Additional Information

Each Tab below contains more information and advice regarding several topics of interest involving drugs, alcohol, addiction, etc.  If you need help we hope you will reach out to the coalition with any further questions you may have.

What is addiction?

Content provided by Elizabeth Eidson and Katharine Cammack, Ph.D., The University of the South

Addiction is characterized by intense cravings, an inability to limit or control drug use, a preoccupation with the drug, and continued use despite negative consequences. Although these consequences can be quite serious (e.g., being arrested, losing a job), people struggling with addiction often continue to take drugs despite causing harm to themselves or their loved ones. People can become addicted to alcohol, tobacco, opioid painkillers, illicit drugs (cocaine, heroin, methamphetamine), food, sex, or gambling.[1][2][3]

Addition is a brain disease, not a moral failing. Your brain can change as a result of being exposed to many kinds of drugs. However, drugs that can lead to addiction almost always alter a specific set of pathways in the brain. These pathways, or brain circuits, send and receive information that help you make decisions, regulate your emotions, and process rewards.  After repeated drug use, these circuits can stop working properly. It can take months or even years for some of those brain circuits to function normally again. This is why seeking treatment and support throughout your recovery is so important.

It is also important to note that addiction is different than physical dependence. When someone is physically dependent on a drug, they may experience withdrawal symptoms when they stop the drug. These symptoms are the body’s response to no longer having the drug. This does not mean that they crave the drug or cannot control how much drug they take. For instance, many people with chronic pain take opioid painkillers (e.g., oxycodone) to manage their pain. Taking medications as prescribed does not lead to addiction, but it can lead to physical dependence. You can also be addicted without being physically dependent. Unlike opioid painkillers, cocaine does not cause many noticeable withdrawal symptoms, but cocaine addiction can be very serious.

©2017 The National Center on Addiction and Substance Abuse

“That’s Right, Addiction is a Disease”:–6LEbksds
“Everything you think you know about addiction is wrong”:


[1] Kalat, James (2016) Biological Psychology, 12th edition


Who can develop an addiction?

Anyone can develop an addiction, but there are certain risk factors that make a person more likely to struggle with addiction. One major set of risk factors is your biology. For instance, you are born with genes (DNA) that may make you respond differently to certain drugs and thus more likely to develop addiction. If you have a history of addiction in your family, that may indicate that your family shares genes that make them more vulnerable to addiction. Another major set of factors is your environment. Examples include if you have friends who abuse drugs, or if you have experienced toxic stress or trauma in your life.

It is important to note that not all people who try a drug will become addicted, and no single factor is guaranteed to cause addiction.[4] The influence of many different factors makes addiction difficult to predict and to treat, but it also means that there are many approaches that might help your recovery.

©2017 The National Center on Addiction and Substance Abuse



Is addiction a choice?

No. Often, your first experiences with drugs or alcohol are choices. Over time, your brain can change and adapt to the drug so that the person must continue taking the drug in order to feel “normal.” Your genes also play an important role in how vulnerable (or resilient) you are to addiction. For instance, genes can influence how your body processes the drug, and how your brain responds to the drug. However, many other factors contribute to drug-taking behaviors, such as your friends, psychological wellbeing, and stress level (i.e., if you like to “take the edge off” after getting home from a long day at work).

A chronic disease is the result of a combination of genetics and behaviors that cannot always be cured, but can be treated and maintained.[5] In this way, addiction is similar to other chronic health conditions (heart disease, diabetes, cancer) that are often influenced by health choices like diet, exercise or sun exposure, but also have a strong genetic component.[6]

©2017 The National Center on Addiction and Substance Abuse



How do drugs affect the brain?

Our brain contains billions of cells called neurons. These neurons communicate with each other like how cell phones communicate. One neuron sends a chemical signal to its neighbor, and the second neuron receives the signal. In other words, one phone places a call, and a second phone answers the call.

Drugs mimic the natural chemical signals, but the calls they make are much stronger, more frequent, or longer lasting than normal signals. Over time, the receiving neurons become overstimulated and stop responding to the signal. In the phone example, the phone volume might be really loud or many calls might be made in a row, so the receiving phone may just stop answering the calls. This process is called tolerance.

