Association of Flavored Tobacco Use With Tobacco Initiation and Subsequent Use Among US Youth and Adults, 2013-2015

Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review

PURPOSE

While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps.

METHODS

We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded.

RESULTS

A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco.

CONCLUSIONS

This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.

Global market trends of flavor capsule cigarettes and menthol (non-capsule) cigarettes: An ecological analysis using commercial data across 78 countries, 2010–2020

INTRODUCTION

This study describes market trends of flavor capsule cigarettes (FCCs) and menthol (non-capsule) cigarettes (MNCCs) across 78 countries from 2010 to 2020 and examines country-level factors associated with market shares of these products.

METHODS

Market share and retail volume data came from the Euromonitor Passport database and country-level data came from the World Health Organization (WHO), World Bank, and International Monetary Fund. Multivariable linear fixed effects panel regression analyses were conducted to evaluate the relationship between predictor variables and the market shares of menthol (non-capsule) cigarettes and flavor capsule cigarettes.

RESULTS

The overall market share (i.e. the percentage retail volume out of total retail volume of all cigarette types) increased from 0.23% in 2010 to 4.5% in 2020 for FCCs and decreased from 5.0% to 3.8% for MNCCs. Market shares of FCCs grew most rapidly in the Americas region and among upper middle-income countries. Market shares of MNCCs remained stable across most regions and were highest in the Western Pacific and Africa regions. The overall market share of FCCs was positively associated with the unemployment rate (β=0.28; 95% CI: 0.12–0.44, p=0.001), and inversely associated with the percent of the population aged 15–29 years (β= -0.57, 95% CI: -0.98 – -0.15, p=0.008), percent of urban population (β= -0.88; 95% CI: -1.28 – -0.48, p<0.001), GDP PPP per capita (β= -0.13; 95% CI: -0.24 – -0.03, p=0.015), and age-standardized prevalence of cigarette smoking (β= -0.93; 95% CI: -1.38 – -0.49, p<0.001). In contrast, the overall market share of MNCCs was positively associated with urbanicity (β=0.24; 95% CI: 0.08–0.40, p=0.003), and negatively associated with the unemployment rate (β= -0.09; 95% CI: -0.17 – -0.02, p=0.014).

CONCLUSIONS

Global sales of flavor capsule cigarettes grew substantially in the last decade, surpassing menthol (non-capsule) cigarettes, which also continued to be high in many regions. There is a need for increased efforts to address flavors and novel tobacco products, features that are known to appeal to youth.

The impact of two state-level approaches to restricting the sale of flavored tobacco products

Background

Flavored tobacco products are highly appealing to youth. The Federal government lacks a comprehensive flavored tobacco products policy and states have adopted different approaches restricting these products. This study analyzes the impact of Massachusetts’ comprehensive prohibition and New Jersey’s partial restriction on the sale of flavored tobacco products.

Methods

NielsenIQ Retail Scanner data were used to construct four log per capita dependent variables: e-liquid milliliters, cigarette packs, cigars, and smokeless tobacco ounces for products flavored as fruit, menthol, mint, tobacco and other. All models used difference-in-differences regressions, with Virginia and Pennsylvania serving as controls. The models controlled for state level product prices, population percentages by race/ethnicity, proportion male, median household income, unemployment rate, minimum legal sales age, tobacco 21 policies, and cumulative cases and deaths of COVID-19; the models accounted for time-specific factors by using 4-week period fixed-effects.

Results

There was a significant decrease in sales across all flavored tobacco products in Massachusetts, including fruit [-99.83%, p < 0.01], menthol [-98.33%, p < 0.01], and all other flavored [-99.28%, p < 0.01] e-cigarettes. The cigar group “all other-flavors" [-99.92%, p < 0.01] and menthol flavored cigarettes [-95.36%, p < 0.01] also significantly decreased. In New Jersey, there was a significant decrease in per capita sales of menthol-flavored e-cigarettes [-83.80%, p < 0.05] and cigar group “all other-flavors" experienced a significant increase in per capita sales [380.66%, p < 0.01].

Conclusions

This study contributes to the growing body of evidence demonstrating the impact of sales prohibitions on reducing sales of flavored tobacco products. Statewide comprehensive approaches appear more effective than partial restrictions and should be prioritized.

Implications

Results from this study support emerging research that demonstrates the promising effects of comprehensive flavoring sales prohibitions. This study can be used to inform future flavored tobacco product policy solutions developed by advocates and policy makers to curb overall tobacco initiation and use by youth and adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14172-y.

E-cigarette addiction and harm perception: Does initiation flavor choice matter?

Introduction

The 21^st century was marked by a dramatic increase in adolescent e-cigarette use in the United States (US). The popularity of non-traditional flavor types, including fruit and pastry, is thought to contribute toward growing product use nationally, leading to a variety of federal and state regulations limiting the use of non-traditional flavors in the US. The relationship between flavor type and increased adolescent use suggests a possible link between flavor use and addiction and harm perception. This study assessed if the flavor type used when initiating e-cigarette use predicted addiction and harm perceptions.

Methods

The study utilized data from the multi-wave youth Population Assessment of Tobacco Health Study. It explored the impact initiating e-cigarette use with traditional versus non-traditional flavor types among cigarette users on the outcome variables: e-cigarette addiction and harm perception. Both e-cigarette addiction and harm perception were measured using self-report, Likert scale questionnaires. Descriptive statistics characterized the study variables and linear regression analyses performed to test whether flavor initiation type is associated with addiction and harm perception.

Results

The study sample consisted of 1,043 youth (weighted N = 1,873,617) aged 12 to 17 years who reported at least one instance of e-cigarette use. After adjusting for age, age of onset, sex, race and annual household income there was no statistically significant difference in addiction levels between those initiating with traditional versus non-traditional flavors (p = 0.294). Similarly, traditional versus non-traditional flavor initiation did not show a statistically significant difference in adolescent e-cigarette harm perceptions (p = 0.601).

Conclusions

Traditionally flavored e-cigarette initiation produces similar risk for addiction and harm perceptions as non-traditionally flavored initiation. These findings suggest that banning non-traditional flavors alone may be ineffective in curbing e-cigarette addiction and harm perception. Additional research is needed to better understand which e-cigarette product characteristics and behaviors may be associated with greater addiction and reduced harm perceptions.

Menthol preference moderates the relationship between cigarette nicotine content choice and reactions in young adults who smoke infrequently

BACKGROUND

Half of young adults who smoke use menthol cigarettes, which is associated with continued smoking and greater nicotine dependence. Additionally, early subjective reactions to cigarettes predict future use. Menthol may blunt the sensory effects of nicotine. We investigated the moderating role of menthol on subjective reactions to, and choice of varied nicotine content cigarettes in young adults who smoke infrequently.

METHODS

In three counterbalanced, double-blinded sessions, young adults who smoke ≤ 15 days/month smoked fixed doses from very low (VLNC), intermediate (INC), and normal (NNC) nicotine content cigarettes, which were menthol or non-menthol depending on preference. Participants chose their preferred cigarette in a final session. Positive and negative subjective reactions were measured in each session. ANOVA tests investigated the relationship between menthol preference, nicotine content, and subjective reactions.

RESULTS

Participants (N = 87) were 18-25 years old and reported smoking 15.2 cigarettes per month over 8 days (35 % menthol). Non-menthol preferring participants had increased negative reactions with greater nicotine content (F(1, 55)= 10.76, p < .001); menthol preferring participants did not. Choice of higher nicotine cigarettes was associated with having reported a greater difference in positive reactions to NNC and VLNC for non-menthol preferring participants (F(1, 55)= 12.72, p < .001) but not for menthol preferring participants.

CONCLUSIONS

Young adults who smoke infrequently are a priority tobacco control population given their high risk of transitioning to daily smoking. Results from this study in the form of subjective reactions indicate that a menthol ban is required for a nicotine reduction standard to be maximally effective in this vulnerable group.

