining the health effects of filter-ventilated cigarettes. We only included relevant papers published during or before 1990. We examined and synthesized the extracted data using a framework designed specifically to inform tobacco regulatory decision-making. [ABSTRACT FROM AUTHOR]

This article explores the importance of integrating legal education into public health curricula. It argues that understanding public health law goes beyond simply summarizing statutes or court decisions. The article suggests that the Council on Education for Public Health should revise its competencies to include law explicitly and advocates for hiring faculty with legal training to effectively teach legal concepts and skills. Lawyers can support faculty members in incorporating law into their courses and contribute to research projects examining the relationship between law and health outcomes. However, there are challenges to hiring lawyers, such as salary differences and tenure expectations. SPPHs can utilize resources and partnerships to enhance their capacity to teach legal concepts and skills. [Extracted from the article]

Background: The US Food and Drug Administration (FDA) is considering reducing nicotine levels in cigarettes to "minimally or non-addictive levels." However, important research gaps remain, and the FDA must determine when the available research is sufficient to support moving forward.Methods: The authors conducted a systematic review of research articles in PubMed relating to nicotine reduction. Building on a review of risk assessment best practices, the authors also developed a risk assessment framework for tobacco regulation and used it to guide a gap analysis of nicotine reduction research.Results: The final sample consisted of 78 articles. The majority examined either nicotine dependence on very low nicotine cigarettes (VLNCs) or markers of potential health effects of using VLNCs. One-third of the identified articles reported results from four large randomized controlled trials (RCTs). While these studies report promising results and suggest that a nicotine reduction rule would be a powerful tool to reduce cigarette smoking, our gap analysis suggests that there is a need for studies that better reflect the use and availability of a wide range of tobacco/nicotine products and the potential for dual- or multi-product use.Conclusion: The current body of research on nicotine reduction is weighted towards RCTs, which is appropriate for a policy that has not yet been implemented anywhere in the world. The FDA must consider a wide range of factors that may impact a product standard's public health impact, including those difficult to assess in RCTs, such as a nicotine reduction rule's impact on smoking initiation and relapse.Implications: This systematic review presents a gap analysis based on a risk assessment framework to help identify remaining research priorities to inform FDA's potential product standard to reduce nicotine levels in cigarettes. Quickly addressing those gaps would support the FDA's effort to develop a nicotine reduction product standard that will be effective and withstand legal challenges. [ABSTRACT FROM AUTHOR]

State, county, and city governments across the country have filed hundreds of lawsuits against opioid manufacturers, distributors, and retailers. The odds are high that these lawsuits will culminate in a "global settlement agreement" that requires the defendants to pay billions of dollars to states and localities that have been harmed by the opioid epidemic. Though much of that money will--and should--be spent to reimburse communities for opioid-related costs they have already incurred, such a settlement would also provide a tremendous opportunity to strengthen the nation's public health system infrastructure in order to better protect against future public health challenges. The experience of the 1998 Master Settlement Agreement (MSA) with the major tobacco companies, however, suggests that setting aside funds for public health will not be easy. This article reviews the history of how states spent their MSA funds, with a focus on the efforts of public health advocates to ensure that some portion of the funds were spent on tobacco prevention and cessation. These efforts were, in many cases, successful in the short term, but they were not sustained over time. This article will summarize lessons learned from the MSA experience that can be applied to a potential opioid settlement agreement. [ABSTRACT FROM AUTHOR]

State, county, and city governments across the country have filed hundreds of lawsuits against opioid manufacturers, distributors, and retailers. The odds are high that these lawsuits will culminate in a "global settlement agreement" that requires the defendants to pay billions of dollars to states and localities that have been harmed by the opioid epidemic. Though much of that money will--and should--be spent to reimburse communities for opioid-related costs they have already incurred, such a settlement would also provide a tremendous opportunity to strengthen the nation's public health system infrastructure in order to better protect against future public health challenges. The experience of the 1998 Master Settlement Agreement (MSA) with the major tobacco companies, however, suggests that setting aside funds for public health will not be easy. This article reviews the history of how states spent their MSA funds, with a focus on the efforts of public health advocates to ensure that some portion of the funds were spent on tobacco prevention and cessation. These efforts were, in many cases, successful in the short term, but they were not sustained over time. This article will summarize lessons learned from the MSA experience that can be applied to a potential opioid settlement agreement. [ABSTRACT FROM AUTHOR]

