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

What Is (Un)Flavored? A Scoping Review of the Conceptualization of Flavored Cigarillos

INTRODUCTION

To identify how flavor is conceptualized with respect to cigarillos to illuminate areas of concordance and discordance and provide a pathway for the harmonization of tobacco flavor measurement.

AIMS AND METHODS

Three methods were used to identify research measuring flavors respective to cigarillo products including: (1) querying research databases using key words "cigarillo," "tobacco" and "flavor"/'flavour,' (2) sub-sampling of the eligible literature with backward and forward reference searching, and (3) a bibliographic search of key experts. Two reviewers independently screened titles, abstracts, and full texts. Inclusion criteria required manuscripts to be available in English, published prior to 3/1/2022, be original and peer-reviewed, and include a measure of flavor pertaining to cigarillo products. A total of 163 manuscripts met these criteria and were subsequently evaluated.

RESULTS

Cigarillo flavor determinations were made based on the presence of flavoring agents, sensory characteristics, marketing or package characteristics, pre-defined lists, the absence of any of these, and/or were undefined. Individual flavors and their related classifications were not altogether mutually exclusive due to differences in conceptualization which has evolved over time.

CONCLUSIONS

Flavor measures continue to evolve, likely in response to both tobacco control policies and industry shifts. There is a lack of standardization in flavor conceptualization that can be ameliorated through intentional integration of multiple forms of research such as identifying patterns of flavoring agents and/or marketing strategies that elicit a specific flavor profile. By doing this, we may more comprehensively evaluate the impact of flavors, their constituents, and related marketing strategies on broader population health.

IMPLICATIONS

There are discrepancies in the conceptualization of flavor in tobacco and nicotine products. The lack of standardized, definitive language limits our ability to comprehensively evaluate the population-level health impact of flavors in addition to our ability to effectively inform, implement, and enforce policies restricting flavors in tobacco and nicotine products.

Bitter taste of the tobacco industry interference in Brazil

OBJECTIVE

Although Brazil became the first country worldwide to ban the sale of all tobacco products with any additive that could alter their flavours and tastes in 2012, its implementation was effectively halted by tobacco industry lawsuits, including a constitutional challenge filed in the Federal Supreme Court in 2013. This study aimed at examining, for the first time in the country, the evolution over time of the new registrations of tobacco products with additives that would have been banned if not for the tobacco industry's interference ('counterfactual scenario').

METHODS

We used the newly available public database on the registration of tobacco products developed by the Health Regulatory Agency (from 2008 onwards). All types of tobacco products intended for the domestic market that contained 'banned additives in a counterfactual scenario' and were registered between January 1 and December 31 of each year were selected.

RESULTS

Between 2012 and 2023, a total of 1112 new registrations of tobacco products with 'banned additives' were recorded. The spread of hookah tobacco registrations started in 2014, and by 2023, the cumulative incidence of registrations containing 'banned additives' was 641. Both manufactured cigarettes and hookah products reached their peaks in new registrations in 2020.

CONCLUSIONS

After 12 years since the resolution intended to ban all additives that change the aroma and taste of tobacco products in Brazil, primarily to prevent smoking initiation, the tobacco industry's interference continues to successfully block its implementation. Countries facing similar challenges in tobacco control could consider generating comparable national data that might help expose the adverse impacts of tobacco industry interference on public health.

Associations between tobacco 21 and state flavour restrictions with young adult tobacco use

BACKGROUND

States have recently enacted tobacco-related age and flavour restrictions in addition to federal T21 laws. Little is known about the independent effects of these policies on young adult tobacco use.

METHODS

Linking 2011-2022 Behavioural Risk Factor Surveillance System data on 2 696 870, 18-59 years from 50 states and DC with policy data, we conducted probit regression models to evaluate the associations between state and federal T21 laws and state flavour restrictions with cigarettes, electronic nicotine delivery system (ENDS) and smokeless tobacco use. Models were adjusted for sociodemographics, additional tobacco policies, COVID-19-related factors, year and state. We tested two-way and three-way interactions between age, state T21 and federal T21 laws.

RESULTS

Although we did not find evidence that state T21 laws were associated with cigarette, smokeless tobacco or ENDS use overall, the federal T21 law was associated with lower use of all three tobacco products by 0.39-0.92 percentage points. State flavour restrictions were associated with lower use of cigarettes by 0.68 (-1.27 to -0.09) and ENDS by 0.56 (-1.11 to -0.00) percentage points, but not with smokeless tobacco. A three-way interaction revealed that state and federal T21 laws together were associated with a lower prevalence of ENDS use among 18-20 years, but there were no differences in cigarette use from both policies combined versus either alone.

CONCLUSION

State and federal T21 laws are broadly effective at reducing adult tobacco use, while state flavour restrictions specifically lower use of cigarettes and ENDS.

A Longitudinal Analysis of Flavored Cigar Use and Cigar Smoking Cessation Among US Adults

BACKGROUND

Flavorings in cigars increase their appeal, mask the harsh taste of tobacco, and may hinder successful cigar smoking cessation; however, limited evidence has examined whether flavors are associated with short- or long-term cigar smoking cessation.

AIMS AND METHODS

Using restricted data from the Population Assessment of Tobacco and Health Study Waves 1-5, we examined whether flavored cigar use was associated with 30-day-plus and 1-year-plus cigar smoking cessation among US adults. Multivariable discrete-time survival models were fit to a nationally representative sample of US adult (18+) respondents who had a current, established cigar use, smoked five or more days in the past 30 days, and did not exclusively smoke traditional premium cigars at baseline. Models adjusted for age, sex, race and ethnicity, income, cigar and cigarette smoking intensity, and blunt use.

RESULTS

At baseline, 44.6% of respondents (n = 674) were 18-34 years old, 75.0% were male, 56.7% were non-Hispanic White, 78.9% had household incomes of <$50,000, and 56.2% smoked flavored cigars. In fully adjusted models, flavored cigar use was associated with a lower risk of 30-day-plus (HR = 0.76, 95% CI = 0.60, 0.97) but not 1-year-plus cigar smoking cessation (HR = 0.81, 95% = 0.62, 1.05).

CONCLUSIONS

We found that flavored cigar use was associated with a lower risk of short-term but not long-term cigar smoking cessation. More work is needed to understand the dynamics of cigar smoking transitions, including initiation, cessation, and relapse, particularly in larger cohorts and among those who exclusively use cigars or dual-use cigars and cigarettes.

IMPLICATIONS

As local and some state jurisdictions continue to adopt partial or complete bans of flavored cigar products and the United States Food and Drug Administration considers a national ban of all characterizing flavors in cigars, there is a need for more longitudinal work examining the associations between flavorings in cigars and short and long-term cigar-smoking behaviors, including but not limited to initiation, cessation, intensity of use, and relapse, particularly in diverse cohorts.

Cigarettes and waterpipe use and risk of colorectal cancer in Iran: the IROPICAN study

We aimed to investigate the association between cigarettes and waterpipe use and colorectal cancer (CRC) in an Iranian population. We analyzed data from a multicenter hospital-based case-control study in Iran (IROPICAN). Data on tobacco smoking, including cigarettes, and waterpipe smoking, were collected in detail. Multivariate logistic regressions estimated the odds ratios (ORs) and 95% confidence intervals (CIs) for the association between cigarette and waterpipe smoking and CRC, accounting for confounders including age, sex, socioeconomic status, opium use, marital status, family history of cancer, red meat, fiber, body shape at age 15 and perceived physical workload, and each other of the two exposures. The study population consisted of 3215 controls and 848 cases, including 455 colon and 393 rectum cancers. We found no association between CRC and cigarette smoking (OR, 0.8; 95% CI, 0.6-1.0) or waterpipe smoking (OR, 1.1; 95% CI, 0.9-1.5). Analysis by categories of cigarette pack-year and frequency of waterpipe smoking (head-year) did not show associations. We observed an inverse association between colon cancer and cigarette smoking (OR, 0.6; 95% CI, 0.5-0.9). There was, however, no significant association by pack-year categories. Cigarette and waterpipe smoking was not associated with CRC in the Iranian population. Further studies are needed to better understand the role of waterpipe on CRC.

Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019

BACKGROUND

The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC.

METHODS

Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level.

RESULTS

Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors.