Longitudinal associations between flavored tobacco use and tobacco product cessation in a national sample of adults

Use of flavored tobacco has been associated with lower likelihood of short-term abstinence from tobacco. It is unknown whether longer-term associations exist, particularly for a variety of products and specific flavor categories. This study used adult survey data from the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). We tested associations of past 30-day tobacco product use at wave 2 using both a 2-category any flavor versus unflavored variable and 4-category specific flavor (menthol/mint, sweet, and both menthol/mint and sweet) versus unflavored variable with past 12-month cessation from the same product two years later at wave 4. Separate models were run for each product (combustible cigarettes, cigars, hookah, e-cigarettes, and smokeless), adjusting for wave 1 sociodemographic characteristics. For all five products, past 30-day use of any flavored (versus unflavored) product at wave 2 was associated with reduced likelihood of same-product cessation at wave 4. Most specific flavor categories were associated with reduced odds of same-product cessation across all products. Any flavor use was also associated with reduced likelihood of longer-term cessation (i.e., past 24-months at both waves 3 and 4) and cessation from all five tobacco products in several analyses. Exploratory moderation results indicated that the association between e-cigarette flavor use and lower likelihood of cessation was stronger for young adults (18-24) versus older adults (25+). Current use of flavored tobacco products is associated with lower likelihood of product cessation. Flavored tobacco products warrant consideration in regulatory policy to reduce the adverse public health impact of tobacco use.

Association of device type, flavours and vaping behaviour with tobacco product transitions among adult electronic cigarette users in the USA

BACKGROUND

Few studies assess whether electronic cigarette (e-cigarette) device characteristics or flavours impact longitudinal patterns of cigarette and e-cigarette use.

DESIGN

We examined data from waves 2-4 of the Population Assessment of Tobacco and Health Study (2014-2018). Among adult (≥18 years) current e-cigarette users at wave 2 who were current smokers (dual users; n=1759) and former smokers (exclusive e-cigarette users; n=470), we classified participants into four use patterns at wave 3 (~12 months later) and wave 4 (~24 months later): (1) dual use of e-cigarettes and cigarettes; (2) exclusive cigarette smoking; (3) exclusive e-cigarette use; (4) non-use of both products. We used multinomial logistic regression to assess correlates of changing use patterns at 24 months, relative to no change, adjusting for sociodemographic factors.

RESULTS

At 24 months, 26.5% of baseline exclusive e-cigarette users, and 9% of baseline dual users, abstained from both vaping and smoking. Participants who vaped non-tobacco flavours (vs tobacco flavours), and used refillable tank or modifiable devices (vs disposable, cartridges and other devices) were less likely to transition to non-use of both products and to exclusive cigarette smoking. Baseline daily vaping (vs non-daily) was positively associated with exclusive e-cigarette use at 24 months for baseline daily cigarette smokers, but negatively associated with exclusive e-cigarette use and non-use of both products at 24 months for baseline non-daily smokers.

CONCLUSIONS

Non-tobacco flavours, daily vaping and modifiable e-cigarette devices may help some smokers abstain from cigarette smoking via transitioning to exclusive e-cigarette use, but are also associated with ongoing exclusive e-cigarette use.

Factors associated with changes in flavored tobacco products used: Findings from wave 2 and wave 3 (2014-2016) of the population assessment of tobacco and health (PATH) study

INTRODUCTION

Flavored non-cigarette tobacco product use is widespread in the U.S. The availability of flavor options could be playing a role in recent increases in use, especially for non-cigarette tobacco products, among youth and young adults. Little is known about specific flavor preferences of youth and adult flavored tobacco product users, as well as how preferences may change over time.

METHODS

This study analyzes PATH Study data from completed Wave 2 (2014-2015) and Wave 3 (2015-2016) youth (12-17 years), and adult (18 + years) interviews to estimate the prevalence of flavored non-cigarette tobacco product use. We assess flavor switching by examining changes between flavors and characteristics of those who changed flavors between waves.

RESULTS

Across age groups, and at both waves, fruit-flavored products were the most frequently used flavor by past 30-day electronic nicotine delivery systems (ENDS), cigar, cigarillo, and hookah users. In the past 30 days, a higher proportion of youth and young adults used candy/sweets-flavored ENDS than adults. Among adult ENDS users, the odds of changing flavors were highest among younger users and decreased with increasing age.

CONCLUSIONS

Flavored tobacco product use is prevalent across non-cigarette tobacco products. Stability in the number of flavors used, as well as specific flavors, is higher among adult tobacco users, while the use of multiple flavors, and change in specific flavor, is more prevalent among youth tobacco users. Additional longitudinal research can further examine the role flavors play in appeal, product trial, and switching.

Brazilian smokers are ready for the ban on flavour additives in tobacco to be implemented

Brazil became the first country to approve a national policy to ban all flavour additives in all tobacco leaf products in 2012. However, as of February 2022, the policy remained to be implemented. Cross-sectional data come from the International Tobacco Control (ITC) Brazil Wave 3 Survey among adult smokers (N = 1216) in 2016-2017. The majority of smokers supported a ban on menthol (56.0%; 95%CI: 51.7-60.2%) and a ban on all additives (61.7%; 57.5-65.8%), with no significant differences across sociodemographic groups in adjusted logistic regression models. More than half of menthol smokers reported they would either quit or reduce the amount they smoked if menthol cigarettes were banned. Findings suggest that there is support for Brazil's ban on flavour additives, which is a determinant of successful policy implemented. Continued delays will postpone an important measure with demonstrated public health gains.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Use of Menthol Cigarettes, Smoking Frequency, and Nicotine Dependence Among US Youth

IMPORTANCE

Menthol may make cigarette smoke less aversive and could lead youth to smoke more frequently and become more dependent on nicotine.

OBJECTIVE

To assess the association of menthol use with cigarette smoking frequency and nicotine dependence (ND) among youth cigarettes users.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a pooled sample of cohorts of US youth (aged 12-17 years at their baseline and follow-up interviews) in the Population Assessment of Tobacco and Health Study (September 2013 to November 2019). Household interviews were conducted using audio computer-assisted self-interviews. US youth who were past-30-day cigarette smokers at any of wave 2 through wave 5, completed the preceding survey (eg, wave 2 past-30-day cigarette smokers completed wave 1), and indicated whether they used menthol cigarettes were eligible. The association of menthol use with smoking frequency and ND was estimated using inverse probability of treatment weighting adjusted mean differences (aMDs), adjusted risk ratios (aRRs), and corresponding 95% CIs. Data were analyzed from December 2021 to March 2022.

EXPOSURES

Menthol use and transitions in use (switching to or from menthol cigarettes).

MAIN OUTCOMES AND MEASURES

Main outcomes were the number of days smoked in the past 30 days, the risk of frequent smoking (smoking ≥20 days in the past 30 days), and symptoms of ND.

RESULTS

There were a total of 1492 observations among 1096 US youth cigarette smokers, of whom 49.4% were female, 67.2% were non-Hispanic White, and 28.7% were aged 12 to 14 years at their baseline survey (all percentages are weighted). Among those who switched from not smoking to smoking (61% of the sample), menthol use was associated with smoking on 3.1 additional days (aMD; 95% CI, 1.9 to 4.2 days), 59% higher risk of being a frequent smoker (aRR, 1.59; 95% CI, 1.23 to 2.06), and 10% higher ND scores (aMD, 1.09; 95% CI, 1.02 to 1.17). Switching from smoking menthol to smoking nonmenthol (vs maintaining menthol use) was associated with smoking on 3.6 fewer days (aMD; 95% CI, -6.3 to -0.9 days) and 47% lower risk of being a frequent smoker (aRR, 0.68; 95% CI, 0.50 to 0.92).

CONCLUSIONS AND RELEVANCE

These findings suggest that the addition of menthol to cigarettes is associated with increased smoking frequency and ND among US youth.

Youth Tobacco Use Before and After Local Sales Restrictions on Flavored and Menthol Tobacco Products in Minnesota

PURPOSE

Minneapolis and St. Paul, Minnesota, implemented sales restrictions on all flavored tobacco products in 2016 ("flavor policy") and expanded the restrictions to menthol tobacco products in 2018 ("menthol policy"). We examined data from surveys of Minnesota youth collected before and after the flavor and menthol policies.

METHODS

We measured changes in youth tobacco use prevalence using data from the Minnesota Youth Tobacco Survey and the Minnesota Student Survey. We analyzed tobacco use overall and, where possible, by product category and flavor category among survey respondents in the Twin Cities area (including Minneapolis and St. Paul) and the rest of the state of Minnesota (ROS).