Objective: Risk assessment is a process that uses a transparent, reproducible and pre-established methodology to evaluate alternatives for managing health-related risks. Although an array of federal agencies regularly use risk assessment to inform regulatory decisions, its application to tobacco regulation is new. Methods: This paper provides an overview of the risk assessment framework developed by the National Research Council and typically applied by federal regulatory agencies. It then reviews examples of the US Food and Drug Administration's (FDA's) application of this risk assessment framework to both food and tobacco, identifying some of the challenges involved in applying standard risk assessment methodologies to tobacco regulation. Results: There are inherent challenges in applying standard risk assessment methodologies to tobacco regulation, including the need to: (1) apply a unique population-level legal standard; and (2) consider many factors that risk assessments have not emphasized traditionally, including marketing and promotion, packaging/branding, price, social influences, consumer perception, and addiction. Conclusion: For the FDA to address these challenges, it must work with researchers to develop a tobacco-specific approach to risk assessment that reflects the Tobacco Control Act's regulatory framework and the distinctive features of tobacco products and tobacco use. [ABSTRACT FROM AUTHOR]

Introduction: The US Food and Drug Administration (FDA) has purview over tobacco products. To set policy, the FDA must rely on sound science, yet most existing tobacco research methods have not been designed to specifically inform regulation. The NCI and FDA-funded Consortium on Methods Evaluating Tobacco (COMET) was established to develop and assess valid and reliable methods for tobacco product evaluation. The goal of this article is to describe these assessment methods using a US manufactured "snus" as the test product.Methods: In designing studies that could inform FDA regulation, COMET has taken a multidisciplinary approach that includes experimental animal models and a range of human studies that examine tobacco product appeal, addictiveness, and toxicity. This article integrates COMET's findings over the last 4 years.Results: Consistency in results was observed across the various studies, lending validity to our methods. Studies showed low abuse liability for snus and low levels of consumer demand. Toxicity was less than cigarettes on some biomarkers but higher than medicinal nicotine.Conclusions: Using our study methods and the convergence of results, the snus that we tested as a potential modified risk tobacco product is likely to neither result in substantial public health harm nor benefit.Implications: This review describes methods that were used to assess the appeal, abuse liability, and toxicity of snus. These methods included animal, behavioral economics, consumer perception studies, and clinical trials. Across these varied methods, study results showed low abuse-liability and appeal of the snus product we tested. In several studies, demand for snus was lower than for less toxic nicotine gum. The consistency and convergence of results across a range of multi-disciplinary studies lends validity to our methods and suggests that promotion of snus as a modified risk tobacco products is unlikely to produce substantial public health benefit or harm. [ABSTRACT FROM AUTHOR]

The US Food and Drug Administration has announced that it is considering lowering nicotine levels in cigarettes to "minimally addictive or nonaddictive levels." This could be a transformative public health measure, but the tobacco industry is likely to challenge such an action in court. This article reviews some of the key legal arguments that industry is likely to advance and considers possible responses. As we demonstrate, there are strong arguments that the US Food and Drug Administration has the authority to implement a policy to reduce nicotine in cigarettes to nonaddictive levels. [ABSTRACT FROM AUTHOR]

Balancing on a tightrope twenty feet above the ground is outside the comfort zones of many health law professors. Being there forces you to consider in new ways yourself, your skills, and your surroundings. Fears arise, and yet you must still act. And you must trust that the person who offered you this opportunity cared about you and your well-being, and that they would ensure there was a way to get from where you began to the other side. [ABSTRACT FROM AUTHOR]

Objectives.To examine the health insurance coverage options for Medicaid expansion enrollees if the Affordable Care Act (ACA) is repealed, using evidence from Ohio, where more than half a million adults have enrolled in thestate's Medicaid program through the ACA expansion. Methods. The Ohio Medicaid Assessment Survey interviewed 42 000 households in 2015. We report data from a unique battery of questions designed to identify insurance coverage immediately prior to Medicaid enrollment. Results. Ninety-five percent of new Medicaid enrollees in Ohio did not have a private health insurance option immediately before enrollment. These new enrollees are predominantly older, low-income Whites with a high school education or less. Only 5% of new Medicaid enrollees were eligible for an employer-sponsored insurance plan to which they could potentially return in the case of repeal of the ACA. Conclusions. The vast majority of Medicaid expansion enrollees would have no plausible pathway to obtaining private-sector insurance if the ACA were repealed. Demographic similarities between the expansion population and 2016 exit polls suggest that coverage losses would fall disproportionately on members of the winning Republican coalition. [ABSTRACT FROM AUTHOR]