CONCLUSIONS

In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity.

IMPLICATIONS

We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

Come for the Tobacco, Stay for the Flavor: Flavored Cigarillo-Use Trajectories Among Young Adult Sexual Gender Minority Women

INTRODUCTION

The purpose of this research was to identify how young adult sexual gender minority (SGM) women who use cigarillos may respond to cigar flavor restrictions.

AIMS AND METHODS

Young adults aged 21-28 years in the United States who currently use cigarillos were recruited between October 2020 and April 2021 to participate in an online survey. Due to high prevalence of cigarillo use among individuals who identify as sexual and/or gender minority (SGM) women, their (n = 192) flavored tobacco-use behaviors and anticipated responses to cigarillo flavor restrictions were compared to cisgender heterosexual (CisHet) women (n = 110). Logistic regression was used to model cigarillo cessation and product-switching behaviors (flavored and unflavored).

RESULTS

SGM women were significantly less likely to report the use of flavor at the initiation of cigarillo use (61.7% vs. 86.1%) but were no different in current flavor use compared to CisHet women, with more than 80% of all women using any flavor. SGM women were 2.36 times as likely to say they would discontinue using cigarillos if flavors were unavailable. Among those who would continue using cigarillos, SGM women were 4.53 times as likely to endorse switching to an unflavored tobacco product but had the same likelihood of saying they would switch to flavored product compared to CisHet women.

CONCLUSIONS

Flavor restriction policies may not reduce the initiation of cigarillos among SGM women and may elicit differential cigarillo use and tobacco product substitution by SGM identity. Flavor restriction policies should be coupled with targeted cessation resources to address potential remaining disparities.

IMPLICATIONS

SGM US women have a unique cigarillo-use trajectory. These women are more likely to initiate cigarillos without flavor and then later integrate it into their behavior. National cigar flavor restrictions are expected to have a greater impact decreasing cigarillo initiation among CisHet women and decreasing current cigarillo use among SGM women. However, for those who would continue using unflavored cigarillos, SGM women may remain at risk for nicotine dependence due to increased product substitution. SGM women should be prioritized for cessation resources to reduce tobacco-use disparities leading up to and following the implementation of cigar flavor restrictions.

Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity

INTRODUCTION

This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017).

AIMS AND METHODS

Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol.

RESULTS

Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories.

CONCLUSIONS

After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity.

IMPLICATIONS

Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

Use of Menthol-Flavored Tobacco Products Among US Middle and High School Students: National Youth Tobacco Survey, 2022

Introduction

Menthol cigarettes have been associated with increased smoking initiation. Although numerous studies have focused on correlates of menthol cigarette smoking among youths, fewer studies have assessed the prevalence and correlates of overall menthol-flavored tobacco product use among middle and high school students.

Methods

We analyzed 2022 National Youth Tobacco Survey data to estimate the prevalence of menthol-flavored tobacco product use among US middle and high school students who used tobacco products within the past 30 days. Characteristics associated with menthol-flavored tobacco product use were also examined.

Results

Use of menthol-flavored tobacco products was reported by 23.8% of students who currently used any tobacco product and by 39.5% of students who currently used any flavored tobacco product. Among students who reported past 30-day use of a flavored tobacco product, characteristics associated with a higher prevalence of menthol-flavored tobacco product use included non-Hispanic White race and ethnicity, frequent tobacco product use, use of multiple tobacco products, wanting to use a tobacco product within the first 30 minutes of awakening, and craving tobacco products within the past 30 days.

Conclusion

Unlike results of prior research focused on cigarette smoking among young people, prevalence of use of any menthol-flavored tobacco product was highest among non-Hispanic White youths. Any use of menthol-flavored tobacco products of any type (alone or in combination with other flavors) among young people may be associated with continued product use and symptoms of dependence.

Examining the relationship of flavored tobacco product policy restrictions and flavored tobacco product use, among adolescents and young adults in the U.S

OBJECTIVE

This work examines the relationship between local flavor policy exposure and any tobacco product use and flavored tobacco product use among U.S. youth and young adults, as well as the equity potential of these policies by race/ethnicity.

METHODS

Participants were aged 15-36 (n = 10,893) surveyed from September-December 2019 using national, address- and probability-based sampling. Local flavor policies enacted before survey completion were linked to participant home address. Weighted cross-sectional multivariable logistic regression examined individual coverage by flavor policy vs. no flavor policy, with current any tobacco or flavored tobacco use, controlling for individual and county-level demographics, psychosocial variables, and other tobacco control policies. Interactions between race/ethnicity and any tobacco use and flavored tobacco use were assessed.

RESULTS

Those covered by a flavor policy vs. no policy had lower odds of any tobacco use (aOR = 0.74, 95% CI = 0.55-1.00) and current flavored tobacco use (aOR = 0.67, 95% CI = 0.48-0.93). Compared with Non-Hispanic (NH)-White individuals, NH-Black individuals (aOR = 1.08, CI = 1.04-1.12) had higher odds of any tobacco use, and non-Hispanic Asian individuals had lower odds of any tobacco use (aOR = 0.67, CI = 0.53-0.85). Hispanic individuals exposed to policy had lower odds of flavored tobacco use compared to NH-White peers.

CONCLUSIONS

Exposure to flavor restriction policies is associated with lower odds of any tobacco and flavored use among youth and young adults. Flavor restrictions may be beneficial in reducing tobacco use in youth from diverse racial/ethnic backgrounds. However, passing policies covering NH-Black individuals is needed to mitigate disparities in tobacco use by flavor policy coverage over time.

Impact of the European Union's menthol cigarette ban on smoking cessation outcomes: longitudinal findings from the 2020-2021 ITC Netherlands Surveys

INTRODUCTION

To reduce the appeal of tobacco, the European Union (EU) banned menthol as a characterising flavour in cigarettes in May 2020. This pre/post-study evaluated the impact of the menthol ban on smoking cessation outcomes among a representative cohort of Dutch smokers.

METHODS

Adult (18+ years) smokers were recruited at wave 1 (pre-ban) of the International Tobacco Control Netherlands Surveys (February-March 2020) and followed post-ban at wave 2 (September-November 2020) and wave 3 (June-July 2021) (N=1326 participated in all three waves). Weighted bivariate, logistic regression and generalised estimating equation model analyses were conducted.

RESULTS

Usual menthol use decreased from pre-ban (7.8%) to post-ban (4.0% at wave 2 and 4.4% at wave 3) (p<0.001). Pre-ban menthol smokers had greater odds of making a post-ban quit attempt than non-menthol smokers (66.9% vs 49.6%, adjusted OR (aOR)=1.89, 95% CI: 1.13 to 3.16). Compared with pre-ban non-menthol smokers, a higher proportion of menthol smokers quit by wave 2 (17.8% vs 10.2%, p=0.025) and by wave 3 (26.1% vs 14.1%, p=0.002), although this was not significant after adjusting for other factors. Female pre-ban menthol smokers had greater odds of quitting by wave 3 than female non-menthol smokers (aOR=2.23, 95% CI: 1.10 to 4.51). Most pre-ban menthol smokers (n=99) switched to non-menthol cigarettes (40.0%) or reported that they continued to smoke menthol cigarettes (33.0%) at wave 3.

CONCLUSIONS

The EU menthol ban was effective in reducing menthol use and in increasing quit attempts and quitting among pre-ban menthol smokers. Impact could be maximised by closing gaps that allow post-ban menthol cigarette use.

Perceptions of African American Youth and Adults Regarding Tobacco Use-Related Factors in Their Community: A Mixed-Methods Approach in Richmond, Virginia

INTRODUCTION

The US Food and Drug Administration is poised to restrict the availability of menthol cigarettes and flavored cigars, products disproportionately used by Black/African American (B/AA) individuals. We examined B/AA youth and adult perceptions regarding factors contributing to tobacco use, as well as prevention/cessation resources.

METHODS

In 2 mixed-methods studies in Richmond, Virginia, we conducted cross-sectional surveys among youth (n = 201) and adult (n = 212) individuals who were primarily B/AA and reported past 30-day cigar smoking or nontobacco use, followed by focus groups with a subset (youth: n = 30; adults: n = 24). Focus groups were analyzed using a thematic analysis framework, and descriptive survey data provided context to themes.