RESULTS

In the Minnesota Youth Tobacco Survey, overall youth use of any tobacco product significantly increased in ROS (by 26.6%) but did not change in the Twin Cities after the flavor policies. Similarly, the Minnesota Student Survey showed the youth use of any tobacco product increased to a greater extent in ROS (by 44.6%) than that in the Twin Cities (by 34.6%) after implementation of the menthol policies. In both surveys, increases in youth use of particular tobacco products were less pronounced in the Twin Cities relative to the rest of the state.

DISCUSSION

Policies restricting sales of all flavored and menthol tobacco products may be associated with attenuated increases in youth use of tobacco product categories. Policy exemptions and proximity to nonpolicy jurisdictions may have diluted the effect of policies on overall tobacco product use among youth tobacco users.

JUUL's 2019 Removal of Mint-Flavored Pods and Changes to the Retail Environment of Electronic Nicotine Delivery Systems in Florida and the United States

INTRODUCTION

The increase in youth electronic nicotine delivery system (ENDS) use coincided with JUUL's rapid rise, which prompted investigations and lawsuits aimed at this leading brand. In response, JUUL discontinued sweet flavors in late 2018, followed by mint flavors in November 2019. We assessed ENDS sales and prices at both the state and national level before and after JUUL's removal of mint flavors.

METHODS

Nielsen retail sales data on ENDS products from convenience and food stores in 4-week aggregates were analyzed between January 2019 and January 2020 in Florida and the United States. Standardized units were created. Unit market share and growth rates were calculated for top brands and flavors in the periods before and after JUUL's mint removal. Average prices within brand and product type were calculated.

RESULTS

Following JUUL's removal of mint in November 2019, JUUL's market share dropped from over 66% in Florida and the United States to 37.1% (Florida) and 55.1% (United States). In January 2020, the second leading brands were Puff Bar (15.0%) in Florida and Vuse (18.1%) in the United States. Mint market share decreased and share of all other flavor categories increased, particularly menthol and concept. Total ENDS sales increased in Florida but decreased in the United States. Average prices of ENDS devices decreased.

CONCLUSIONS

While JUUL's actions led to a decline in its sales, Puff Bar emerged and menthol and concept flavors experienced growth. Findings also demonstrate how changes by influential brands differentially affect purchase patterns at the national and state level.

IMPLICATIONS

These findings support the growing body of evidence that tobacco industry self-regulation, with selective flavor removal by the leading ENDS brand in this case, is insufficient to reduce total ENDS sales, including sales of flavored products which are preferred by youth. Results suggest that brand and flavor substitution compensated for the removal of mint JUUL pods. Understanding changes to the ENDS market in response to industry actions, at both the state and national level, can inform future regulation and interventions. These findings can also inform efforts to prevent and reduce youth ENDS use.

Cigarillo Flavor and Motivation to Quit among Co-Users of Cigarillos and Cannabis: A Structural Equation Modeling Approach

Flavored cigar restrictions have the potential to benefit public health. Flavor availability facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis, an increasingly prevalent behavior among young adults. Data were collected (2020-2021) in a cross-sectional online survey administered to a convenience sample of young adults who smoked cigarillos from 15 areas with high cigar use prevalence. We assessed the relationship between flavored cigarillo use and motivation to quit cannabis and cigarillo use among past 30-day co-users (N = 218), as well as several covariates (e.g., cigarillo price and flavor/cannabis policy). Flavored cigarillo perceived appeal and harm were hypothesized parallel mediators. Most co-users reported usually using flavored cigarillos (79.5%), which was not significantly associated with motivation to quit cigarillos or cannabis. Perceived cigarillo harm (β = 0.17, 95% CI = 0.00, 0.33), advertising exposure (β = 0.12, 95% CI = 0.00, 0.24), and income (among racial/ethnic minorities; β = -0.13, 95% CI = -0.25, -0.02) were significant predictors of motivation to quit cigarillos. There were no significant predictors of motivation to quit cannabis. Cigarillo flavor was not associated with motivation to quit, so findings could suggest that banning flavors in cigars may have a neutral impact on co-use with cannabis among young adults.

Multiple tobacco product use among cigarette smokers: a longitudinal examination of menthol and non-menthol smokers during young adulthood

BACKGROUND

Multiple tobacco product (MTP) use is common among young adults. Most MTP users are combustible cigarette smokers that use one or more other tobacco products. This study aims to explore menthol as a risk factor for MTP use among a cohort of young adult cigarette smokers.

METHODS

Participants were 18-29 years cigarette smokers at 24 Texas colleges in a 6-wave study. Participants (n=4700 observations) were classified as: single product users (ie, exclusive cigarette smoking); dual product users and poly product users. A multilevel, ordered logistic regression model was used to examine the association between menthol cigarette smoking and MTP use. Two longitudinal, multilevel, multinomial logistic regressions were used to examine the relationship between menthol cigarette smoking and number of tobacco products used.

RESULTS

Overall, 40.7% of the sample were single product users, 33.7% were dual product users and 25.6% were poly product users. Menthol was associated with 1.28 greater odds of MTP use. Further, menthol was associated with 1.19 greater risk of dual and 1.40 greater risk of poly product use, relative to single product use. Lastly, menthol cigarette smoking was associated with 1.18 greater risk of poly product use, relative to dual product use.

CONCLUSIONS

There was a gradient relationship between menthol cigarette smoking and number of tobacco products used among young adult cigarette smokers. Findings provide for greater regulatory and programmatic efforts to reduce the use of menthol cigarettes.

Youth use of e-liquid flavours-a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation

BACKGROUND AND AIMS

There is concern that young people may be attracted to e-liquid flavours, prompting long-term vaping in naive users and potentially subsequent tobacco smoking. We aimed to review the use of e-liquid flavours by young people and describe associations with uptake or cessation of both regular vaping and tobacco smoking, adverse effects and subjective experiences.

DESIGN

Systematic review, including interventional, observational and qualitative studies reporting on the use of e-cigarette flavours by young people (aged < 18 years).

SETTING

Studies published in English language from any country or cultural setting.

PARTICIPANTS

Young people and their carers (aged < 18 years).

MEASUREMENTS

A meta-analysis was not possible due to substantial heterogeneity, inconsistency in reporting of flavour categorizations and non-interventional study designs; thus, we narratively report findings.

FINDINGS

In total, 58 studies were included. The quality of the evidence was extremely low. Most (n = 39) studies were cross-sectional survey designs. In total, 11 longitudinal cohort studies assessed trajectories; eight qualitative studies reported on user experiences. Studies reported views and experiences of a total of 512 874 young people. Both cross-sectional and longitudinal studies suggested that flavours are important for initiation and continuation of vaping. Qualitative evidence shows interest and enjoyment in flavours. There was judged to be insufficient evidence that use of e-liquid flavours specifically is associated with uptake of smoking. No studies found clear associations between flavours and cessation in this population. We found no included reports of adverse effects of flavours.

CONCLUSIONS

Flavours may be an important motivator for e-cigarette uptake, but the role of flavours in tobacco smoking uptake or cessation is unclear. The quality of the evidence on use of e-cigarette flavours by young people is low overall.

Smoking Quit Rates Among Menthol vs Non-Menthol Smokers: Implications Regarding a US Ban on the Sale of Menthol Cigarettes

BACKGROUND

A ban on the sale of menthol cigarettes in the United States is currently under consideration. A justification is that menthol cigarettes are harder to quit, particularly for African American smokers who use menthols much more frequently than White smokers, but epidemiologic data are limited.

METHODS

In a cohort of 16,425 mostly low income African American and White current cigarette smokers enrolled during 2002-2009, we computed smoking quit and re-uptake rates at three follow ups conducted means of 4.6, 7.7 and 11 years after entry. Generalized estimation equations were used to compute odds ratios (OR) and 95% confidence intervals (CI) for quitting and resuming smoking for menthol vs non-menthol smokers adjusted for race, age, education, income, and smoking pack years.

RESULTS

Crude annual quit rates among current smokers were 4.3% for menthol and 4.5% for non-menthol smokers, with adjusted ORs of quitting for menthol vs non-menthol smokers of 1.01 (95% CI = 0.91-1.11) overall, 0.99 (95% CI = 0.87-1.12) among African American and 1.02 (95% CI = 0.88-1.20) among White smokers. Crude annual smoking re-uptake rates were somewhat higher among menthol (8.4%) than non-menthol smokers (7.1%), with an adjusted OR of 1.19 (95% CI = 0.97-1.47), but net quit rates remained similar (OR = 1.01 [95% CI = 0.90-1.13] overall; OR = 1.00 [95% CI = 0.86-1.15] among African American participants; and OR = 1.04 [95% CI = 0.87-1.24] among White participants).