When tolerance occurs, more drug is needed to stimulate that neuron in the same way. Your brain gets used to the drug and adapts, so increasing amounts of drug are needed to cause the same effect. Tolerance can continue to build, until a person is consuming way more drug than they intended or planned. In the phone example, now five phones might need to call repeatedly to get the message through to the receiving phone, instead of just one. In response to this barrage of calls, the receiving phone may be put on mute or turned off completely.

It takes time and energy to return the brain back to its normal state. The brain may be able to send normal signals again after weeks, months or even years. During this time, it is critical to remain drug-free, so that the brain can heal itself.

Different drugs act like different chemical signals in the brain. A drug will act on every single brain cell that can receive/process its signal. As the brain contains ~100 billion neurons, that could mean a lot of neurons! For instance, a drug like alcohol affects very common chemical signals and could thus affect billions of brain cells at once.

While the brain sends lots of different types of chemical signals, one of the most important – and well studied – is dopamine. Dopamine signals help the brain identify things that are rewarding. Every time something positive or rewarding happens in your life, dopamine signals are released to tell you that this is something that it wants to happen again and is therefore worth pursuing. This can be anything from a good grade on a test to your first kiss to scoring a touchdown. Drugs increase dopamine signals in the brain, telling the brain that the drug is rewarding and should be pursued.

Tolerance builds in the dopamine system, too, so after frequent drug use, the neurons receiving the dopamine signals can adapt and become less responsive to the drug. This has two negative consequences. First, more drug is needed to cause the same original rewarding/euphoric effect, so the user takes more drug to try to achieve the original effect. Second, the brain has trouble recognizing normal dopamine signals anymore – it just recognizes stronger, more frequent signals caused by drugs. This means that other things that you used to enjoy doing (eating a good meal, playing football) aren’t as rewarding anymore. This can lead to depression and lead to further drug use to alleviate these negative feelings.

“Why do our brains get addicted?” by Nora Volkow, Director of the National Institute on Drug Abuse:


Which drugs can lead to addiction?

Many drugs can lead to addiction. Different drugs act on different receptors in the brain, but virtually every abused drug affects dopamine signaling (see “How do drugs affect the brain,” above).


Click on each drug to learn more.[7]




How do I know if I am or someone I know is addicted?

            If you or someone you know is experiencing significant distress due to their drug use, or is continuing to use drugs despite negative consequences, you may want to consult with a health care or treatment professional.



You may wish to consult with a health care provider if you have experienced two or more of the following symptoms in the last year:

  • Often taking more of the substance for a longer period than intended
  • Ongoing desire or unsuccessful efforts to reduce use
  • Great deal of time spent to obtain, use or recover from substance
  • Craving the substance
  • Failing to fulfill obligations at work, home or school as a result of continued use
  • Continued use despite ongoing social or relationship problems caused or worsened by use
  • Giving up or reducing social, occupational or recreational activities because of use
  • Repeated use in physically dangerous situations (e.g., drinking or using other drugs while driving)
  • Continued use despite ongoing physical or mental health problems caused or worsened by use
  • Developing tolerance (feeling less effect from the substance with continued use)
  • Experiencing withdrawal symptoms after reducing use (note: not all drugs produce withdrawal symptoms, e.g., inhalants, hallucinogens)

©2017 The National Center on Addiction and Substance Abuse




How do I get help?

The most important aspect of getting help with addiction is to not be ashamed. Understand that addiction is a brain disorder that can affect one’s ability to make healthy decisions, regulate emotions, and process rewards. If you or someone you love is struggling with addiction, please ask for help – there are many local resources available to help you. It can also be difficult and frustrating to support a friend or family member struggling with addiction. Remember that their brain might be working in slightly different ways as a result of their drug use. Don’t hesitate to reach out a local resource to help support and guide you.

Recovery from addiction can be a long-term process. Avoiding triggers is important. Triggers can be anything in a person’s life that might remind them of the drug. Research suggests that being exposed to a trigger (e.g., needles, burners) causes strong cravings and increases the likelihood that someone will relapse. Over time, the association between these triggers and the drug will fade, as the brain rewires itself, but this process cannot occur overnight. Trying to minimize your exposure to triggers, and finding ways to distract yourself if you are exposed to a trigger, will help protect your brain as it heals.