RESULTS

Among focus group participants, 20% of youth and 75% of adults reported current cigar smoking. Six themes emerged across the groups: advertising/brands, sensory experiences, costs, social factors, youth-related factors, and dependence/cessation. Youth and adults perceived cigars as popular; cigar use was attributed to targeted advertising, flavors, affordability, and accessibility. While adults expressed concern regarding youth tobacco use, youth did not perceive tobacco prevention programs as helpful. Adults and youth reported limited access to community tobacco prevention/cessation programs.

DISCUSSION

Expanded tobacco prevention and cessation resources for B/AA people who smoke could leverage federal regulatory actions to ban tobacco products targeted toward this group and decrease disparities in tobacco-related morbidity and mortality.

Addiction potential of combustible menthol cigarette alternatives: a randomised cross-over trial

INTRODUCTION

The Food and Drug Administration (FDA) has issued proposed product standards banning menthol as a characterising flavour in cigarettes and cigars. The public health benefits of these product standards may be attenuated by the role of plausible substitutes in the marketplace. Therefore, the present study examined the addiction potential of plausible combustible menthol alternatives compared with usual brand menthol cigarettes (UBMC).

METHODS

Ninety-eight adult menthol cigarette smokers completed four visits, smoking their UBMC at the first session and three menthol cigarette alternatives in random order at the subsequent visits: (1) a preassembled menthol roll-your-own (mRYO) cigarette using menthol pipe tobacco and mentholated cigarette tube, (2) a menthol filtered little cigar (mFLC) and (3) a non-menthol cigarette (NMC). Measures of smoking topography, exhaled carbon monoxide (CO), craving and withdrawal, subjective effects and behavioural economic demand indices were assessed.

RESULTS

Compared with UBMC, menthol cigarette alternatives resulted in different puffing topography and CO exposure (except mRYO), and lower levels of positive subjective experience and behavioural economic demand indices. Among the alternative products, participants reported the highest level of positive subjective experience and higher demand for mRYO, compared with mFLC and NMC. Similarly, participants were significantly more likely to want to try again, purchase and use the mRYO product regularly compared with mFLC and NMC.

CONCLUSIONS AND RELEVANCE

mRYO cigarettes were the most highly rated cigarette alternative among study products, suggesting their potential appeal as a menthol cigarette substitute and needed inclusion of menthol pipe tobacco and cigarette tubes in FDA's proposed ban.

Use patterns of flavored non-cigarette tobacco products among US adults, 2010-2019

OBJECTIVE

Flavored non-cigarette tobacco product (NCTP) use is common among US adult tobacco users. To update the estimates of use patterns of flavored NCTPs, this study assessed current NCTP use among adults by flavor use and flavor categories from 2010 to 2019.

METHODS

We analyzed data from the 2010-2019 Tobacco Use Supplement to the Current Population Survey to estimate the weighted proportion of adult NCTP users by flavor use across survey waves. Flavor use was defined as past 30-day use of any menthol/mint or fruit/other flavors. We used the 2018-2019 data to examine the differences in demographic characteristics and tobacco use patterns among users of menthol/mint or fruit/other flavors compared to exclusive users of tobacco flavor, by product type.

RESULTS

Compared to 2014-2015, electronic nicotine delivery system (ENDS) users were more likely (79.0% vs. 66.6%, p < 0.001) to report flavor use in 2018-2019, whereas cigar (26.9% vs. 31.2%, p = 0.030) and pipe (56.3% vs. 65.5%, p = 0.015) smokers were less likely to report flavor use in 2018-2019. In 2018-2019, the most prevalent flavor categories were exclusive use of tobacco flavor among cigar (73.1%) and smokeless tobacco (48.3%) users, and use of fruit/other flavors among ENDS (64.9%) and pipe (48.4%) users. Flavored users were more likely to be young adults aged 18-24 years (cigars, ENDS, smokeless tobacco) and Non-Hispanic Black or Hispanic persons (cigars, ENDS, pipes) compared to tobacco-flavored users.

CONCLUSIONS

Flavored product use increased among adult ENDS users but decreased among cigar and pipe smokers. These findings could inform tobacco regulatory efforts concerning flavored NCTPs.

The Impact of High or Low Doses of Nicotine in a Mouse Model of Vapor Self-Administration

INTRODUCTION

A wide variety of nicotine concentrations and formulations are available to users of electronic nicotine delivery systems (ENDS). This is increasingly true when considering the many flavors available with ENDS products. To date, there have been few preclinical investigations into the impact of nicotine doses, with and without flavors, on vaping-related behaviors. This present study evaluated how nicotine concentrations relevant to tank-based and pod-based ENDS, with and without flavors, impact reinforcement-related behavior in a mouse model.

AIMS AND METHODS

Adult male and female C57/BL6J mice were used in vapor-inhalation self-administration assays. Mice were assigned e-liquids containing 6 mg/mL or 60 mg/mL nicotine. Additional mice were assigned these nicotine doses with green apple or menthol flavorants. Mice were trained on fixed-ratio 1 for 10, 2-hour sessions, then five sessions at FR3, three progressive ratio sessions, and two FR3 sessions.

RESULTS

We observed male mice exhibited higher reinforcement-related behavior to menthol-flavored 6 mg/mL nicotine when compared to female mice. Males were only observed to have a menthol-induced enhancement of self-administration at 6 mg/mL nicotine and not 60 mg/mL nicotine. However, female mice exhibited significant menthol-induced increases in reinforcement-related behaviors with 60 mg/mL nicotine.

CONCLUSIONS

These data provide evidence that males and females exhibit different dose sensitivities to nicotine. These sex-dependent differences in nicotine sensitivity also indicate that flavor-induced enhancement in nicotine intake is dependent on the different doses for each sex.

IMPLICATIONS

There has been much discussion recently regarding the impact of flavors on vaping-related behavior. Our current study may support prior investigations that suggest flavors enhance the palatability of nicotine-containing products. However, this current study provides evidence that males and females exhibit different sensitivities to nicotine.

Doing more with less: A proposal to advance cigarette packaging regulations in the United States

Cigarette packages are potent marketing tools. Following guidance from the WHO Framework Convention on Tobacco Control, many countries have sought to diminish this marketing power by mandating that (1) large graphic health warnings be affixed to the packages (i.e., text warnings combined with graphic images of the health consequences of smoking) and (2) all packages be fully "plain" in their design (i.e., all packages use the same drab/bland color and font type; no brand logos, other colors, or designs are permitted). Yet, the United States lags other countries in implementing regulations designed to blunt the marketing power of cigarette packages. This is not because of a lack of effort on the part of the Food and Drug Administration, the main governmental body charged with regulating tobacco products in the United States. Rather, it is because the regulatory options that that have been advanced in the country (e.g., graphic health warnings) have not been found - yet - to be legally feasible by its courts. This commentary works through some of the conceptual, practical, and legal issues regarding packaging regulations in the United States. It considers the political and bureaucratic risks involved with issuing new regulations. The overall intent is to prompt our field to think creatively about what is realistic in this regulatory space and to offer a novel perspective that may help move the United States tobacco control community forward in its efforts to reduce the promotional power of cigarette packages.

Social Ecological Influences on Nicotine/Tobacco Use Among Gender-Varying and Gender-Stable Adolescents and Adults in the USA

BACKGROUND AND PURPOSE

Our study examined individual-, interpersonal-, community-, and policy-level associations with nicotine/tobacco use among gender-varying and gender-stable U.S. individuals.

METHODS

Data from Waves 2-4 (2014/15-2016/18) of the Population Assessment of Tobacco and Health (n = 33,197 U.S. adolescents and adults aged ≥14 years) and state-level gender minority policy data were used. Using multivariable logistic regression, the odds of past-30-day nicotine/tobacco use at W4 were estimated as a function of gender stability/variability, psychological distress, number of tobacco products used by family/friends, anti-tobacco marketing exposure, and change in gender minority-related policies from 2015 to 2017.