CONCLUSIONS

This large-scale prospective survey revealed similar quit rates among menthol and non-menthol smokers. Results contribute to policy discussions, especially if, as a meta analysis suggests, lung cancer risk is higher for non-menthol smokers and a ban leads menthol smokers to switch to non-menthol cigarettes.

Toxicological Assessment of Flavor Ingredients in E-Vapor Products

Many flavor ingredients are often used in potentially reduced-risk tobacco products (such as e-vapor products). Although most are “generally recognized as safe (GRAS)” when used in food, there is limited information available on their long-term health effects when delivered by inhalation. While obtaining route-of-exposure-specific toxicological data on flavor ingredients is critical to product evaluation, the large number of individual flavor ingredients available and their potential combinations render classical toxicological assessment approaches impractical, as they may require years of preclinical investigations and thousands of laboratory animals. Therefore, we propose a pragmatic approach in which flavor ingredients are initially assigned to groups of structurally related compounds (Flavor Groups), from which flavor group representatives (FGR) are then selected and tested individually and as a mixture in vitro and in vivo. The premise is that structurally related compounds would have comparable metabolic and biological activity and that the data generated using FGRs could support the toxicological assessment of other structurally related flavor ingredients of their respective Flavor Groups. This approach is explained in a step-wise manner and exemplified by a case study, along with its strengths, limitations as well as recommendations for further confirmatory testing. Once completed, this FGR approach could significantly reduce the time and resources required for filling the data gap in understanding the health risks of many flavor ingredients while also minimizing the need for laboratory animals.

Individual Health Determinants that Predict Low Risk of Transitioning to Tobacco Use During Young Adulthood: An in-Depth Examination of Race and Ethnicity

Introduction

The present study examines the contributions of individual-level health determinants on young adult tobacco use initiation to improve understanding of racial and ethnic distinctions and to inform effective tobacco prevention strategies.

Methods

Using time-to-event analyses, the 10–wave (2011–2016) Truth Initiative Young Adult Cohort, a probability-based, nationally representative sample of the US young adults aged 18–34 years (N = 7 665), provides data to examine differences in variables that influence tobacco uptake, by race and ethnicity.

Results

Among Non–Hispanic White young adults, having fewer peers who smoke cigarettes is protective against any tobacco initiation, whereas hazard of tobacco initiation increases for males, having low confidence to resist smoking, and having higher proclivity for sensation seeking. Depressive and anxiety symptoms increase uptake hazard most in the Non–Hispanic All Other Races group and least among Non–Hispanic Black individuals. Among Hispanic young adults, being female and perceiving tobacco as harmful are notably protective while being male is a notable uptake hazard. Unlike other groups, higher income levels do not lower hazards among Hispanic individuals. Cannabis use and overestimating the smoking rate among peers increase hazard least among Hispanic individuals. In the Non–Hispanic All Other Races group, aging is least protective; hazard increases notably if individuals engage in regular alcohol or cannabis use.

Conclusions

Tobacco prevention efforts are critical during young adulthood. Specific tobacco uptake hazard and protective factors exist by race and ethnicity and should be considered when developing selective young adult prevention, particularly among groups with the highest risk for tobacco initiation during this life stage.

Implications

Rising rates of tobacco initiation among the US young adults necessitate expanded efforts to prevent tobacco use initiation and progression beyond youth. Results highlight nuanced and differential tobacco uptake hazards by race and ethnicity for late initiation and sustained non–tobacco use among young adults. The study confirms existing evidence on tobacco use patterns and contributes to new knowledge on risk and protective factors. Tobacco prevention and control interventions, including policies, tailored in more meaningful ways could reduce tobacco use disparities among those most disproportionately affected.

Preferred flavors and tobacco use patterns in adult dual users of cigarettes and ENDS

OBJECTIVES

This study examined how adult dual users of cigarettes and electronic nicotine delivery system (ENDS) flavor preference varied by demographics, tobacco history, motives, and expectancies for ENDS, and how ENDS flavor preference was associated with changes in cigarette and ENDS use over 12 months.

METHODS

Data come from the baseline and 12-month waves of an observational study of adult dual cigarette and ENDS users (N = 406). Flavor preferences were grouped into 4 categories: tobacco (12.6%), menthol/mint (34.7%), sweet (44.8%), and other (7.9%).

RESULTS

Users of sweet-flavored ENDS were significantly younger than those who used tobacco- or menthol flavors. Black dual users were significantly more likely than other racial groups to use menthol and less likely to use sweet flavors. Dual users who preferred sweet flavors smoked cigarettes on fewer days than those who preferred tobacco and menthol flavors, were less cigarette dependent, more strongly endorsed boredom reduction expectancies and motives related to taste and sensory experience and were more likely to stop smoking by 12 months.

CONCLUSIONS

Dual users of cigarettes and ENDS who preferred sweet flavored ENDS differed in demographics, tobacco history, motives, expectancies, and smoking changes. Findings have implications for interventions and regulations.

Behavioral economic assessment of abuse liability for Black & Mild cigar flavors among young adults

Cigars are available in a variety of flavors that may impact uptake and use, but little is known about how different flavors affect abuse liability. This study used 3 behavioral economic tasks to examine abuse liability of Black & Mild cigars differing in flavor among young adult cigarette smokers. Participants were 25 cigar-naïve young adults (aged 18-25 years) who smoked ≥ 5 cigarettes/day. In 5 Latin square-ordered laboratory visits, participants completed 3 abuse liability tasks (drug purchase task, cross-price purchase task, and multiple-choice procedure) for each of 4 cigar flavors (original, cream, wine, or apple) and own-brand cigarettes. In the drug purchase task, relative to own-brand cigarettes, all cigar flavors were associated with lower abuse liability using most measures (intensity, breakpoint, maximum total tobacco expenditure for 1 day [ps < .05]), although only wine-flavored cigars scored significantly lower using 1 measure (price at maximum total tobacco expenditure for 1 day). When cigars and cigarettes were available concurrently in the cross-price purchase task, all cigar flavors functioned as substitutes for cigarettes. Using the multiple-choice procedure, crossover points for wine- (mean = $0.61) and apple-flavored cigars (mean = $0.71) were significantly lower than own-brand cigarettes (mean = $0.86) and original-flavored cigars (mean = $1.00); no significant differences existed between own-brand cigarettes and original-flavored cigars. Thus, whereas abuse liability may be highest for participants' own-brand cigarette, young adult smokers may be willing to use flavored cigars. Furthermore, abuse liability varies by cigar flavor, with original- and cream-flavored cigars appearing to have the highest abuse liability. Characterizing flavors and flavor additives in cigars represent an important tobacco regulatory target. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Internalizing problems are associated with initiation and past 30-Day use of flavored tobacco products

OBJECTIVE

Tobacco use remains disproportionately common among adults with internalizing problems. The rising prevalence of flavored tobacco use among this population may be a contributing factor. Using data from Wave 4 of the Population Assessment of Tobacco and Health Study, this study examined differences across adult ever tobacco users by severity of internalizing problems, in initiation of tobacco use with a flavored product and past 30-day (current) flavored tobacco use (n = 27,425). Severity of internalizing problems was measured using the Global Appraisal of Individual Needs-Short Screener Internalizing Disorder Screener. Tobacco use variables included initiation with or current use of a flavored product, assessed separately for each product. Weighted chi-square tests and multivariable modified Poisson regression models were used to examine the associations between severity of internalizing problems and each outcome.

RESULTS

Controlling for covariates, ever users with severe internalizing problems were more likely to have initiated with flavors for cigarettes (adjusted prevalence ratio [aPR]: 1.16, 95% confidence interval [CI]: 1.09,1.24), cigarillos (aPR: 1.09, 95% CI: 1.03, 1.16), electronic nicotine products (aPR: 1.08, 95% CI: 1.03, 1.13) and smokeless tobacco (aPR: 1.15, 95% CI: 1.04, 1.27), relative to those with low internalizing problems. Ever users with severe internalizing problems were more likely to currently use a flavored tobacco product for cigarettes (aPR: 1.15, 95% CI: 1.07, 1.24) and cigarillos (aPR: 1.15, 95% CI: 1.04, 1.28).