A reprint of the article "The Supreme Court's Crisis Pregnancy Center Case— Implications for Health Law," by Wendy E. Parnet, which appeared on the website NEJM.org on August 29, 2018, is presented. It presents the court case National Institute of Family and Life Advocates v. Becerra (NIFLA) regarding health law for pregnant women.

The article discusses an interdisciplinary and community-engaged public health law course that was developed as part of The Future of Public Health Law Education faculty fellowship program. It states that the law and public health students worked collaboratively to assist a local health department in preparing for the law-related aspects of Public Health Accreditation Board (PHAB) review. It highlights the topics covered in the course such as motorcycle safety and school wellness policies.

Considerable research has examined how cigarette point-of-sale advertising is closely related to smoking-related disparities across communities. Yet few studies have examined marketing of alternative tobacco products (e.g., e-cigarettes). The goal of the present study was to examine external point-of-sale marketing of various tobacco products and determine its association with community-level demographics (population density, economic-disadvantage, race/ethnicity) in urban and rural regions of Ohio. During the summer of 2014, fieldworkers collected comprehensive tobacco marketing data from 199 stores in Ohio (99 in Appalachia, 100 in Columbus), including information on external features. The address of each store was geocoded to its census tract, providing information about the community in which the store was located. Results indicated that promotions for e-cigarettes and advertising for menthol cigarettes, cigarillos, and cigars were more prevalent in communities with a higher percentage of African Americans. Cigarillos advertising was more likely in high-disadvantage and urban communities. A greater variety of products were also advertised outside retailers in urban, high-disadvantage, African American communities. Findings provide evidence of differential tobacco marketing at the external point-of-sale, which disproportionately targets urban, economically-disadvantaged, and African American communities. There is a need for tobacco control policies that will help improve equity and reduce health disparities. [ABSTRACT FROM AUTHOR]

Objective: Evidence-based tobacco regulation requires a comprehensive scientific framework to guide the evaluation of new tobacco products and health-related claims made by product manufacturers. Methods: The Tobacco Product Assessment Consortium (TobPRAC) employed an iterative process involving consortia investigators, consultants, a workshop of independent scientists and public health experts, and written reviews to develop a conceptual framework for evaluating tobacco products. Results: The consortium developed a 4-phased framework for the scientific evaluation of tobacco products. The 4 phases addressed by the framework are: (1) premarket evaluation, (2) pre-claims evaluation, (3) post-market activities, and (4) monitoring and re-evaluation. For each phase, the framework proposes the use of validated testing procedures that will evaluate potential harms at both the individual and population level. Conclusions: Whereas the validation of methods for evaluating tobacco products is an ongoing and necessary process, the proposed framework need not wait for fully validated methods to be used in guiding tobacco product regulation today. [ABSTRACT FROM AUTHOR]

This article discusses the importance of attorney-scientist collaborations in developing research to inform pressing legal and policy issues. The emerging field of 'tobacco regulatory science' is one promising context for fostering such collaborations. This article highlights experiments relating to tobacco advertising and promotion at the point-of-sale that demonstrate the promise of attorney-scientist partnerships. [ABSTRACT FROM AUTHOR]

The article discusses the history of America's commercial speech doctrine in relation to manipulative marketing and the First Amendment to the U.S. Constitution. U.S. Supreme Court (USSC) reviews of commercial speech restrictions are mentioned, along with the strict scrutiny judicial review standard and the relationship between marketing and cognitive psychology. Several USSC cases are examined, including Rubin v. Coors Brewing Co. which deals with the U.S. Constitution's Free Speech Clause.

The article discusses the First Amendment to the U.S. Constitution in relation to commercial speech (CS) regulations and the legal aspects of manipulative marketing and advertising in America. The U.S. Supreme Court and a strict scrutiny standard of review are mentioned, as well as consumer protection laws in the country. The connection between marketing and cognitive psychology is examined, as well as several CS- and advertising law-related legal cases such as Rubin v. Coors Brewing Co.