RESULTS

Gender-varying individuals had higher odds of nicotine/tobacco use compared with gender-stable individuals (AOR range = 1.7-2.3, p < .01). In the overall sample, positive change in gender minority policy protections (tallied from medium to high) was associated with lower odds of any nicotine/tobacco, other tobacco, and poly-tobacco use (AOR = 0.8, p < .05) compared to states with no change in their negative policies. Anti-tobacco marketing exposure was associated with lower odds of any tobacco, cigarette, e-cigarette, and poly-tobacco use compared with those who had no anti-tobacco marketing exposure (AOR = 0.9, p < .05). Higher psychological distress (AOR range = 1.7-2.4, p < .001) and an increasing number of tobacco products used by family/friends (AOR range = 1.1-1.3, p < .001) were associated with increased odds of nicotine/tobacco use.

CONCLUSIONS

Multilevel prevention and intervention strategies are needed to reduce the risk of nicotine/tobacco use among gender-varying and gender-stable individuals.

Changes in Pack Features Among Top-Selling Cigarettes in the U.S., 2018 and 2021

INTRODUCTION

Cigarette packaging is designed to increase consumer appeal and remains a primary promotional tool in many countries, including the U.S. This study documented changes in the prevalence of pack characteristics among the top-selling cigarette products in the U.S. in 2018 and 2021.

METHODS

The 50 cigarette packs with the highest national unit sales in U.S. convenience stores in 2018 and 2021 were identified using Nielsen's Scantrack data and subsequently purchased. Packs were coded for features such as dominant color(s), descriptive text, and promotional language. Descriptive analyses conducted in 2022 weighted by total annual unit sales compared the prevalence of pack characteristics between years.

RESULTS

Three brands-Marlboro, Newport, and Camel-constituted over 80% of pack sales among the top-selling products. Packs with red as a dominant color grew less popular between years (33.3% vs 29.5%), whereas those with green became more prevalent (25.2% vs 28.9%), consistent with a rise in the proportion of menthol sales. The prevalence of descriptors such as flavor and fresh decreased from 46.0% to 39.4% and 9.7% to 5.2%, respectively. Meanwhile, the prevalence of promotional language (e.g., rewards programs) increased from 60.9% to 69.0%.

CONCLUSIONS

The use of visual and named colors remains common, which can implicitly communicate sensory or health-related attributes. Moreover, promotions may help recruit and retain consumers in the context of more restrictive tobacco control policies and price increases. Given the strong influence that cigarette packaging exerts on consumers, packaging-focused policies, such as plain packaging laws, may reduce appeal and accelerate declines in cigarette use.

Effect of sweet flavouring on the rewarding and reinforcing value of cigarillo use among young adults

INTRODUCTION

Cigarillos dominate the US cigar market, and young adults largely drive use. While young adults prefer flavoured to non-flavoured cigarillos, especially those flavoured to taste like fruit or other sweets, the factors that underlie this preference have received little attention. We sought to determine if key indicators of abuse liability, the rewarding and reinforcing effects, are greater for sweet versus non-flavoured cigarillos.

METHODS

Young adults (18-24 years old) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerised choice task) and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavoured versus non-flavoured cigarillos. General linear regression models were fit with the appropriate family link for each outcome measure.

RESULTS

Young adults rated sweet-flavoured cigarillos as more rewarding (estimated marginal mean (EMM) =4.52, 95% CI 4.00 to 5.03) than the non-flavoured cigarillo (EMM=3.31, 95% CI 2.80 to 3.83; B=1.20, 95% CI 0.80 to 1.60, p<0.001). The reinforcing value of sweet-flavoured cigarillos, measured by break point, was higher relative to non-flavoured cigarillos (6.34 out of 10), especially among young adults with a preference for flavoured cigarillos (B=1.94, 95% CI 0.71 to 3.18, p=0.003). Young adults took 1.9 times the number of puffs (35.75 vs 19.95) from sweet-flavoured cigarillos compared with non-flavoured cigarillos (Rate Ratio =1.94, 95% CI 1.30 to 2.90, p<0.001).

CONCLUSIONS

Sweet flavouring increases the abuse liability of cigarillos among young adults as reflected in greater liking, motivation to use and actual use. Banning sweet flavouring in cigarillos may diminish their use in young adults.Trial registration number CT.gov (NCT05092919).

Optimising a product standard for banning menthol and other flavours in tobacco products

In this paper, we highlight key issues that policymakers should consider when developing a product standard banning menthol and other flavours in tobacco products based on research evidence and experiences learnt from other countries. A flavour product standard may be optimised by (1) having a clear and comprehensive definition of flavour that includes a complete ban on additives that have flavour properties and/or evoke sensory/cooling effects (ie, menthol analogues and synthetic coolants that stimulate the cooling receptor of the brain) rather than only as a 'characterising flavour' and (2) applying the standard to all tobacco product categories as well as all components or parts of the tobacco product (ie, the tobacco, filter, wrapper or paper), including separate flavourings that can be added to the product.

Characterising advertising strategies and expenditures for conventional and newer smokeless tobacco products

OBJECTIVE

Nicotine pouch products are an emerging and rapidly growing smokeless tobacco (ST) category in the USA. Little is known about the promotional strategies and media channels used to advertise this ST category or the extent to which the marketing strategies differ from strategies used to promote 'conventional' smokeless products (eg, snuff). We describe the nature, timing of and expenditures related to conventional, snus and newer ST product advertising on print, broadcast and internet media.

METHODS

Advertising expenditures were collected using Kantar Media's 'Stradegy' tool, which provides advertising data including dollars spent promoting specific products across various media channels, including print magazines and newspapers, broadcast television and radio, outdoor posters and billboards, and internet. We identified 306 smokeless products within Kantar database and collected ad expenditures retrospectively for January 2018-April 2020. Promotional expenditures were aggregated by product category, by month and by designated market area (DMA).

RESULTS

Kantar data analysis returned 28 conventional ST, 22 oral nicotine and 3 snus products (53 total) advertised during the period of observation, with over $71 million spent collectively on ST promotion. Across categories, more advertising dollars were spent on conventional ST products (63%) than newer oral nicotine products (25%) or snus (12%). However, during the later 9-month period from August 2019 to April 2020, oral nicotine products accounted for the majority of monthly ad spending. Most ad spending was placed in the national market ($66.5 million), with Atlanta ($1.1 million), Houston ($1 million) and Las Vegas ($0.8 million) as the top three local DMAs for expenditures.

DISCUSSION

Advertising expenditures for nicotine pouches have recently exceeded conventional ST product advertising and nicotine pouches are being promoted nationally. Marketing surveillance as well as understanding consumer appeal, perceptions and consumption are critical next steps in tracking potential uptake of these new products.

Early evidence of flavored tobacco product restrictions in Massachusetts and New York State

INTRODUCTION

With many US states and localities enacting policies that restrict flavored e-cigarette sales, evaluation of these restrictions is critical to inform future efforts. This study analyzed both survey and retail scanner data to assess early-stage impacts of flavored tobacco sales restrictions in Massachusetts and New York State on e-cigarettes sales and product use among young people.

METHODS

This study uses state-level e-cigarette retail sales data and survey data from youth and young adults (aged 13-24 years). Cross-sectional surveys were conducted at two time points in Massachusetts (both post policy implementation) and New York (pre and post policy implementation); retail sales data in both states were analyzed from 2019 through 2020 and compared to sales in control states.

RESULTS

E-cigarette unit sales decreased significantly following the implementation of statewide restrictions on flavored e-cigarettes in both Massachusetts and New York State (p<0.001). Survey data showed a decrease in mint flavored e-cigarette use in Massachusetts and an increase in tobacco flavored e-cigarette use in New York State over time (p=0.001). In both states, a greater proportion of respondents reported using disposable e-cigarettes at Time 2 compared to Time 1 (p=0.001). Among those who reported using fruit-flavored e-cigarettes in New York State, a significantly greater proportion reported disposable device use at Time 2 compared to Time 1 (p=0.004).

CONCLUSIONS

Findings from these case studies from two US states suggest that statewide policies reduce the availability of e-cigarettes and have the potential to reduce use of many youth-appealing flavors. The increase in use of disposable e-cigarettes likely reflects existing loopholes in federal policy, which may be attenuating the potential impact of strong state-level policies.

Changes in Retail Tobacco Product Availability Following a Chicago City Ordinance Restricting Sales of Menthol and Other Flavored Tobacco Products Near Schools

BACKGROUND

In April 2016, the City of Chicago implemented an ordinance restricting the sale of all flavored (including menthol) tobacco products (FTPs), including electronic cigarettes, at retailers located within 500 feet of any public, private, or alternative elementary, middle ("primary"), or high ("secondary") school. We examined changes in retail availability of FTPs from before to after policy implementation among policy-affected retailers compared with retailers not subject to the policy.