CONCLUSIONS

Flavored tobacco use seems disproportionately common among tobacco users with severe internalizing problems, across a variety of measures.

Classifying the comprehensiveness of flavoured tobacco sales restrictions: development and application of a tool to examine US state and local tobacco policies

OBJECTIVES

Comprehensive tobacco control policies with minimal exemptions can reduce tobacco use and sales. Many states and localities have adopted flavoured tobacco product (FTP) sales restrictions. This study describes the development and application of a schema to characterise the comprehensiveness of these FTP sales restrictions.

DESIGN

We coded state and local FTP sales restrictions enacted June 2007-March 2021 for retailer, tobacco product, and flavour inclusions and exemptions. Guided by FTP literature, legal resources and meetings with FTP policy experts, we developed a six-level classification scheme to characterise coded FTP policies from least to most comprehensive. We present descriptive statistics of FTP policy features and comprehensiveness.

RESULTS

As of 31 March 2021, 7 state-level and 327 local-level FTP sales restrictions were enacted in the USA. Most state-level policies (71.4%) were categorised in the second lowest comprehensiveness category; local policies most commonly fell within the lowest (48.9%) or highest (26.0%) comprehensiveness categories. Across jurisdictions, adult-only retailers were most frequently exempted from the FTP sales restrictions (state: n=1, 14.3%; local: n=184, 56.3%); and most jurisdictions included electronic cigarettes (e-cigarettes) as a banned product (state: n=6, 87.5%; local: n=327, 100%). While just over half of state (n=4, 57.1%) and local (n=169, 51.7%) sales restrictions included menthol e-cigarettes, most excluded menthol cigarettes and/or menthol smokeless tobacco.

CONCLUSIONS

Comprehensiveness of FTP sales restrictions in the USA varies widely. Current and future FTP policies would be strengthened by including all flavours and all tobacco products-particularly menthol cigarettes-and by avoiding exemptions for certain retailers, particularly adult-only retailers.

Smoking cessation strategies used by former menthol cigarette smokers after a menthol ban

INTRODUCTION

Menthol cigarettes were banned in Ontario, Canada on January 1st, 2017. We used concept mapping, a mixed-method approach, to describe how menthol cigarette smokers quit smoking after the Ontario menthol ban.

METHODS

Pre-ban daily and non-daily menthol cigarette smokers who reported smoking abstinence 24 months after the ban (n = 62; 53.2% women; mean age = 43.6, SD = 12.5) generated statements describing reasons and strategies for smoking cessation/reduction after the menthol ban. Participants sorted a final list of 57 statements into groups of similar content and rated statements on how true each statement was for them and multidimensional scaling analysis identified thematic clusters.

RESULTS

Six clusters were identified: Mental and Environment Changes, Direct Ban Impacts, Health Reasons, Cues to Action, Family and Friends, and Cessation Strategies. The highest rated statements (i.e., most true) suggested many participants were motivated to quit smoking before or after the ban and 30.7% of participants believed the menthol ban helped with smoking cessation. Some of the lowest rated statements included using nicotine replacement therapy products, medication (i.e., Champix), or other tobacco products suggesting these strategies were less common. Statement ratings suggested many smokers quit without using replacement products or medication, but modifying cognitions and avoiding smoking cues were common.

CONCLUSIONS

The menthol ban aided some menthol smokers to quit, while others reported the ban did not play a role in smoking cessation. These data suggest the menthol ban had direct and indirect effects on smoking reduction behavior. Campaigns supporting similar bans that target both types of effects will likely be most effective for smoking reduction.

Integrating Self-Report and Psychophysiological Measures in Waterpipe Tobacco Message Testing: A Novel Application of Multi-Attribute Decision Modeling

BACKGROUND

Waterpipe (i.e., hookah) tobacco smoking (WTS) is one of the most prevalent types of smoking among young people, yet there is little public education communicating the risks of WTS to the population. Using self-report and psychophysiological measures, this study proposes an innovative message testing and data integration approach to choose optimal content for health communication messaging focusing on WTS.

METHODS

In a two-part study, we tested 12 WTS risk messages. Using crowdsourcing, participants (N = 713) rated WTS messages based on self-reported receptivity, engagement, attitudes, and negative emotions. In an in-lab study, participants (N = 120) viewed the 12 WTS risk messages while being monitored for heart rate and eye-tracking, and then completed a recognition task. Using a multi-attribute decision-making (MADM) model, we integrated data from these two methods with scenarios assigning different weights to the self-report and laboratory data to identify optimal messages.

RESULTS

We identified different optimal messages when differently weighting the importance of specific attributes or data collection method (self-report, laboratory). Across all scenarios, five messages consistently ranked in the top half: four addressed harms content, both alone and with themes regarding social use and flavors and one addiction alone message.

DISCUSSION

Results showed that the self-report and psychophysiological data did not always have the same ranking and differed based on weighting of the two methods. These findings highlight the need to formatively test messages using multiple methods and use an integrated approach when selecting content.

Inequitable distribution of FTP marketing by neighborhood characteristics: further evidence for targeted marketing

Introduction

Flavored tobacco products (FTPs) are disproportionately used among young people and racial/ethnic minority populations. However, few studies have examined the retail distribution of such product marketing beyond menthol cigarettes. This study created geographic-based predictions about marketing of FTPs (overall, cigarettes, cigars, e-cigarettes, and smokeless) in stores across Washington, DC neighborhoods. We examined neighborhood-level demographic correlates of the amount of FTP and non-FTP marketing.

Methods

We conducted photographic audits of interior and exterior tobacco marketing in 96 Washington, DC tobacco retailers visited by 149 young adult respondents between 2018–2019. We created a geographic predictive surface of overall and product-specific tobacco marketing and then estimated the average predicted amount of marketing at the census-tract level using zonal statistics. Using linear regression, we examined neighborhood demographic correlates (race/ethnicity, family poverty, and youth population under 18) of FTP and non-FTP marketing.

Results

The predicted amount of non-FTP ads/displays were evenly distributed with no neighborhood variability (Range 8.46–8.46). FTP marketing overall was geographically concentrated with greater range across neighborhoods (Range 6.27–16.77). Greater FTP marketing overall and flavored cigar marketing was available in neighborhoods with higher percentages of Black residents. Flavored cigar marketing was less available in neighborhoods with more Hispanic residents, but there was greater flavored smokeless tobacco marketing. Nonflavored marketing overall and by product did not vary across neighborhoods.

Conclusions

This study provides evidence of disproportionate distribution of FTP marketing in Black neighborhoods, especially for flavored cigars, at the point-of-sale. Policies that restrict the sale of FTPs may enhance health equity.

Implications

Tobacco marketing has frequently been shown to be more prevalent in neighborhoods with lower household income and more Black residents. Using geographic-based predictions, we find that greater flavored tobacco marketing in these neighborhoods, not decreased marketing for nonflavored tobacco, is driving this disparity. Targeting Black neighborhoods with increased marketing of flavored tobacco products, which has been found to be more appealing, easier to use, and harder to quit is a social justice issue.

Examining Menthol Preference as a Correlate of Change in Cigarette Smoking Behavior over a One-Year Period

Menthol cigarette use has been shown to be a contributing factor in the changes in smoking over time among youth. The current study aim was to use prospective survey data to identify if menthol cigarette use was associated with changes in smoking among adults. A representative cohort from the 2010 U.S. Tobacco Use Supplement to the Current Population Survey was interviewed at two time points one year apart. Respondents were past-30-day cigarette smokers at Wave 1 or Wave 2 categorized by menthol vs. non-menthol flavor preference (n = 3668). Trajectories were categorized as maintained, increased, or decreased smoking behavior between Waves. Multinomial logistic regressions examined if menthol cigarette use was associated with an increase/decrease in smoking behavior, adjusting for age, race/ethnicity, and sex. Menthol cigarette use was not associated with change over time in cigarette smoking in adult smokers. Age, race/ethnicity and sex were associated with changes in cigarette smoking. Young (vs. older) adults were more likely to increase smoking. Black and Hispanic smokers (vs. white smokers) were more likely to report any change in smoking. Males were less likely than females to change smoking behavior. Menthol status was not associated with changes in smoking among adults; however, young age, race/ethnicity, and sex were, suggesting populations to target for intervention.