How can I prevent my child from using drugs?

     Childrens’ brains continue to develop through their early 20s. This means that early exposures to drugs and alcohol can affect normal brain development.

Work to be an involved, positive role model in childrens’ lives. Set the right example by using alcohol responsibly and refraining from drug use. A child with involved parents is less likely to use drugs than a child without involved parents, and children who have activities after school and hobbies which keep them focused and busy are less likely to use drugs. [9]



©2017 The National Center on Addiction and Substance Abuse


Drug overdose deaths in the United States continue to increase in 2015

 91 Americans die every day from an opioid overdose (that includes prescription opioids and heroin).Drug overdose deaths and opioid-involved deaths continue to increase in the United States. The majority of drug overdose deaths (more than six out of ten) involve an opioid.1  Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled.2 From 2000 to 2015 more than half a million people died from drug overdoses. 91 Americans die every day from an opioid overdose.

We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled,2 yet there has not been an overall change in the amount of pain that Americans report.3,4 Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999.5

Heroin use is trending up

From 2002–2013, past month heroin use, past year heroin use, and heroin addiction have all increased among 18-25 year olds.6 The number of people who started to use heroin in the past year is also trending up. Among new heroin users, approximately three out of four report abusing prescription opioids prior to using heroin.7 The increased availability, lower price, and increased purity of heroin in the US have been identified as possible contributors to rising rates of heroin use.8,9 According to data from the DEA, the amount of heroin seized each year at the southwest border of the United States was approximately 500 kg during 2000–2008. This amount quadrupled to 2,196 kg in 2013.10

Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015. The largest increase in overdose deaths from 2014 to 2015 was for those involving synthetic opioids (other than methadone), which rose from 5,544 deaths in 2014 to 9,580 deaths in 2015. One of these synthetic opioids, illegally-made fentanyl, drove the increase.1 It was often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge.

What can be done?

We need to improve prescribing of opioids, expand treatment of addiction, and reduce access to illegal opioids.

  • Improve opioid prescribing to reduce exposure to opioids, prevent abuse, and stop addiction.
  • Expand access to evidence-based substance abuse treatment, such as Medication-Assisted Treatment, for people already struggling with opioid addiction.
  • Expand access and use of naloxone—a safe antidote to reverse opioid overdose.
  • Promote the use of state prescription drug monitoring programs, which give health care providers information to improve patient safety and prevent abuse.
  • Implement and strengthen state strategies that help prevent high-risk prescribing and prevent opioid overdose.
  • Improve detection of the trends of illegal opioid use by working with state and local public health agencies, medical examiners and coroners, and law enforcement.


  1. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December 2016. DOI:
  2. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at
  3. Chang H, Daubresse M, Kruszewski S, et al. Prevalence and treatment of pain in emergency departments in the United States, 2000 – 2010. Amer J of Emergency Med 2014; 32(5): 421-31.
  4. Daubresse M, Chang H, Yu Y, Viswanathan S, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000 – 2010.  Medical Care 2013; 51(10): 870-878.
  5. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at
  6. Centers for Disease Control and Prevention. Demographic and Substance Use Trends Among Heroin Users — United States, 2002–2013. MMWR 2015; 64(26):719-725
  7. Muhuri PK, Gfroerer JC, Davies C. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review, 2013.
  8. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past fifty years. JAMA Psychiatry 2014;71:821–6.
  9. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers — United States, 2002–2004 and 2008–2010. Drug Alcohol Depend 2013;132:95-100.
  10. US Department of Justice Drug Enforcement Administration. National Drug Threat Assessment Summary. DEA-DCT-DIR-002-15 2014.

Underage Drinking

Alcohol is the most commonly used and abused drug among youth in the United States.1

  • Excessive drinking is responsible for more than 4,300 deaths among underage youth each year, and cost the U.S. $24 billion in economic costs in 2010.2,3
  • Although drinking by persons under the age of 21 is illegal, people aged 12 to 20 years drink 11% of all alcohol consumed in the United States.4 More than 90% of this alcohol is consumed in the form of binge drinks.4
  • On average, underage drinkers consume more drinks per drinking occasion than adult drinkers.5
  • In 2010, there were approximately 189,000 emergency rooms visits by persons under age 21 for injuries and other conditions linked to alcohol.6

Drinking Levels among Youth

The 2015 Youth Risk Behavior Survey7 found that among high school students, during the past 30 days

  • 33% drank some amount of alcohol.
  • 18% binge drank.
  • 8% drove after drinking alcohol.
  • 20% rode with a driver who had been drinking alcohol.

