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Jayne Morgan, MD, a cardiologist and vice president of medical affairs at Hello Heart who specializes in womens health and cardiovascular research, said the first few cigarettes can in fact do the most damage

Further, the questionnaires we use and how we conceptualise tobacco use are often derived from cigarettes (eg, smokeless tobacco and early ENDS dependence questionnaires were adapted from cigarette dependence measures).133 This may also need to change, as the use of new products may not be comparablewe see this already with ENDS that are puffed throughout the day rather than in discrete bouts.134 The growth of polytobacco use (ie, regular concurrent use of two or more tobacco products) further complicates studying product useasking about use behaviours for three products within a survey can be time consuming, but ignoring quantity and frequency of use of multiple products within individuals may present a misleading picture of tobacco use in the population

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