Systematic content analysis of online information on herbal smoking products

BACKGROUND

Herbal smoking products (HSPs) are marketed as a safer alternative to tobacco. These are easily available at affordable prices in the online retail websites. This study aimed to analyze the HSP-related informational content available in the most popular online platforms.

METHODS

Google, Yahoo, Bing and YouTube online platforms were searched for HSP related content using appropriate keywords. First 50 search results were retrieved and screened for potential eligibility. The included web-pages were categorized as video and still records. From each included record, information regarding source, primary theme, health benefits/hazards and tone was abstracted. Additionally, video production quality, like ratio and video power index was also computed for each video record. All included records were subjected to descriptive statistics and Chi-square test, as appropriate. Level of significance was set at <0.05.

RESULTS

174 still and 94 video records were included. 35.6% of the included still records were sourced by manufacturers/suppliers while that of scientific origin was 12.1%. 83% of the video-records were posted by general public. About 90% of the included records had not mentioned anything regarding age restrictions. 67.8% of the still records and 87.2% of the video records promoted the use of HSPs.

CONCLUSIONS

The informational content presented online is huge, mostly posted by the general public without any scientific rationale and exclusively favors the use of HSPs. There is no age restriction as to who can access the information, making this content easily accessible to people of all ages. Such spread of information may mislead the public in adopting the smoking of these herbal products. Since HSPs may act as a potential gateway to tobacco smoking, there is an urgent need to regulate the content available online.

Increasing use of flavoured tobacco products amongst youth

Adolescence and early adulthood are the most susceptible phase of life for tobacco initiation and its use during this period can have profound public health implications. Anti-smoking campaigns have helped in reducing the social acceptability of smoking; however, newer nicotine products are becoming increasingly popular, globally. Evidence suggests that flavours play a key role in youth initiation of tobacco use. Flavoured Tobacco Products (FTP) are disproportionately used by the youth and young adults due to their high palatability and misperceptions regarding reduced ill effects of their constituents. Early use of a flavoured tobacco product puts youth and young adults at risk of continued tobacco use and other substance use. The prevalence of FTP use (72.7%) is much higher in young adults as compared to non-flavoured tobacco products.

Nicotine self-administration with menthol and audiovisual cue facilitates differential packaging of CYP2A6 and cytokines/chemokines in rat plasma extracellular vesicles

In this study, we investigated whether intravenously self-administered nicotine with menthol and audiovisual cue modulates nicotine-metabolizing CYP2A6, oxidative stress modulators, and cytokines/chemokines in plasma extracellular vesicles (EVs) in rats. We assigned rats to self-administered nicotine with: (a) audiovisual cue (AV), (b) menthol, and (c) menthol and AV cue. We found increased levels of CD9 in plasma EVs after self-administered nicotine with menthol and AV cue. Moreover, expression of CYP2A6 in plasma EVs was significantly increased after self-administered nicotine in response to menthol and AV cue. However, despite an upward trend on SOD1 and catalase, increase was not found to be statistically significant, while total antioxidant capacity was found to be significantly increased in plasma and plasma EVs obtained after self-administered nicotine with menthol and AV cue. Among cytokine and chemokine profiling, we found a significant increase in the levels of MCP-1 after self-administered nicotine with menthol and AV cue and complete packaging of IL-1β in EVs. Taken together, the study provides evidence that nicotine in response to menthol and AV cues can package altered levels of CYP2A6, and cytokines/chemokines in plasma EVs that may contribute to cell–cell communication, nicotine metabolism, and inflammation upon cigarette smoking.

Electronic Cigarettes and Alternative Methods of Vaping

Vaping, the inhalation of heated aerosols, received widespread attention during the outbreak of electronic-cigarette (e-cigarette) or vaping-associated acute lung injury cases in 2019. E-cigarette use is now widely recognized as a potential cause of acute lung injury. Vaping is often perceived by physicians as referring exclusively to the use of e-cigarette devices. However, inhalation of nicotine or tetrahydrocannabinol-containing aerosol through alternate methods such as "dabbing" and "dripping" are increasingly common. However, the health impact of these alternate methods remains poorly understood. The use of alternate methods and devices may go unrecognized because of lack of clinician familiarity with them. In this review, we discuss e-cigarettes devices, electronic-liquid components, the expanded spectrum of methods used to consume aerosolized substances, and the potential for lung injury.

How Does the Use of Flavored Nicotine Vaping Products Relate to Progression Toward Quitting Smoking? Findings From the 2016 and 2018 ITC 4CV Surveys

INTRODUCTION

There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression toward quitting.

AIMS AND METHODS

Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England, and the United States. Participants were asked about their main vaping flavor categorized as: (1) tobacco or unflavored, (2) menthol or mint flavored, and (3) "sweet" flavors (eg, fruit or candy). We examined whether flavor was associated with progression toward quitting smoking between survey years.

RESULTS

Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared with users of tobacco flavors, those vaping "sweet" flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted odds ratio [aOR] = 1.61, 95% confidence interval [CI] 1.01-2.58, p < .05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR = 0.87, 95% CI 0.43-1.47, p = .69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR = 0.60, 95% CI 0.39-0.92, p = .02). Sweet flavor users were no more likely to continue vaping compared with tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up.

CONCLUSIONS

Use of fruit and other sweet flavored e-liquids is positively related to smokers' transition away from cigarettes.

IMPLICATIONS

With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared with those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.

Menthol and Mint Cigarettes and Cigars: Initiation and Progression in Youth, Young Adults and Adults in Waves 1-4 of the PATH Study, 2013-2017

INTRODUCTION

This study examined in youth (12-17 years), young adults (18-24 years), and adults (25+ years): (1) the prevalence of the first menthol cigarette and menthol/mint cigar use among new tobacco users; (2) association between the first menthol/mint use, subsequent tobacco use, and nicotine dependence ~1 year later compared with the first non-menthol/mint use.

AIMS AND METHODS

Longitudinal analysis of data from Waves 1 to 4 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2017; 10 086 youth and 21 281 adults). Main outcome measures were past 12-month and past 30-day cigarette and cigar use, and nicotine dependence.

RESULTS

Youth and young adult new cigarette users are more likely to smoke a menthol cigarette or indicate that they do not know the flavor compared with adults aged 25+. A greater proportion of adults aged 25+ first used menthol/mint-flavored cigars (13.4%) compared with youth (8.5%) and young adults (7.4%). Among young adults, first use of a menthol cigarette is associated with past 12-month use of cigarettes at the subsequent wave and first use of any menthol/mint-flavored cigars is associated with past 30-day use of these products at the subsequent wave in both youth and young adults. In youth and adults, there were no significant relationships between first use of a menthol/mint cigarette or cigar and nicotine dependence scores at a subsequent wave in multivariable analyses.

CONCLUSIONS

The first use of menthol/mint cigarettes and cigars is associated with subsequent cigarette and cigar use in young people aged 12-24.

IMPLICATIONS

This study examined the relationship between initiation with menthol cigarettes and menthol/mint cigars, subsequent tobacco use, and nicotine dependence in US youth, young adults, and adults who participated in Waves 1-4 of the Population Assessment of Tobacco and Health study. New use of menthol cigarettes was associated with greater past 12-month cigarette use in young adults and new use of menthol/mint-flavored cigars was associated with greater past 30-day cigar use in youth and young adults compared with non-menthol use. Initiation with menthol/mint cigarette and cigar products may lead to subsequent use of those products.

E-cigarette and vaping product use-associated lung injury in the pediatric population: A critical review of the current literature

Use of electronic nicotine delivery systems (ENDS), also known as e-cigarettes, in the adolescent population has significantly increased over the past several years. This rise led to an outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) in the summer of 2019. Since that time, numerous case reports and case series on vaping and EVALI have been published but the majority of literature highlights the adult population with few articles focusing on pediatric patients. Given the addictive nature of these products and the lack of full understanding of the human health effects, there is concern that use of ENDS may have lasting impacts on users, especially adolescents and young adults. The goal of this review is to critically assess published data on ENDS use in children, report our institutional experience, discuss the reasons why the use of ENDS have increased among young individuals, outline the current understanding of EVALI as it pertains to the pediatric population, and discuss future opportunities for health policy implementation.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990-2019

Background

Universally, smoking cessation rates among established smokers are poor. Preventing young people from starting use of and becoming addicted to tobacco products remains a key strategy to end the tobacco epidemic. Previous country-specific studies have found that initiation of smoking tobacco use occurs predominantly among young people and have found mixed progress in reducing the prevalence of smoking tobacco use among young people. Current and comparable estimates for all countries are needed to inform targeted interventions and policies.