Other national surveys

  • In 2015, the National Survey on Drug Use and Health reported that 20% of youth aged 12 to 20 years drink alcohol and 13% reported binge drinking in the past 30 days.8
  • In 2015, the Monitoring the Future Survey reported that 10% of 8th graders and 35% of 12th graders drank during the past 30 days, and 5% of 8th graders and 17% of 12th graders binge drank during the past 2 weeks.9

Consequences of Underage Drinking

Youth who drink alcohol 1,5,10 are more likely to experience

  • School problems, such as higher absence and poor or failing grades.
  • Social problems, such as fighting and lack of participation in youth activities.
  • Legal problems, such as arrest for driving or physically hurting someone while drunk.
  • Physical problems, such as hangovers or illnesses.
  • Unwanted, unplanned, and unprotected sexual activity.
  • Disruption of normal growth and sexual development.
  • Physical and sexual assault.
  • Higher risk for suicide and homicide.
  • Alcohol-related car crashes and other unintentional injuries, such as burns, falls, and drowning.
  • Memory problems.
  • Abuse of other drugs.
  • Changes in brain development that may have life-long effects.
  • Death from alcohol poisoning.

In general, the risk of youth experiencing these problems is greater for those who binge drink than for those who do not binge drink.10

Youth who start drinking before age 15 years are six times more likely to develop alcohol dependence or abuse later in life than those who begin drinking at or after age 21 years.8

Prevention of Underage Drinking

Reducing underage drinking will require community-based efforts to monitor the activities of youth and decrease youth access to alcohol. Recent publications by the Surgeon General1 and the Institute of Medicine5 outlined many prevention strategies for the prevention of underage drinking, such as enforcement of minimum legal drinking age laws, national media campaigns targeting youth and adults, increasing alcohol excise taxes, reducing youth exposure to alcohol advertising, and development of comprehensive community-based programs.


  1. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking. Rockville, MD: U.S. Department of Health and Human Services; 2007.
  2. Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC.
  3. Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 National and State Costs of Excessive Alcohol Consumption. Am J Prev Med 2015; 49(5):e73–e79.
  4. Office of Juvenile Justice and Delinquency Prevention. Drinking in America: Myths, Realities, and Prevention Policy [PDF-1.03MB]. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 2005.
  5. Bonnie RJ and O’Connell ME, editors. National Research Council and Institute of Medicine, Reducing Underage Drinking: A Collective Responsibility. Committee on Developing a Strategy to Reduce and Prevent Underage Drinking. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press, 2004.
  6. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits [PDF-410KB]. Rockville, MD; 2012.
  7. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance United States, 2015. MMWR Surveill Summ 2016;65(No. SS-6):1–174.
  8. Center for Behavioral Health Statistics and Quality. 2015 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD; 2016.
  9. Johnston, LD, O’Malley PM, Miech RA, Bachman, J G, & Schulenberg J E. Monitoring the future national survey results on drug use, 1975-2015: 2015 Overview- Key findings on adolescent drug use [PDF-3.3 MB]. Ann Arbor, MI: Institute for Social Research, The University of Michigan.
  10. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics 2007;119:76–85.

Electronic Nicotine Delivery Systems: Key Facts
CDC Office on Smoking and Health
October 2016

This document outlines key facts related to electronic nicotine delivery systems (ENDS), including e-cigarettes.