METHOD

Observational data were collected in June to September 2015 (Wave 1; pre-policy) and November to December 2016 (Wave 2; post-policy) from a panel of 194 randomly selected policy-area stores (located within 500 feet of a school), and a panel of 199 randomly selected comparison-area stores (located more than 500 feet from a school). Using generalized estimation equation regression, we assessed differences in FTP availability changes across study areas.

RESULTS

We observed a statistically significant policy effect on FTP availability (Area × Wave interaction, p < .05); however, more than half of policy-area retailers continued to display at least one FTP after policy implementation (87.11% at Wave 1, 57.73% at Wave 2, p < .05). Similar reductions were seen for the availability of flavored cigarillos/little cigars and menthol cigarettes, while policy effects varied across store types.

DISCUSSION

FTP availability reductions appear to be associated with policy implementation, but FTPs remained readily available at retailers subject to the policy. This study contributes to the evidence base indicating that policies with exclusions or exemptions for certain flavors, products, store types, or retailer locations have a limited effect on retail availability of FTPs.

Flavored Tobacco and Nicotine Use Among California Adolescents: Preferences by Use Experience and Survey Format Effects

PURPOSE

This study assessed flavored tobacco use among adolescent e-cigarette, cigarette, cigar, hookah, and smokeless tobacco users; specific e-cigarette flavor preferences; risk profiles of youth that use various flavors; and the impact of survey question wording on prevalence.

METHODS

Cross-sectional data from 4,956 California adolescent participants (aged 12-17 years) in the Teens, Nicotine, and Tobacco 2021-2022 online panel survey estimated the survey-weighted prevalence of flavored tobacco use. An embedded randomized experiment assessed survey wording effects (i.e., any vs. "usual" flavor use). Qualitative data from four contemporaneous cycles of Teens, Nicotine, and Tobacco focus groups with California adolescents (N = 63) added themes relevant to the quantitative findings.

RESULTS

88.1% of current any tobacco users reported flavored tobacco use in the past 30 days. Flavor use was lowest for cigarettes (66.7%) and highest for hookah (92.8%). Fruit was the most popular e-cigarette flavor (51.6% any use; 28.8% usual use). E-cigarette users also commonly reported use of candy and cooling flavors. Sweet flavors were used most often among adolescents otherwise at low risk of tobacco use. Survey item format did not meaningfully affect overall prevalence of flavored product use but did impact reports of specific e-cigarette flavors. Focus group participants described sweet and fruity flavors as a motivating factor in their own e-cigarette use and as designed to appeal to children.

DISCUSSION

Despite local policies, flavored tobacco use remains common among California adolescents. Survey items asking about any flavor use rather than usual use provide more information without affecting the overall prevalence of flavored tobacco use.

A Survey of Vaping Use, Perceptions, and Access in Adolescents from South-Central Texas Schools

Despite efforts to dissuade major manufacturers and retailers from marketing and selling vape products to adolescents, the practice of vaping continues to increase in this population. Few studies have assessed adolescent perceptions of vaping, access to vaping, and use of vaping, and most rely, at least in part, on inferential conclusions drawn from data on smoking traditional combustible cigarettes. A novel electronic survey was created to assess the use of vapes, perceptions of vaping, and access to vaping among a convenience sample of adolescents (ages 12-20 years) in eleven schools in South-Central Texas from May to August 2021. The students' perceived threat of negative health outcomes due to vaping was calculated based on questions soliciting perceptions of severity (perceived danger) and susceptibility (perceived likelihood of illness). Trends were identified using descriptive and bivariate statistical tests. A total of 267 respondents were included; 26% had tried vaping. A majority (63%) did not believe vaping and smoking were synonymous. Most (70%) thought it was easy to obtain supplies and (76%) vape before and after (88%) or even during (64%) school. Respondents who vaped had a 34% lower perceived threat when compared to respondents who did not vape. In this sample of adolescents from South-Central Texas, one in four reported that they had tried vaping. Easy access to vapes and misperceptions regarding the safety of vaping might create a false sense of security with respect to vaping as an alternative to smoking, particularly among those who reported vaping, and is likely contributing to the increased use of vapes.

Examining the Comprehensiveness of Amended Flavored Tobacco Product Sales Restrictions

CONTEXT

Flavored tobacco products contribute significantly to youth tobacco initiation and tobacco use disparities. In the last decade, 362 jurisdictions have enacted policies restricting the sale of flavored tobacco products; however, many policies are not fully comprehensive due to menthol and adult-only retailer exemptions. Although several of these restrictions have been amended since their original passage, to date, little is known about how amendments have affected policy comprehensiveness.

OBJECTIVE

To describe how amendments to flavored tobacco product sales restrictions affect policy comprehensiveness.

DESIGN

We identified flavored tobacco product sales restrictions that had been amended at least once using an internal database of US state and local flavored tobacco product sales restrictions. To characterize policy comprehensiveness, we applied a 6-level flavored tobacco policy classification scheme-level 6 being most comprehensive-to amended restrictions. We conducted a descriptive analysis of each initial policy and its most recent amendment to identify changes in retailer, product, and flavor inclusions, as well as overall comprehensiveness.

MAIN OUTCOME MEASURES

Comprehensiveness of amended flavored tobacco product sales restrictions.

RESULTS

As of March 31, 2022, no states and 50 localities had amended their flavored tobacco product sales restriction. Amendments largely increased policy comprehensiveness; most laws prior to amendment were categorized as level 1 (n = 28, 56.0%), while after amendment, the plurality were categorized as level 6 (n = 25, 50.0%). Most commonly, amendments removed menthol exemptions (n ≥ 30, 60.0%) and adult-only retailer exemptions (n = 12, 24.0%).

CONCLUSIONS

Several local flavored tobacco product sales restrictions have been amended. Nearly all amendments increased policy comprehensiveness, primarily by removing exemptions for menthol products and exemptions for adult-only retailers. While policy advocates remain focused on passing comprehensive policies at initial passage, amendments have served as a tool to strengthen existing sales restrictions. This study along with ongoing flavored tobacco product sales restriction surveillance can inform policy advocacy and evaluation efforts.

Pan-American prevalence of smokeless tobacco use and association with oral potentially malignant disorders and head and neck cancer: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence of smokeless tobacco (SLT) use and its association with oral potentially malignant disorders (OPMDs) and head and neck cancer (HNC) in the Pan-American Health Organization (PAHO) region.

STUDY DESIGN

A literature search was conducted across 9 databases and other sources. The eligibility criteria were pediatric (0-18 years old) and adult (19 years and older) populations consuming any type of SLT. Meta-analysis was performed to determine the prevalence of SLT and the association between its use and OPMDs/HNC in the PAHO region; the Grading of Recommendations Assessment, Development, and Evaluation tool was used to verify the certainty of evidence.

RESULTS

Fifty-nine studies from 6 PAHO countries were included, of which 51 were also subjected to quantitative analysis. The pooled SLT prevalence of use was 15% (95%CI: 11.93-18.69) overall, 17% (95%CI: 13.25-22.65) in adults, and 11% (95%CI: 8.54-14.78) in the pediatric population. The highest reported SLT prevalence of use was 33.4% (95%CI: 27.17-39.93) in Venezuela. HNC was positively associated with SLT use (OR = 1.98, 95%CI: 1.54-2.55), with a moderate certainty of evidence. Among OPMDs, only leukoplakia reported a positive association with SLT use (OR = 8.38; 95%CI: 1.05-67.25). However, the quality of the evidence was very low.

CONCLUSION

A high consumption of SLT use, chewing tobacco and snuff, is reported among the adult population residing in the PAHO region with a positive association with the development of oral leukoplakia and HNC.

Illicit purchasing and use of flavour accessories after the European Union menthol cigarette ban: findings from the 2020-21 ITC Netherlands Surveys

BACKGROUND

The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use-(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers.

METHODS

Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February-March 2020, N = 2067) and after the ban (Wave 2: September-November 2020, N = 1752; Wave 3: June-July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data.