Methods

We modelled two indicators: prevalence of current smoking tobacco use among young adults aged 15–24 years, and the age at which current smokers aged 20–54 years in 2019 began smoking regularly. We synthesised data from 3625 nationally representative surveys on prevalence of smoking and 254 on age at initiation. We used spatiotemporal Gaussian process regression to produce estimates of the prevalence of smoking and age of initiation by sex, for 204 countries and territories for each year between 1990 and 2019.

Findings

Globally in 2019, an estimated 155 million (95% uncertainty interval 150–160) individuals aged 15–24 years were tobacco smokers, with a prevalence of 20·1% (19·4–20·8) among males and 4·95% (4·64–5·29) among females. We estimated that 82·6% (82·1–83·1) of current smokers initiated between ages 14 and 25 years, and that 18·5% (17·7–19·3) of smokers began smoking regularly by age 15 years. Although some countries have made substantial progress in reducing the prevalence of smoking tobacco use among young people, prevalence in 2019 still exceeds 20% among males aged 15–24 years in 120 countries and among females aged 15–24 years in 43 countries.

Interpretation

The fact that most smokers start smoking regularly before age 20 years highlights the unique window of opportunity to target prevention efforts among young people and save millions of lives and avert health-care costs in the future. Countries can substantially improve the health of their populations by implementing and enforcing evidence-based tobacco control policies that prevent the next generation from initiating smoking.

Funding

Bloomberg Philanthropies.

Identifying message content to reduce vaping: Results from online message testing trials in young adult tobacco users

INTRODUCTION

Young adults' e-cigarette use is associated with perceptions that e-cigarettes are less harmful or addictive than cigarettes, socially acceptable, and appealing. This study developed and tested vaping educational messages addressing these factors: 1) Harm Perceptions, 2) Addictiveness, 3) Social Use, and 4) Flavors.

METHODS

Two message trials were conducted in U.S. Amazon Mechanical Turk workers aged 18-24 using a 2 (content: addiction, harm) × 3 (theme: alone, + flavors, + social) design with multiple messages in each of the six categories. Participants were assigned to view a random subset of messages and report on likeability and perceived message effectiveness (PME). Phase 1 (n = 200) tested 33 messages and 32 images. Phase 2 (n = 769) tested combinations of Phase 1's 24 most effective messages with 6 images rated most likeable or effective. Linear mixed effects models assessed the effect of content, theme, image, and their interactions on message response.

RESULTS

In both trials, most participants were past 30-day tobacco users. Harm content messages produced higher PME ratings than addiction content messages, and flavor theme messages were correlated with higher likeability scores than "content alone" theme messages. In Phase 2, flavor and social message themes decreased the PME of harm messages. There was no effect of images on either outcome controlling for the independent or interaction effects of content, theme, and image.

CONCLUSIONS

Messages conveying the harms of vaping may be best for reducing vaping in young adult tobacco users; flavor and social themes may diminish their effectiveness.

Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users

Rationale: The use of electronic cigarettes (e-cigarettes) has rapidly increased in the United States, and thousands of e-cigarette flavors are available. However, there remains a dearth of evidence on e-cigarette flavor use patterns among older e-cigarette users.

Objectives: This longitudinal study examined changes in flavor use patterns in long-term e-cigarette users, assessed self-reported adverse reactions, and evaluated users’ anticipated reactions to possible U.S. Food and Drug Administration e-cigarette flavor regulatory scenarios.

Methods: The study population was 383 adult participants who completed two online e-cigarette surveys in 2012–2014 (baseline survey) and in 2017–2019 (follow-up survey). In both surveys, participants were asked, “Thinking about your preferred liquid, what is the name of this liquid flavor?” and to list all flavors used in the past 30 days. Flavor preference was classified using the Penn State Three-Step Flavor Classification method. Participants reported adverse events (open-ended description) with the associated flavor. Regulatory scenarios were presented, and participants selected perceived actions from among a list of 15 options.

Results: Participants’ age averaged 44 ± 12 years; 86% were exclusive e-cigarette users, and 13% reported “poly-use” (i.e., e-cigarette and other tobacco product use). E-cigarette flavor preference migration occurred in all demographic groups: only 36–44% maintained a preference for their original flavor. Preference for tobacco and menthol or mint decreased over time (40% baseline vs. 22% follow-up); preference for fruit remained stable (23% baseline and follow-up), but chocolate/candy or other sweets preference significantly increased (16% baseline vs. 29% follow-up), and other flavors increased slightly. Migration to sweet flavors was more noticeable in younger adults (18–45 yr); exclusive e-cigarette users preferred sweet flavors more commonly than poly-users did (31% vs. 19%). Flavor-associated adverse reactions, mainly respiratory irritations, were reported by 26 (6.9%) participants. Nearly 50% of the participants reported that they would “find a way” to buy their preferred flavor or add flavoring agents themselves if nontobacco flavors were banned.

Conclusions: Flavor migration toward sweet flavors occurred in long-term e-cigarette users, a trend most pronounced in younger and exclusive e-cigarette users. The anticipated maintenance of access to flavors despite regulation suggests an element of e-cigarette–related dependence that requires further evaluation. This information could help clinicians understand the health impacts of e-cigarette flavors, develop appropriate strategies for smoking cessation, and inform the U.S. Food and Drug Administration to plan future regulation of e-cigarette flavors.

Herbal smoking products: a systematic content analysis and mapping of the e-retail market

OBJECTIVE

To assess the online availability and e-marketing strategies of herbal smoking products (HSPs).

METHODOLOGY

Google, Yahoo and Bing were searched using relevant keywords related to HSPs. The first 50 records were retrieved and duplicates were removed. Two trained and calibrated authors screened the records according to the eligibility criteria and extracted data from each selected retail-webpage as per the pre-tested data extraction form.

RESULTS

Out of the initial 1044 records obtained, 73 retail webpages were finally included. Most of the webpages about HSPs hailed from India followed by the USA. The results showed 24 brands with about 189 flavour variants that are readily available online to all age groups including minors, with price per pack (20 sticks) of herbal cigarettes ranging from INR (₹) 51 to 1830 (median 588). There are no regulations regarding the sale and marketing of HSPs concerning age restrictions and display of health warnings.

CONCLUSION

HSPs are readily available online at affordable prices and attractive variants for customers of all ages. The flavour appeal and the health benefit appeal is being used to target minors and young women. There is an urgent need for some regulations on the sale and e-marketing of such products that have an enormous potential to be used as a gateway to tobacco smoking.

Shared Environmental Influences on Electronic Cigarette Use Among Adolescent and Young Adult Females

INTRODUCTION

Electronic cigarettes are now the most commonly used form of tobacco product among youth in the United States. Current evidence suggests that although e-cigarettes are perceived as less harmful and preferred over combustible cigarettes by adolescents, adolescents who try e-cigarettes are at greater risk of transitioning to combustible cigarettes. The genetic and environmental contributions to liability for e-cigarette use have not yet been examined using a behavioral genetic design.

METHODS

Behavioral genetic models of lifetime and current e-cigarette use and friends who use e-cigarettes were examined among female monozygotic and dizygotic twins.

RESULTS

A total of 41 female twin pairs (65.9% monozygotic twins; age = 19.7, SD = 1.6) with complete data on the study variables were included in the present analyses. The majority of the sample (68.1%) had at least some friends who use e-cigarettes. Additive genetic effects on e-cigarette use were not present, but the shared environment explained 98.7% of the variance in lifetime e-cigarette use, 96.6% in current e-cigarette use, and 94.9% in affiliation with friends who use e-cigarettes.

CONCLUSION

This first study on the behavioral genetics of e-cigarette use among adolescents and young adults suggest that environmental factors shared by twins within a family seem to play a predominant role in the initial stages of e-cigarette use, a finding that is consistent with what has been found for tobacco. The findings emphasize the importance of continuing population-based tobacco control interventions to reduce the burden of e-cigarette use among adolescents.

IMPLICATIONS

The shared environment significantly influences the initiation and regular use of electronic cigarettes and affiliation with friends who use electronic cigarettes among adolescent and young adult females. These findings underscore the importance of formulating preventive interventions that mitigate the social effects of familial influences on e-cigarette use through social skills training, education on harms of e-cigarettes for young people, or altering social norms regarding initiation of novel tobacco products.

