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A 2015 report by the National Academy of Medicine (previously called the Institute of Medicine) concluded that increasing the tobacco age of sale to 21 would, over time, significantly reduce the number of youth and young adults who start smoking, as well as smoking-caused deaths

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The product is typically available in soft and hard pack configurations , as well as carton formats, often with layered or compartment-style packaging designs in certain editions

"Enticed by fruit, candy and other appealing flavors, high school and middle school students throughout the U.S

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Additionally, it disrupts the gutliver axis, leading to endotoxemia and Kupffer cell activation [67]