A belief that the government does (and should) have broad authority to protect and improve health, coupled with an understanding that collective action is often necessary to address public health challenges effectively, is central to the public health mindset. But many are questioning whether this vision of a strong government role is applicable to non-communicable disease threats and the social determinants of health. Arguments about public health paternalism are playing a role in political opposition to new law and policy interventions and in legal challenges aimed at striking down existing public health laws. This article explores the forces behind the cultural and political resonance of concerns about public health paternalism, 'personal responsibility,' and the 'nanny state' and attempts to outlines a potential path forward from here. [ABSTRACT FROM AUTHOR]

Even when turning its attention to public health topics such as preventive care and workplace wellness, the Affordable Care Act law embodies a highly individualistic paradigm of health. The provisions of the law implicitly assign the primary responsibility for prevention to individuals, who should be urged to make more responsible and healthier choices about what they consume and how they live. Relatively little in the law reflects the 'population perspective' set forth in public health scholarship that focuses on environmental and social determinants of health. This article explores the cultural and economic factors that led Congress to embrace a highly individualist conception of public health, and it suggests how public health advocates and legal scholars might seek to reframe the public discourse surrounding preventive health issues. [ABSTRACT FROM AUTHOR]

The article focuses on health care reform in the U.S. in 2011. Topics include the U.S. Patient Protection and Affordable Care Act of 2010, the Health Care and Education Reconciliation Act, and the cost of medical care in the U.S. The author discusses why health care reform should focus on the prevention of chronic disease instead of treatment in order to cut medical costs.

The article analyzes the role of the tobacco-related litigations in the evolution of the health law doctrine in the U.S. Public health law refers to the application of administrative tort law to the field of public health. Tobacco cases have developed an anti-regulatory bias health law that made it hard for plaintiffs to find justice over other types of health-related cases. Particular focus is given to the implications of the Supreme Court's decision in FDA v. Brown & Williamson Tobacco Corp. for the ability of agencies to address public health issues.

The article explores the role litigation may play in addressing the entrance of cigarette companies, such as Philip Morris and R.J. Reynolds, into the market of smokeless tobacco in the U.S. Particular focus is given on health effects and harm reduction of tobacco, legal issues raised by cigarette companies, and the Master Settlement Agreement (MSA) which was signed in 1998.

The article discusses various difficulties experienced by the U.S. Food and Drug Administration (FDA) in its role as gatekeeper regulatory role as it pertained to the U.S. legislation the Tobacco Control Act, particularly an exemption in the act for menthol as a flavor in electronic cigarettes.

The article focuses on behavioral contracts adopted by healthcare ethics consultants (HECs) in hospitals across U.S. to navigate the conflict at the bedside. Topics discussed include scholarly papers published on advocating use of modality in regulation of human behavior, use of device proposed by Ronald Mann, behavioral contract pioneer, in 1970 in outpatient mental health context, and interpersonal conduct management between patients and family member in interaction with medical personnel.

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA's obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the public about the health risks and benefits of products it regulates, it also has other roles (and attendant responsibilities) that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence. [ABSTRACT FROM AUTHOR]

In July 2017 the U.S. Food and Drug Administration announced a new "comprehensive plan for tobacco and nicotine regulation." This plan focuses on making cigarettes less addictive while facilitating the development of alternative, and less-harmful, nicotine-containing products. This approach holds promise, and the public health stakes could not be higher-smoking is the leading cause of preventable death in the United States, resulting in roughly 480,000 deaths per year. But a new consumer product is emerging that could upset the FDA's plans for a well-balanced regulatory scheme: synthetic nicotine. Synthetic nicotine products currently fall into a regulatory gap because they do not appear to meet the Federal Food, Drug, and Cosmetic Act's definition of a tobacco product. If this gap remains in place, it is likely that more companies will choose to market synthetic nicotine products in order to evade regulation, undoing the potential benefits of the FDA's plan for tobacco and nicotine regulation. This Article argues that the FDA can, and should, address this problem by regulating synthetic nicotine products as drugs. After reviewing the science of nicotine addiction and the FDA's past and present regulatory schemes for nicotine, this Article explains how the FDA could establish that synthetic nicotine products are drugs under the FDCA's definition. This Article then concludes with a discussion of the policy benefits of categorizing synthetic nicotine products as drugs. [ABSTRACT FROM AUTHOR]

