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Teenagers who use electronic cigarettes are almost twice as likely to go on to smoke tobacco, a major study shows.

For the new JAMA study, authors set out to find out if using e-cigarettes and similar products eventually led teens to smoke cigarettes.

About 90 percent of adult smokers first tried cigarettes by the time they turned 18, according to the study.

Meanwhile, teen smoking rates have declined amid national anti-smoking efforts: About 5.4 percent of teenagers reported smoking cigarettes in 2017, compared to 5.9 percent in 2016, according to the University of Michigan's annual "Monitoring the Future" survey on teens' use of substances.

"For example, using tobacco products might expose adolescents to a different social group or social norms around cigarette smoking".

None of the participants had ever smoked traditional cigarettes prior to the start of the study. "But when you look at these other products too, like smokeless tobacco and cigarillos, they're having the same magnitude of relationship with future smoking", said Shannon Lea Watkins, a postdoctoral fellow at the Center for Tobacco Control Research and Education at the University of California, San Francisco.

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Despite the large size of the study population, one limitation is the relatively small number of tobacco product users by year end, particularly the 2 percent of youth who admitted sampling one or more of these items in the past month. Their most frequent contacts included: signing up for email alerts; reading articles or watching videos online;, using a smartphone to scan a QR (Quick Response ) code about tobacco products to enter a sweepstakes or drawing from a tobacco company; and visiting a tobacco company website. "And even if kids use these products and don't convert to cigarette smoking, it's not the only relevant health concern".

They added that the study has direct implications for regulatory policy aimed at preventing youth smoking.

And in another report released Tuesday, researchers said that almost 3 million American teens had been exposed to online marketing of tobacco, as cigarette manufacturers have shifted their marketing strategies from traditional forms of media to the internet. In order to get the powers that be to effect some sort of regulation of such contacts, one must have evidence that they do, in fact, affect young people's uptake and use of tobacco products. The majority of teens who use these products buy vapes and e-cigarettes with these kinds of flavorings, according another study from the University of MI in 2016.

"I think the FDA needs to be very careful about how they move forward with the message that these products might be useful for cessation", said McIntosh, who was not involved in the current study.

"The healthiest alternative is always to be tobacco free", he said. In all, approximately 12,000 adolescents provided information about their use of tobacco products.