  • Youth use of ENDS continues to rise rapidly in the U.S.
    • From 2011 to 2015, past 30-day use of e-cigarettes increased more than ten-fold for high school students (1.5% to 16.0%) and nearly nine-fold for middle school students (0.6% to 5.3%).
    • Nearly 2.5 million U.S. middle and high school students were past 30-day e-cigarette users in 2014, including about 1 in 7 high school students.
    • In 2013, more than a quarter of a million (263,000) middle and high school students who had never smoked cigarettes had ever used e-cigarettes.
  • Most adult ENDS users also smoke conventional cigarettes, which is referred to as “dual use.”
    • In 2014, 3.7% of adults were past 30 day e-cigarette users, including 20.3% of conventional cigarette smokers. Among adult past 30 day e-cigarette users, 58.8% were also current cigarette smokers (i.e., “dual users”) in 2015.
  • Nicotine poses dangers to pregnant women and fetuses, children, and adolescents. Youth use of nicotine in any form, including ENDS, is unsafe.
    • Nicotine is highly addictive.
    • Nicotine is toxic to developing fetuses and impairs fetal brain and lung development.
    • Because the adolescent brain is still developing, nicotine use during adolescence can disrupt the formation of brain circuits that control attention, learning, and susceptibility to addiction.
    • Poisonings have resulted among users and non-users due to ingestion of nicotine liquid, absorption through the skin, and inhalation.E-cigarette exposure calls to poison centers increased from one per month in September 2010 to 215 per month in February 2014, and over half of those calls were regarding children ages 5 and under.
    • According to the Surgeon General, the evidence is already sufficient to warn pregnant women, women of reproductive age, and adolescents about the use of nicotine-containing products such as smokeless tobacco, dissolvables, and ENDS as alternatives to smoking.
  • Any combusted tobacco use at any age is dangerous.
    • The burden of death and disease from tobacco use in the U.S. is overwhelmingly caused by cigarettes and other combusted tobacco products.
    • There is no safe level of exposure to secondhand tobacco smoke.
  • In order for adult smokers to benefit from ENDS, they must completely quit combusted tobacco use. Smoking even a few cigarettes per day is dangerous to your health.
    • Smokers who cut back on cigarettes by using ENDS, but who don’t completely quit smoking cigarettes, aren’t fully protecting their health:
      • Smoking just 1-4 cigarettes a day doubles the risk of dying from heart disease.
      • Heavy smokers who reduce their cigarette use by half still have a very high risk for early death.
    • Benefits of quitting smoking completely:
      • Heart disease risk is cut in half 1 year after quitting and continues to drop over time.
      • Even quitting at age 50 cuts your risk in half for early death from a smoking-related disease.
  • ENDS are not an FDA-approved quit aid.
    • The evidence is currently insufficient to conclude that ENDS are effective for smoking cessation.
    • Seven medicines are approved by the FDA for smoking cessation, and are proven safe and effective when used as directed.
  • ENDS aerosol is NOT harmless “water vapor” and is NOT as safe as clean air.
    • ENDS generally emit lower levels of dangerous toxins than combusted cigarettes. However, in addition to nicotine, ENDS aerosols can contain heavy metals, ultrafine particulate, and cancer-causing agents like acrolein.
    • ENDS aerosols also contain propylene glycol or glycerin and flavorings. Some ENDS manufacturers claim that the use of propylene glycol, glycerin, and food flavorings is safe because they meet the FDA definition of “Generally Recognized as Safe” (GRAS). However, GRAS status applies to additives for use in foods, NOT for inhalation. The health effects of inhaling these substances are currently unknown.
  • ENDS are aggressively marketed using similar tactics as those proven to lead to youth cigarette smoking.
    • Although the advertisement of cigarettes has been banned from television in the United States since 1971, ENDS are now marketed on television and other mainstream media channels.
    • Spending on advertising of ENDS tripled each year from 2011 to 2013.Sales of ENDS also increased dramatically over a similar period.
    • In 2014, more than 18 million (7 in 10) U.S. middle and high school students were exposed to e-cigarette advertisements in retail stores, on the Internet, in magazines/newspapers, or on TV/movies.
    • ENDS marketing has included unproven claims of safety and use for smoking cessation, and statements that they are exempt from clean air policies that restrict smoking.These messages could:
      • Promote situational substitution of ENDS when smokers cannot smoke cigarettes, rather than complete substitution of ENDS for cigarettes.
      • Undermine clean indoor air standards, smokefree policy enforcement, and tobacco-free social norms.
    • In a randomized controlled trial, adolescents who viewed e-cigarette TV advertisements reported a significantly greater likelihood of future e-cigarette use compared with the control group. They were also more likely to agree that e-cigarettes can be used in places where smoking is not allowed.
    • Some ENDS companies are using techniques similar to those used by cigarette companies that have been shown in the 2012 Surgeon General’s Report to increase use of cigarettes by youth, including: candy-flavored products; youth-resonant themes such as rebellion, glamour, and sex; celebrity endorsements; and sports and music sponsorships.
    • Visual depictions of ENDS use in advertisements may serve as smoking cues to smokers and former smokers, increasing the urge to smoke and undermining efforts to quit or abstain from smoking.
  • Given the currently available evidence on ENDS, several policy levers are appropriate to protect public health:
    • Prohibitions on marketing or sales of ENDS that result in youth use of any tobacco product, including ENDS.
      • States laws prohibiting sales of ENDS to minors that feature strong enforcement provisions and allow localities to develop more stringent policies are more likely to help prevent youth access.
    • Prohibitions on ENDS use in indoor areas where conventional smoking is not allowed could:
      • Preserve clean indoor air standards and protect bystanders from exposure to secondhand ENDS aerosol.
      • Support tobacco-free norms.
      • Support enforcement of smoke-free laws.
    • When addressing potential public health harms associated with ENDS, it is important to simultaneously uphold and accelerate strategies found by the Surgeon General to prevent and reduce combustible tobacco use, including tobacco price increases, comprehensive smoke-free laws, high-impact media campaigns, barrier-free cessation treatment and services, and comprehensive statewide tobacco control programs.