RESULTS

Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8-3.2, Wave 1) to post-ban (1.7%, 1.2-2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25-39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand.

CONCLUSIONS

There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance.

Nicotine pouch awareness, use and perceptions among young adults from six metropolitan statistical areas in the United States

INTRODUCTION

Nicotine pouches, which emerged in the US in 2016 and are marketed as 'tobacco-free', may appeal to young adults. This study examined young adults' nicotine pouch awareness, use, use intentions, and related factors.

METHODS

We analyzed Spring 2022 survey data from 942 young adults recruited via social media from six US cities (mean age=27.61 years, 34.3% men, 33.1% racial/ethnic minority) to characterize nicotine pouch awareness, ever use, use intentions, exposure, and perceptions.

RESULTS

Nicotine pouch awareness and ever use were reported by 34.6% and 9.8%, respectively. Males (AOR=1.79; 95% CI: 1.33-2.38), non-White participants (vs White; AOR=1.64; 95% CI: 1.04-2.61), and those using cigarettes (AOR=2.67; 95% CI: 1.63-4.38), e-cigarettes (AOR=2.28; 95% CI: 1.57-3.31), and smokeless tobacco (SLT) (AOR=14.46; 95% CI: 1.81-115.61) had greater odds of awareness. Among those aware of nicotine pouches, males (AOR=2.27; 95% CI: 1.33-3.85), White participants (vs Asian; AOR=0.40; 95% CI: 0.17-0.94), and SLT users (AOR=4.90; 95% CI: 1.26-18.98) had greater odds of ever use; being male (B=0.39; 95% CI: -0.67 - -0.12) and using SLT (B=1.73; 95% CI: 1.10-2.36) predicted greater use intentions. Overall, 31.4% reported past-month advertising exposure, most often via tobacco retailers (67.3%). Ever users most commonly purchased them at gas stations (46.7%). The most frequently reported use motives were to quit combusted tobacco (16.8%) and reduce tobacco smell (15.4%). Nicotine pouches were perceived as less harmful and less addictive than cigarettes, e-cigarettes, and SLT, and more socially acceptable than cigarettes and SLT.

CONCLUSIONS

Young adults were exposed to advertising, accessed nicotine pouches via various sources, and perceived these products favorably. Marketing and use surveillance is needed to monitor their impact on those likely to use them (e.g. males, SLT users).

Update to the design and methods of the PATH Study, Wave 4 (2016-2017)

The Population Assessment of Tobacco and Health (PATH) Study is a nationally representative study of the US population on tobacco use and its effects on health, with four waves of data collection between 2013 and 2017. Prior work described the methods of the first three waves. In this paper, we describe the methods of Wave 4, during which a replenishment sample was added to the ongoing cohort. We describe the design and estimation methods of the continuing Wave 1 cohort (with four waves of data) and the Wave 4 cohort (the new cohort created at Wave 4). We provide survey quality metrics, including response rates for both cohorts and a panel conditioning analysis, and guidance on understanding the target populations for both cohorts.

Electronic Nicotine Delivery System flavor use over time by age group in the US: A longitudinal analysis

INTRODUCTION

The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥25 years) between 2014 and 2019.

METHODS

Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014-2015), Wave 3 (2015-2016), Wave 4 (2016-2017), and Wave 5 (2018-2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed.

RESULTS

The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58-7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves.

CONCLUSIONS

Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

Temporal Trends in Tobacco Product Use Among US Middle and High School Students: National Youth Tobacco Survey, 2011-2020

OBJECTIVES

Despite significant declines in cigarette smoking during the past decade, other tobacco products gained popularity among middle and high school students. This study examined temporal trends in exclusive and concurrent use of tobacco products among middle and high school students in the United States from 2011 through 2020.

METHODS

We used multiple annual datasets from the National Youth Tobacco Survey from 2011 through 2020 (N = 193 350) to examine trends of current (past 30 days) exclusive, dual, and poly use of tobacco products (ie, cigarettes, electronic cigarettes [e-cigarettes], cigars, hookahs, and smokeless tobacco). We used joinpoint regression models to calculate log-linear trends in annual percentage change (APC).

RESULTS

During 2011-2020, exclusive use of any tobacco product decreased significantly, except for e-cigarettes, which increased significantly at an APC of 226.8% during 2011-2014 and 14.6% during 2014-2020. This increase was more pronounced among high school students (APC = 336.6% [2011-2014] and 15.7% [2014-2020]) than among middle school students (APC = 10.4% [2014-2020]) and among male students (APC = 252.8% [2011-2014] and 14.8% [2014-2020]) than among female students (APC = 13.6% [2014-2020]). During 2011-2020, we also found upward trends in dual use of e-cigarettes and cigarettes (APC = 17.3%). Poly use of e-cigarettes, cigarettes, and any other tobacco products increased significantly at an APC of 57.1% during 2011-2014.

CONCLUSIONS

The emergence of new tobacco products such as e-cigarettes in the US market has shifted the landscape of tobacco use among adolescents in the last decade toward poly product use, in which e-cigarettes are a prominent component. Our findings underscore the increasing complexity of tobacco use among adolescents in the United States and the need for strong policies and regulations adapted to evolving trends in cigarette and noncigarette tobacco products.

Flavour spectrum of the Puff family of disposable e-cigarettes

BACKGROUND

In January 2020, the US Food and Drug Administration prohibited the sale of flavours (except for menthol and tobacco) in prefilled pod devices such as JUUL to decrease youth vaping. Excluded from the prohibition were disposable devices.

OBJECTIVES

To determine the scope and scale of flavours marketed by Puff Bar, a leading disposable brand, and related products.

METHODS

Disposable e-cigarette flavours were identified via online searches encompassing vendor websites, wholesale distributors, manufacturers (eg, made-in-china.com), and social media channel, Instagram, between June and August 2020.

RESULTS

The 'Puff' brand name and iconic cloud logo appear on a variety of products of differing sizes and nicotine e-liquid volumes. Among Puff Bar and its copycats (Puff-a-Likes), 139 flavours were identified. Fruit flavours predominated comprising 82.2% of the flavour varieties (fruit 50%, fruit and menthol/mint 23.6%, and fruity drinks 8.6%). A prevalent new flavour category which combines fruit with menthol/mint (Ice) was offered in 33 varieties such as Lychee Ice, Lush Ice and Banana Ice. Disposable e-cigarette brands are undertaking measures to escape tobacco regulation (eg, non-tobacco-sourced nicotine) and flavour limitations via post-market flavour additions to unflavoured nicotine e-liquid.

CONCLUSIONS

The proliferation of flavoured disposable e-cigarette products, many of which are designed to emulate popular pod devices, illustrates that narrowly limited flavour regulations covering only a single category are destined to fail. To be effective in youth protection, flavour regulations need to apply to all recreational nicotine-containing products and need to include measures to counter post-market flavour addition.

Sensory methods to evaluate perception of flavours in tobacco and other nicotine-containing products: a review

OBJECTIVES

Sensory methods use human senses to evaluate product attributes. This review provides an overview of the types of sensory methods used to evaluate the perception of flavour in tobacco and other nicotine-containing (ToNic) products and to discuss how sensory data could inform flavoured ToNic product policy.

DATA SOURCES

PubMed, Embase and Web of Science.

STUDY SELECTION

All peer-reviewed studies evaluating ToNic products using a sensory method published before 23 May 2020.

DATA EXTRACTION

Two independent coders completed title/abstract and full-text screening to choose articles for inclusion (Cohen's kappa=0.85, strong agreement). Each coder completed data extraction on half the articles, recording relevant information (eg, sensory methods used, results). The coders categorised sensory methods and generated overarching themes.

DATA SYNTHESIS

Of 110 articles identified, we included 29 articles containing 35 studies that used sensory methods to investigate ToNic products. The sensory methods included analytic methods such as discrimination and descriptive tests and hedonic methods such as liking tests. Six themes emerged regarding how sensory methods can be used to understand consumer perception and liking of ToNic products and to inform ToNic product policy.

CONCLUSIONS

The identified studies highlight that sensory data can inform ToNic product policy. Analytic and sensory hedonic ratings can be used to assess a ToNic product's ability to promote addiction in the user (ie, abuse liability). Lastly, hedonic ratings can provide information to assess potential use behaviours.