The Association of E-cigarette Flavors With Satisfaction, Enjoyment, and Trying to Quit or Stay Abstinent From Smoking Among Regular Adult Vapers From Canada and the United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey

Aims

This study examined whether nontobacco flavors are more commonly used by vapers (e-cigarette users) compared with tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers.

Methods

This cross-sectional study included 1603 adults from Canada and the United States who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco–menthol, unflavored, or one of the nontobacco flavors: menthol/mint, fruit, candy, or “other” (eg, coffee).

Results

Vapers use a wide range of flavors, with 63.1% using a nontobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p < .0001) or fruit flavors (26.0%, p = .01) found vaping more satisfying (compared with smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p = .04) or candy flavors (81.1%, p = .003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p = .46). Among exclusive vapers, tobacco and nontobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p = .002) or unflavored (42.5%, p = .005) to vape in order to stay quit.

Conclusions

A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.

Implications

Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

ENDS Flavor Preference by Menthol Cigarette Smoking Status among US Adults, 2018-2019

E-cigarette flavor preference may differ among smokers using e-cigarettes, but little information is available on preferences by menthol cigarette status. Using nationally representative data for US adults from the 2018-2019 Tobacco Use Supplement to the Current Population Survey, we analyzed e-cigarette flavor preference by menthol cigarette status and e-cigarette device type for dual-cigarette and e-cigarette users and e-cigarette users who had recently quit smoking by trying to switch to e-cigarettes ("switchers"). Approximately half (52.2%) of dual users of menthol cigarettes and e-cigarettes reported using menthol/mint-flavored e-cigarettes as did 41.4% of "switchers" who had smoked menthol cigarettes; exclusive menthol/mint flavor use was 13.1% for dual users and 21.3% for "switchers." A similar proportion (45.1%) of dual users who smoked nonmenthol cigarettes used tobacco-flavored e-cigarettes, but only 26.7% of "switchers" who had smoked nonmenthol cigarettes used tobacco-flavored e-cigarettes. Approximately 60% of dual users and "switchers" used fruit/other flavors, regardless of menthol cigarette use. By device type, 63.9% of dual users of cartridge-based e-cigarettes and menthol cigarettes used menthol/mint-flavored e-cigarettes. Approximately 75% of dual users and 85% of "switchers" who used tank or mod systems used fruit/other flavors. Menthol cigarette smokers may be particularly likely to use menthol/mint e-cigarettes, and a majority of dual users and "switchers" used fruit/other flavors. These results can inform policy measures concerning flavored electronic nicotine delivery system products.

Development and Pretesting of Hookah Tobacco Public Education Messages for Young Adults

Young adults’ hookah tobacco use is fueled by misperceptions about risks, appealing flavors, and social use. We developed and pretested public education messages to prevent and reduce hookah tobacco smoking among young adults. We used a two (user status: current hookah user, susceptible never user) by two (risk content: health harms or addiction) by three (message theme: harms/addiction risk alone, harms/addiction risk flavors, or harms/addiction risk social use) design with two messages/condition (n = 12 total messages). Young adults aged 18–30 (N = 713) were randomized to 1 of 12 messages and completed measures assessing message receptivity, attitudes, and negative emotional response. Harms messages were associated with greater receptivity (p < 0.001), positive attitudes (p < 0.001), and negative emotional response (p < 0.001) than addiction messages. Messages with harm or addiction content alone were associated with greater receptivity than social use-themed messages (p = 0.058). Flavor-themed messages did not differ in receptivity from harm or addiction content alone or social use-themed messages. Messages about the health harms of hookah tobacco use resonate more with young adults than addiction risk messages. Social use-themed messages produce the lowest receptivity. These findings can guide population-based approaches to communicate hookah tobacco risks to young adults.

Assessment of Menthol and Nonmenthol Cigarette Consumption in the US, 2000 to 2018

This cross-sectional study examines trends in menthol cigarette use compared with nonmenthol cigarette use in the US.

'I Think Smoking's the Same, but the Toys Have Changed.' Understanding Facilitators of E-Cigarette Use among Air Force Personnel

BACKGROUND

The military has stringent anti-tobacco regulations for new recruits. While most tobacco products have declined in recent years, e-cigarette use has tripled among this population. However, little is known about the factors facilitating this inverse relationship.

OBJECTIVES

Examine the facilitators of e-cigarette use during a high risk period following initial enlistment among young adults.

METHODS

Focus groups were conducted with Airmen, Military Training Leaders (MTLs) and Technical Training Instructors (TTIs) to qualitatively explore unique characteristics of e-cigarettes leading to use in Technical Training.

RESULTS

The most commonly used tobacco product across participants was cigarettes (42.7%), followed by e-cigarettes (28.0%) and smokeless tobacco (22.6%). Almost a third (28.7%) of participants reported using more than one tobacco product. E-cigarette use was much more common among Airmen (76.1%), compared to MTLs (10.9%) and TTIs (13.0%).Four main facilitators around e-cigarette use were identified including: 1) There is no reason not to use e-cigarettes; 2) Using e-cigarettes helps with emotion management; 3) Vaping is a way of fitting in; and 4) Existing tobacco control policies don't work for vaping. E-cigarettes were not perceived as harmful to self and others, which could explain why Airmen were much less likely to adhere to existing tobacco control regulations. Subversion was viewed as the healthy option compared to utilizing designated tobacco use areas due to the potential exposure to traditional tobacco smoke. This coupled with a lack of understanding about e-cigarette regulations and difficulties with enforcement, promoted use among this young adult population.

CONCLUSION

Findings suggest that e-cigarettes are used for similar reasons as traditional tobacco products, but their unique ability to be concealed promotes their widespread use and circumvents existing tobacco control policies. In order to see reductions in use, environmental policies may need to be paired with behavioral interventions at the personal and interpersonal level.

Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation

IMPORTANCE

Several states have banned sales of flavored e-cigarettes, but evidence on the association between vaping flavors and subsequent smoking initiation and cessation is limited.

OBJECTIVE

To evaluate whether new uptake of flavored e-cigarettes is more strongly associated with subsequent smoking initiation and cessation than uptake of unflavored e-cigarettes, separately for youths (12-17 years), emerging adults (18-24 years), and prime-age adults (25-54 years).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study conducted secondary data analyses of longitudinal survey data from waves 1 to 4 of the Population Assessment of Tobacco and Health Study (collected from 2013 to 2018). The analytic sample was limited to 17 929 respondents aged 12 to 54 years at wave 1 who completed at least 3 consecutive waves of the survey and did not use e-cigarettes at baseline. Data were collected from 2013 to 2018 and analyzed in February 2020.

EXPOSURES

Flavored vs unflavored e-cigarette use reported in wave 2 of the Population Assessment of Tobacco and Health Study.

MAIN OUTCOMES AND MEASURES

Binary indicators captured wave 3 smoking among 7311 youths and 4634 emerging adults who did not smoke at baseline (ie, initiation) and not smoking at wave 3 among 1503 emerging adults and 4481 prime-age adults who smoked at baseline (ie, cessation). Smoking status was based on having smoked in the past 30 days for youths and established smoking (ie, current smoking among those who smoked at least 100 cigarettes in their lifetime) for emerging and prime-age adults.

RESULTS

The youths who did not smoke at baseline, emerging adults who smoked at baseline, and prime-age adults who smoked at baseline consisted of 51.4% to 58.0% male participants and 66.9% to 77.0% white individuals. Vaping uptake was positively associated with smoking initiation in youth (adjusted odds ratio [AOR], 6.75; 95% CI, 3.93-11.57; P < .001) and in emerging adults (AOR, 3.20; 95% CI, 1.70-6.02; P < .001). Vaping uptake was associated with cessation in adults (AOR, 1.34; 95% CI, 1.02-1.75; P = .03). Vaping nontobacco flavors was no more associated with youth smoking initiation than vaping tobacco-flavors (AOR in youth, 0.66; 95% CI, 0.16-2.76; P = .56) but was associated with increased adult smoking cessation (AOR in adults, 2.28; 95% CI, 1.04-5.01; P = .04).

CONCLUSIONS AND RELEVANCE

In this study, adults who began vaping nontobacco-flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors. More research is needed to establish the relationship between e-cigarette flavors and smoking and to guide related policy.