News Release

Tobacco and e-cig promotions spark teens' use of nicotine products, Stanford study finds

Peer-Reviewed Publication

Stanford Medicine

Owning items that promote e-cigarettes and other alternative tobacco products doubles the likelihood that a young person will try these products, a new study led by the Stanford University School of Medicine has found. The finding illustrates the influence of such marketing on teenagers.

The study, which will be published online May 17 in JAMA Network Open, followed 757 California teens for a year. At the beginning of the year, participants had never used alternative tobacco products, including e-cigarettes, chewing tobacco, cigars, cigarillos, pipes and hookahs.

But some participants owned marketing materials for these products, such as coupons, samples and branded hats or T-shirts.

"We wanted to see how owning promotional materials would affect young people's use later on," said the study's lead author, Hoda Magid, PhD, a postdoctoral scholar in health research and policy. Among teens, cigarette smoking rates have dropped in recent decades, but their use of e-cigarettes and other tobacco products has risen sharply. "The increase in use of alternative tobacco products poses a threat to the decades of hard work that public health experts have done to reduce tobacco use," Magid said.

"We need to know trajectories of use of alternative tobacco products," said the study's senior author, Bonnie Halpern-Felsher, PhD, professor of pediatrics. Understanding when and why youth start using such products is important for stemming the tide of addiction to them, she said.

Restrictions on conventional smokes

While marketing to minors and providing samples is illegal for all tobacco products, providing coupons and branded promotional items such as T-shirts and hats is not illegal for most alternative tobacco products, except smokeless tobacco. Enforcement of all policies is lacking, Halpern-Felsher said.

"The problem is that the FDA has been very slow to enact new or enforce existing laws and regulations for e-cigarettes," Halpern-Felsher said. "Right now, the FDA is not going after manufacturers who have not put in an application to market e-cigarettes." The Family Smoking Prevention and Tobacco Control Act requires all tobacco companies to submit premarket applications to FDA and receive agency authorization before putting a product on the market, but the compliance dates have been extended to 2021 or 2022, depending on the product. This means thousands of e-cigarettes and other alternative tobacco products are being marketed without any FDA review.

When the study began, participants were 13 to 19 years old and attended California high schools. They completed questionnaires asking whether they had ever used traditional cigarettes or any alternative tobacco products, and whether they or their friends owned promotional items -- such as coupons, free samples, T-shirts, posters and hats -- for any type of nicotine product. The researchers asked similar questions about the use of cigarettes and alternative tobacco products a year later and analyzed changes in the teens' use of e-cigarettes and other tobacco products as a function of owning or receiving promotional materials.

At the start of the study, 81 of the 757 participants owned items that promoted tobacco products, including 52 who owned promotional items for e-cigarettes. Over the course of the study, 129 participants, or 17 percent, began using alternative tobacco products but not traditional cigarettes. Twelve participants began using traditional cigarettes alone or in combination with alternative tobacco products. Before adjusting for confounding factors, teens who owned promotional items were found to be 2.23 times as likely to try alternative tobacco products as those who did not own such items. After adjusting for age, gender, race/ethnicity, maternal education level and baseline alcohol and cigarette use, the teens who owned promotional materials were 2.13 times as likely as their peers to begin using alternative tobacco products. When teens who had tried both alternative tobacco products and cigarettes during the year were included in the analysis, the influence of owning promotional materials did not reach statistical significance.

The findings provide evidence that ownership of marketing materials is strongly associated with more young people using e-cigarettes and other alternative tobacco products, the researchers said. The findings clearly show that no tobacco company, including any e-cigarette company, should be allowed to provide coupons, free samples or other marketing materials to teens, and suggest that the FDA should further restrict and enforce such marketing techniques, Halpern-Felsher said.

"Manufacturers say they're not marketing to teens, but teens are reporting owning these promotional items, and they're reporting use of alternative tobacco products," Magid said. Current restrictions and laws that make marketing cigarettes and other tobacco products to minors should be enforced for all nicotine-containing products, she added.


Halpern-Felsher is a member of Stanford's Maternal & Child Health Research Institute and the Stanford Cancer Institute. Researchers from the University of California-Berkeley and the University of California-San Francisco also contributed to the study. Magid was a graduate student at UC-Berkeley at the time the research was conducted.

The research was supported by grants from the National Cancer Institute (grant 1P50CA180890) and the Food and Drug Administration.

Stanford's Department of Pediatrics also supported the work.

The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit The medical school is part of Stanford Medicine, which includes Stanford Health Care and Stanford Children's Health. For information about all three, please visit

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