1 Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students — United States, 2011–2015. MMWR 65(14);361-367. 2 Bunnell, Agaku, Arrazola, Apelberg, Caraballo, Corey, Coleman, Dube, and King. Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013 Nicotine Tob Res. 3 Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS data brief, no. 217. Hyattsville, MD: National Center for Health Statistics. 2015. 4 National Health Interview Survey, 2015 data. Available at 5 USDHHS. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 6 England, L. et al. Nicotine and the Developing Human: A Neglected Element of the E-cigarette Debate. Am J Prev Med. 2015 Mar 7. [Epub ahead of print]. 7 Centers for Disease Control and Prevention. Notes from the field: calls to poison centers for exposures to electronic cigarettes—United States, September 2010 – February 2014. MMWR 63(13):292-3. 8 USDHHS. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. 9 Bjartveit K, Tverdal A. Health Consequences of Smoking 1-4 Cigarettes per Day. Tobacco Control 2005; 14(5):315-20. 10 Tverdal A, Bjartveit K. Health Consequences of Reduced Daily Cigarette Consumption. Tobacco Control. 2006; 15(6): 472–80. 11 FDA 101: Smoking Cessation Products. Available at: 12 Goniewicz, ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska-Czapla M, Rosik- Dulewska C, Havel C, Jacob P, Benowitz N. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control 2014,23(2): 133–9. 13 Kim AE, Arnold KY, Makarenko O. E-cigarette advertising expenditures in the U.S., 2011–2012. Am J Prev Med 2014;46:409–12. 14 Legacy. Vaporized: E-cigarettes, advertising, and youth. May 2014. Available at: 15 Loomis B et al. National and State-Specific Sales and Prices for Electronic Cigarettes—U.S., 2012–2013. Am J Prev Med 2015 July 7 [Epub ahead of print]. 16 Singh T, Marynak K, Arrazola R, et al. Vital signs: Exposure to electronic cigarette advertising among middle school and high school students – United States, 2014. MMWR Morb Mortal Wkly Rep 2016;64:1403–1408. 17 Farrelly MC et al. A Randomized Trial of the Effect of E-cigarette TV Advertisements on Intentions to Use E-cigarettes. Am J Prev Med 2015 July 8. [Epub ahead of print]. 18 U.S. Department of Health and Human Services (2012). Reports of the Surgeon General. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA), Centers for Disease Control and Prevention (US). 19 Maloney EK, Cappella JN. Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and Perceptions in Daily, Intermittent, and Former Smokers? Health Commun. 2015 Mar 11:1-10. 20 Centers for Disease Control and Prevention. State Laws Prohibiting Sales to Minors and Indoor Use of Electronic Nicotine Delivery Systems — United States, November 2014. MMWR 63(49);1145-1150.