Flavors increase adolescents' willingness to try nicotine and cannabis vape products

BACKGROUND

Certain product characteristics, such as flavor, may increase adolescents' willingness to try vaped nicotine and cannabis (marijuana) products.

METHODS

A discrete choice experiment embedded within the 2021-2022 California Teens Nicotine and Tobacco Project Online Survey was administered to a non-probability sample of N = 2342 adolescents ages 12-17. Participants were sequentially presented four randomly-generated pairs of hypothetical vape products that varied in device type (disposable, refillable), content (nicotine, marijuana, "just vapor"), and flavor (seven options) and asked which of these (or neither) they would be more willing to try if a best friend offered. Conditional logistic regression quantified associations between product characteristics and participants' selections, including interactions by past 30-day use of e-cigarettes, marijuana, or both.

RESULTS

Candy/dessert, fruit, and fruit-ice combination flavors were all associated with greater willingness to try a vape product (versus tobacco flavor) among participants not using e-cigarettes or marijuana, those using only e-cigarettes, and those co-using e-cigarettes and marijuana. Among participants only using marijuana, the most preferred flavors were no flavor, candy/dessert, and icy/frost/menthol. Among participants not using e-cigarettes or marijuana, model-predicted willingness to try a displayed vape product was greater when products were sweet or fruit flavored than tobacco or unflavored, regardless of whether displayed options contained nicotine (fruit/sweet: 21 %, tobacco/unflavored: 4 %), marijuana (fruit/sweet: 18 %, tobacco/unflavored: 6 %), or "just vapor" (fruit/sweet: 29 %, tobacco/unflavored: 16 %).

CONCLUSIONS

In this online non-probability sample, flavors in nicotine and cannabis vape products increased adolescents' willingness to try them. Comprehensive bans on flavored vapes would likely reduce adolescent use.

Messaging to prevent and reduce young adults' waterpipe tobacco smoking: A randomized trial

INTRODUCTION

More than 10% of U.S. young adults have smoked waterpipe tobacco in the past month and >25% of those who have never smoked are susceptible. We tested messages designed to prevent and reduce waterpipe tobacco smoking (WTS).

METHODS

In 2020, we recruited 830 U.S. young adults (18-30 years) who had never smoked waterpipe tobacco and were susceptible or currently smoked waterpipe tobacco for an online study. We randomized participants to intervention messages about the risks of WTS or control messages unrelated to tobacco. Participants had up to four message exposures over 12 weeks and completed two-, four-, and six-month follow-ups. Outcomes were WTS initiation and curiosity (susceptible never smokers), WTS frequency, cessation, motivation to quit (those who currently smoked), and WTS risk perceptions.

RESULTS

Intervention messages increased perceived addictiveness of WTS at two months (β = 0.27; 95% CI: 0.11, 0.43) in susceptible never smokers. There were no significant intervention effects in those who currently smoked. Exploratory analyses among intervention participants showed that higher dose of message exposure decreased WTS initiation at six months in susceptible never smokers (RR = 0.68; 95% CI: 0.48, 0.96) and decreased WTS frequency (IRR = 0.84; 95% CI: 0.73, 0.97) and increased cessation (RR = 1.31; 95% CI: 1.07, 1.59) at six months in those who smoked.

CONCLUSIONS

Although the WTS intervention messages had few significant effects on outcomes overall, a higher dose of message exposure affected behavioral outcomes in the intervention arm. Findings highlight the need to identify effective message content and optimal message dose, especially for digital media campaigns.

Tobacco-Free Oral Nicotine Product Use Among Youth in the U.S., 2019-2021

Introduction

Novel tobacco-free oral nicotine products are not combusted, easy to conceal, available in flavors, and do not contain tobacco leaf. Since 2016, oral nicotine product sales have increased and may be gaining popularity among youth. This study aims to examine the trends in the prevalence and correlates of oral nicotine product use among U.S. youth.

Methods

Data from participants aged 16-19 years in the U.S. International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Survey were analyzed cross-sectionally from August 2019, February 2020, August 2020, February 2021, and August 2021. Weighted descriptive statistics and logistic regressions were used to describe the use and correlates of oral nicotine products.

Results

Oral nicotine product use significantly increased from 3.5% in August 2019 to 4.1% in August 2021. Oral nicotine product use was most prevalent among those aged 18 years, male, and non-Hispanic White. Those who used cigarettes (AOR=2.18, 95% CI=19.37, 40.88), nicotine vaping products (AOR=4.27, 95% CI=3.02, 6.04), and smokeless tobacco (AOR=28.14, 95% CI=19.37, 40.88) in the past 30 days were more likely to report recent use of oral nicotine products.

Conclusions

Although oral nicotine products are less popular among U.S. youth than cigarettes, nicotine vaping products, and smokeless tobacco, their prevalence of use significantly increased. Oral nicotine product users are more likely to use other nicotine products, but the availability of flavors and easy-to-conceal design may be appealing to those who may not use nicotine products. Researchers should continue to observe the behaviors associated with oral nicotine product use to inform the need for future regulatory efforts.

The Effects of Oral Nicotine Pouch Packaging Features on Adult Tobacco Users' and Non-Users' Product Perceptions

BACKGROUND

Oral nicotine pouches (ONPs) are novel products that are marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (ST). This study examined the effects of ONP packaging features on adult tobacco users' and non-users' product perceptions.

MATERIALS AND METHODS

Adult tobacco users (cigarettes, ST, and dual cigarette/ST) and non-users (total N = 301) viewed ONP pack images in a 4 × 3 × 2 between-subject experiment testing the effects of the displayed flavor (cool mint, coffee, dark frost, and smooth), nicotine concentration (none displayed on the package, 3 mg, and 6 mg), and addiction warning label (yes or no). The outcomes were perceived substitutability of ONPs for cigarettes and ST and perceived risks. We modeled the effects of tobacco user status and the experimental factors on these outcomes.

RESULTS

All tobacco user groups perceived ONPs to be significantly less harmful and less addictive than non-users. There were significant effects of nicotine concentration on perceived risks. Compared to packages that did not display nicotine concentration, packages displaying 6 mg nicotine concentration produced significantly lower perceived harm (β = -0.23, 95% CI -0.44, -0.02), perceived addictiveness (β = -0.28, 95% CI -0.51, -0.05), risk appraisals of harm (β = -0.50, 95% CI -0.88, -0.12) and risk appraisals of addictiveness (β = -0.53, 95% CI -0.95, -0.11).

CONCLUSIONS

The study findings demonstrate that the nicotine concentration displayed on ONP packaging can affect adults' perceptions of ONPs. Further research on the effects of ONP packaging features emphasizing nicotine (e.g., "tobacco free" nicotine claims) on tobacco users and non-users is needed to assess their potential public health impact.

Advocacy for Global Tobacco Control and Child Health

Tobacco and secondhand smoke remain leading threats to public health. Evidence since the 1950s has shown that the tobacco industry has acted in bad faith to deceive the public about the health effects of smoking. They have specifically targeted vulnerable populations including children and adolescents with various-and often misleading-marketing efforts and promotions. The increased popularity and weak regulation of electronic cigarettes have created a new generation of smokers who mistakenly believe they are "safer" from harm. Continued research, advocacy, and government action are needed to protect public health. Public health advocates must know the evidence, build coalitions, and prepare for industry countermeasures. Persistence is key, but public health efforts have successfully decreased tobacco-related deaths.

Mouth Level Intake of Nicotine from Three Brands of Little Filtered Cigars with Widely Differing Product Characteristics Among Adult Consumers

Little filtered cigars are tobacco products with many cigarette-like characteristics. However, despite cigars falling under the U.S. Food and Drug Administration regulatory authority, characterizing flavors, which are still allowed in little filtered cigars, and filter design may influence how people use the products and the resulting exposure to harmful and potentially harmful constituents. We estimated nicotine mouth level intake (MLI) from analyses of little cigar filter butt solanesol levels, brand characteristics, carbon monoxide boost, and puff volume in 48 dual cigarette/cigar users during two repeat bouts of ad lib smoking of three little filtered cigar brands. Mean nicotine MLI for the three brands was significantly different with Swisher Sweets (0.1% ventilation) Cherry at 1.20 mg nicotine, Cheyenne Menthol (1.5%) at 0.63 mg, and Santa Fe unflavored (49%) at 0.94 mg. The association between nicotine MLI and puff volume was the same between Cheyenne Menthol and Santa Fe unflavored. However, these were different from Swisher Sweets Cherry. At least five main factors─flavor, ventilation, filter design, nicotine delivery related to tar, and user puff volume─may directly or indirectly impact MLI and its association with other measures. We found that users of little filtered cigars that have different filter ventilation and flavor draw dissimilar amounts of nicotine from the product, which may be accompanied by differences in exposure to other harmful smoke constituents.