Objective: We aimed to improve understanding of young adults' perceptions and interpretations of the contexts surrounding use. Methods: We conducted focus groups with young adult hookah users (ages 18-28) to examine hookah-use experiences and risk perceptions. Results: Two dominant themes that emerged from the discussions were the social aspects of use (eg, "ending up" at a hookah café while out with friends), and the mental and physiological reactions to use (eg, relaxation and a "high" feeling). Participants often argued that because they only used hookah every few weeks, hookah use was much less dangerous than cigarette use. Conclusions: Findings suggest that hookah research should account for heuristic processing and point to several areas where better health communication and stricter regulatory policies are needed. [ABSTRACT FROM AUTHOR]

The article discusses the prevalence of cigarette smoking in the U.S. and the challenges associated with quitting. Topics discussed include the importance of the U.S. Food and Drug Administration (FDA) in helping people quit smoking by regulating nicotine and tobacco products, the division of authority between the Center for Tobacco Products (CTP) and the Center for Drug Evaluation and Research (CDER) within the FDA, and limited oversight of cigarettes.

Examine trends in e-cigarette use, and Juul use specifically, among U.S. college students. In 2016, we established a cohort of 529 incoming first-year students to a large Midwestern University. In 2018, these students (now third-years) were re-contacted, and a new sample of 611 incoming first-year students was enrolled. First-year students in 2016 completed a survey assessing their e-cigarette use; in 2018, first- and second-year students reported on e-cigarette use, and use of Juul specifically. From 2016 to 2018, past 30-day e-cigarette use rose from 5.9% to 27.7%. In 2018, for Juul alone, ever use was above 35% and past 30-day use was above 20% for both cohorts. Juul use did not differ by gender, but was associated with higher socioeconomic status (SES) and being White. Findings present disturbing possibilities for long-term nicotine addiction among the next generation, and underscore the need for a rapid public health response. [ABSTRACT FROM AUTHOR]

Introduction: Tobacco 21 (T21), which sets the minimum legal sales age for tobacco to age 21, is now a national law in the United States. Although T21 is expected to help curb youth tobacco use, its impact may be dampened due to poor retailer compliance. Even within environments where enforcement is strong (ie, compliance checks are conducted with tough sanctions for violations), compliance might vary due to other factors.Aims and Methods: Three studies were conducted in Columbus, OH, where T21 became strongly enforced in 2018. These studies examined how retailer compliance related to features of the neighborhood in which a retailer was located (Study 1), features of the retailer (Study 2), and features of the retail cashier (Study 3).Results: Study 1 found that, after controlling for race- and age-based factors, retailers located in high (vs. low)-poverty neighborhoods had a lower likelihood of conducting identification (ID) checks. Study 2 found that ID checks were related to whether retailers displayed signage about T21, as required by the city law. Study 3 found that, among cashiers, T21 awareness (which was high) and perceptions about T21 (which were moderate) were not generally related to their retailer's compliance; having (vs. not having) scanners for ID checks was related to a higher likelihood of compliance.Conclusions: These studies emphasize the many, multilevel factors influencing T21 outcomes. Findings also indicate the potential for T21 to widen disparities in tobacco use, indicating the need for strategies to equitably improve T21 compliance.Implications: T21, which sets the minimum legal sales age for all tobacco products to age 21, is now a national law in the United States. Despite optimistic projections about what T21 could achieve, the ultimate impact may be dampened when it is applied in real-world settings. Our project revealed the many, multilevel factors influencing T21 compliance. Findings also indicate the potential for T21 to widen disparities in tobacco use if gaps in compliance persist. Strategies for equitably improving T21 compliance are discussed. This article is of relevance to areas interested in implementing or improving their local T21 enforcement. [ABSTRACT FROM AUTHOR]

The article discusses the adverse effects of electronic cigarettes on the disease-naive oral microbiome. Topics discussed include effects of e-cigarette exposure in the oral cavity; information about brisk proinflammatory signal in clinically healthy e-cigarette users, equivalent to patients with severe periodontitis; and the safety of e-cigarettes and the harm reduction narrative promoted by advertising campaigns.

Background: Previous studies have examined what adolescents find appealing in tobacco and alcohol advertisements and how different themes in advertisements are used to manipulate consumer behaviors. Yet, we know little about the relationship between the themes portrayed in advertisements and youth attitudes towards those themes. Objectives: This study compared attitudes towards advertisements for different consumer products in a sample of urban and rural adolescent boys in order to examine how key marketing themes impact adolescent attitudes towards those advertisements. Methods: Participants were 11- to 16-year-old boys (N = 1220) residing in either urban or rural Ohio Appalachian counties. Each participant viewed five print advertisements (one each for cigarettes, electronic cigarettes (e-cigarettes), smokeless tobacco (SLT), non-alcoholic beverages, and alcohol), presented in a random order, for eight seconds each. All advertisements had appeared in magazines that adolescent males commonly read. Attitudes towards each of the five advertisements were assessed. The advertisements were then coded for the presence of various themes, including social acceptance and masculinity. Analyses were conducted to determine associations between advertisement type and the attitude measure, and between the presence of a theme and the attitude measure. Results: Overall, participants preferred non-tobacco advertisements to tobacco advertisements, rural participants had less positive attitudes and participants who had peers who used tobacco had more positive attitudes. Social acceptance and entertainment themes increased the appeal of SLT advertisements, and sex appeal increased the appeal of e-cigarette advertisements. Conclusions/Importance: Findings suggest that advertisements that promote the social nature of use in SLT advertisements may be of particular concern for their influence on adolescent boys. [ABSTRACT FROM AUTHOR]

Objectives: Few e-cigarette social media posts are authentic posts to friends; most come from commercially sponsored influencers. Potential disclosure strategies need to be tested to confirm whether users recognize such posts as commercially sponsored.Methods: Between July - August 2019, young adult (ages 16-24; n = 200) participants were recruited to view their native Instagram feed on a laboratory mobile device. Posts from e-cigarette influencers were manipulated to add either #ad or #sponsored while eye tracking software measured visual attention. Participants self-reported their interpretation of the hashtags in open-ended responses. Logistic regression analyses compared recognition of commercial content by condition, and qualitative content analyses summarized the key themes related to the hashtags.Results: The #ad condition had nearly twice the odds of commercial recognition compared to #sponsored (OR = 1.98, CI: 1.14-3.38). Every second of attention paid to the hashtag significantly increased the odds of commercial recognition by 22% (OR: 1.22, CI: 1.00-1.33).Conclusion: The #ad disclosure attracted visual attention and significantly increased recognition of commercial sponsorship from young social media users. Labeling commercially sponsored content on social media is a promising strategy to better inform users about paid social media influence. [ABSTRACT FROM AUTHOR]

Introduction: Electronic cigarette (e-cigarette) use among adolescents is associated with increased risk of subsequent cigarette smoking initiation in observational research. However, the existing research was not designed to answer causal questions about whether adolescent e-cigarette users would have initiated cigarette smoking if they had never used e-cigarettes. The current study used a causal inference framework to identify whether male adolescent e-cigarette users were at increased risk of initiating cigarette smoking and smokeless tobacco (SLT) use, compared to similar boys who had never used e-cigarettes.Methods: Boys from urban and Appalachian Ohio (N = 1220; ages 11-16 years at enrollment) reported use of e-cigarettes, cigarettes, and SLT at baseline and every six months for two years. A propensity score matching design was implemented, matching one e-cigarette user to two similar e-cigarette non-users. This analysis was completed in 25 multiple imputed datasets to account for missing data. Risk ratios (RRs) comparing risk of initiating cigarettes and SLT for e-cigarette users and nonusers were estimated.Results: Compared to non-users, e-cigarette users were more than twice as likely to later initiate both cigarette smoking (RR = 2.71; 95% CI: 1.89, 3.87) and SLT (RR = 2.42; 95% CI: 1.73, 3.38). They were also more likely to become current (i.e., past 30-day) cigarette smokers (RR = 2.20; 95% CI: 1.33, 3.64) and SLT users (RR = 1.64; 95% CI: 1.01, 2.64).Conclusions: Adolescent boys who used e-cigarettes had increased risk of later initiating traditional tobacco products when compared to similar boys who had never used e-cigarettes. [ABSTRACT FROM AUTHOR]