Common Measures to Evaluate Flavored Tobacco Products: Recommendations From the Tobacco Centers for Regulatory Science (TCORS) Flavored Tobacco Products Measurement Subcommittee

INTRODUCTION

Flavored electronic nicotine delivery systems (ENDS) and tobacco products are associated with the initiation and progression of tobacco use. With recent restrictions around flavored products, it is critical to measure both the product and the flavor being used. The Tobacco Centers of Regulatory Science (TCORS) Flavored Tobacco Products Measurement Subcommittee (FTPMS) was established to develop core measures to assess flavored tobacco and ENDS product usage, facilitate data harmonization, replicability, and comparisons across studies.

AIMS AND METHODS

The FTPMS used a mixed-method approach to inform the development of recommended measures (first use, current use, reasons for use) to assess tobacco and ENDS product flavors. This included reviewing existing surveys, identifying priority areas, developing new measures, cognitive testing, and finalization of recommended measures.

RESULTS

Recommended measures were selected from national surveys (e.g. PATH study) and survey items used in TCORS studies to evaluate first use, current use, and reasons for use of tobacco and ENDS products. Response options were expanded for questions about specific flavors and adapted to allow for assessments relevant to recent federal policies. Supplemental measures were developed for researchers conducting more in-depth research around flavored products.

CONCLUSIONS

Using an expert consensus process supplemented with cognitive testing, the FTPMS developed recommendations for core and supplemental measures for flavored tobacco and ENDS products. Harmonizing data on these factors for flavored tobacco and ENDS products are critical for researchers and may provide actionable evidence to federal, state, and local regulators and policymakers, as well as support evaluations of policies restricting flavors in these products.

IMPLICATIONS

The development of core measures to assess first use, current use, and reasons for use of flavored tobacco and ENDS products will facilitate data harmonization, replicability, and comparisons across studies conducted in different samples or across communities with varying levels of regulation for these products. Use of these standardized measures will allow for a greater understanding of the role of flavors and helps to build a more robust evidence base to inform regulatory decisions to reduce tobacco and ENDS use at the population level.

Racial Disparities in Flavored Tobacco Product Use, Curiosity, Susceptibility, and Harm Perception, National Youth Tobacco Survey 2019-2020

Introduction

Studies characterizing differences in youth flavored tobacco product use prevalence, curiosity/susceptibility, and harm perceptions by race and ethnicity are limited. This study comprehensively examines flavored tobacco product use and harm perceptions among U.S. middle and high school students, by race and ethnicity.

Methods

Data came from the 2019 (N=19,018) and 2020 (N=14,531) National Youth Tobacco Surveys (NYTS). Weighted prevalence estimates of flavored tobacco product use and curiosity, susceptibility, and harm perception are reported by race and ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, or NH Other). t-Tests assessed differences in prevalence by years and racial/ethnic groups.

Results

Among youth with past 30-day tobacco use, use of most flavored tobacco products increased across all racial/ethnic groups; the largest increase was observed among Hispanic youth using other flavored tobacco products (30.3%). The group with the highest susceptibility to future electronic cigarette (e-cigarette) use was Hispanic students (42.3%). Hispanic students had the highest curiosity about and susceptibility to future use of cigarettes and cigars as well.

Conclusions

Increases in the use of and higher susceptibility to other flavored tobacco products, particularly among Hispanic youth, suggest a need for additional changes in environmental conditions and possibly targeted or tailored tobacco control interventions for Hispanic youth.

Implications

Given that flavored tobacco use is prevalent among youth and aggressively marketed more to racial/ethnic minority populations, it is important to understand how susceptibility and perceptions relate to tobacco use. Our results suggest a need for a better understanding of social and environmental factors that drive tobacco use behaviors and perceptions, particularly among Hispanic youth, to address the root causes of these differences and create more equitable tobacco control interventions.

Electronic cigarette or vaping use among adolescents in the United States: A call for research and legislative action

Vaping among adolescents is increasingly common and may result in poor health outcomes; however, little research has been conducted evaluating the risks of vaping among adolescents and the knowledge and perceptions that drive use. We must gain a better understanding of vaping outcomes and adolescents' perceptions while identifying potential ways to lessen or eradicate the health burdens associated with vaping. This knowledge could then inform robust educational and public health programs to prevent and mitigate vaping among youths. Health education incorporating a target populations' world view, spheres of influence, readiness, motivation, intention, and determination promotes informed decision making. There are few resources currently being allocated to the problem even though legislators and enforcement agencies are aware. We cannot simply rely on existing laws to serve as a sufficient deterrent to prevent underaged usage. Further efforts are needed in the areas of behavioral science, health education, and public policy to tackle this urgent public health concern.

Centering racial justice for Black/African American and Indigenous American people in commercial tobacco product regulation

Although overall health in the United States (US) has improved dramatically during the past century, long-standing health inequities, particularly the unequal and unjust burden of tobacco-related disease and death among racialized populations, persist. A considerable gap exists in our understanding of how commercial tobacco product regulations and policies cause and/or exacerbate race-based health inequities among Black/African American (B/AA) and Indigenous American people. The purpose of this paper is to 1) describe how existing US commercial tobacco regulatory policies may contribute to structural racism and undermine the full benefits of tobacco prevention and control efforts among B/AA and Indigenous American groups; and 2) initiate a call to action for researchers and regulators of tobacco products to examine policies using an equity lens. These actions are imperative if empirically-informed regulation of commercial tobacco products is to address health equity.

Closing the loopholes on a flavored cigar ban: Anticipated challenges and solutions

For the first time since Congress authorized the U.S. Food and Drug Administration (FDA) to regulate tobacco in 2009, FDA proposed two tobacco product standards on May 4, 2022. After a period of public comment and agency review, if the product standards are finalized in their current form, they will ban menthol cigarettes (U.S. Food and Drug Administration, 2022b), which comprised 37% of the U.S. cigarette market in 2019 and 2020 (Federal Trade Commission, 2021), and flavored cigars (U.S. Food and Drug Administration, 2022a), which have exceeded 50% of cigar sales since 2012 (Delnevo et al., 2021b). This commentary examines potential challenges to banning flavored cigars and highlights issues FDA and Congress should consider.

Impact of tobacco flavoring on oral nicotine consumption in C57BL/6J mice

BACKGROUND

The continued use of flavors in tobacco products has been a prominent factor in their popularity, yet little is known regarding their role in nicotine dependence. This study aimed to investigate the impact of tobacco flavoring on oral nicotine consumption in mice using the two-bottle choice (2BC) test and assessed the potential impact of age and sex in their interactions.

METHODS

Adolescent and adult male and female C57BL/6J mice were used. First, voluntary consumption of tobacco flavor concentrate from a commercial electronic cigarette liquid vendor (Avail Vapor LLC) was measured; then, the effects of tobacco flavoring in combination with nicotine were examined. In one approach, tobacco flavor concentration was kept constant while nicotine concentration varied, and in the second, nicotine was kept constant while the tobacco flavor concentration varied.

RESULTS

Overall, tobacco flavoring decreased oral nicotine consumption in mice, and its effects were sex- and age-dependent. Although females consumed the tobacco-flavored solution at a slightly higher rate than males, male mice were more sensitive to the effects of the combination (nicotine + tobacco). Furthermore, adolescent mice showed a starker reduction in nicotine consumption in the presence of tobacco flavoring compared to adult mice. This attenuation was most likely due to a basal aversion to the tobacco flavoring itself, thus, creating a negative synergistic effect with nicotine.

CONCLUSIONS

Tobacco flavoring increases aversion to nicotine in the 2BC test in C57BL6J mice, suggesting that some flavors may diminish rather than enhance oral nicotine consumption in rodents.