E-Cigarette Flavors and Frequency of E-Cigarette Use among Adult Dual Users Who Attempt to Quit Cigarette Smoking in the United States: Longitudinal Findings from the PATH Study 2015/16-2016/17.

Maciej L. Goniewicz,Geoffrey T. Fong,Marushka L. Silveira,Lisa D. Gardner,Izabella Zandberg,Shannon Gravely,Kathryn C. Edwards,Andrew Hyland,Karin A. Kasza,Michael D. Sawdey

doi:10.3390/ijerph18084373

Abstract

Potential mechanisms by which e-cigarette use may relate to combustible cigarette smoking cessation are not well-understood. We used U.S. nationally representative data to prospectively evaluate the relationship between e-cigarette flavor use and frequency of e-cigarette use among adult cigarette/e-cigarette dual users who attempted to quit smoking cigarettes. Analyses used Population Assessment of Tobacco and Health (PATH) Study data from adult dual users (2015/16) who attempted to quit smoking between 2015/16 and 2016/17 (Wave 3-Wave 4, n = 685, including those who did/did not quit by 2016/17). E-cigarette flavor use (usual/last flavor, past 30-day flavor; assessed in 2015/16) was categorized into Only tobacco; Only menthol/mint; Only non-tobacco, non-menthol/mint; and Any combination of tobacco, menthol/mint, other flavor(s). The key outcome, evaluated at follow-up in 2016/17, was frequent e-cigarette use, which was defined as use on 20+ of past 30 days. Logistic regression was used to evaluate associations between e-cigarette flavor use in 2015/16 and frequent e-cigarette use at follow-up in 2016/17. Dual users who attempted to quit smoking had greater odds of frequent e-cigarette use at follow-up when they used only non-tobacco, non-menthol/mint flavor than when they used only tobacco flavor as their regular/last e-cigarette flavor (OR = 1.9, 95% CI: 1.1–3.4); findings were no longer significant when adjusted for factors including e-cigarette device type (AOR = 1.4, 95% CI: 0.7–2.8). Past 30-day e-cigarette flavor use results were generally similar, although frequent e-cigarette use at follow-up was highest among those who used any combination of tobacco, menthol/mint, or other flavors. Findings indicate that e-cigarette flavor use among dual users who attempt to quit smoking may be related to e-cigarette use frequency overall, which may indicate a mechanism underlying findings for e-cigarette use and smoking cessation. Further longitudinal research may help to disentangle how e-cigarette characteristics uniquely impact e-cigarette use frequency and smoking cessation/sustained use.

Highlights

A 2020 Cochrane Systematic Review concluded with moderate certainty that use of electronic nicotine products (“e-cigarettes”) increases combustible cigarette quit rates [1]; the role that various e-cigarette characteristics may play in combustible cigarette cessation behaviors remains unclear [2], and investigation into intermediate measures may provide insight on potential mechanisms of action underlying overall clinical trial findings
Frequent e-cigarette use at follow-up was highest among those who used only non-tobacco, non-menthol/mint flavor(s) (31.3%, 95% Confidence Intervals (CI): 26.5–36.6), followed by those who used any combination of tobacco, menthol/mint, or other flavor(s)
Frequent e-cigarette use at follow-up was highest among those who used any combination of tobacco, menthol/mint, or other flavors (40.5%, 95% CI: 27.2–55.3), followed by those who used only non-tobacco, non-menthol/mint flavor(s)

Summary

Introduction

A 2020 Cochrane Systematic Review concluded with moderate certainty that use of electronic nicotine products (“e-cigarettes”) increases combustible cigarette quit rates [1]; the role that various e-cigarette characteristics may play in combustible cigarette cessation behaviors remains unclear [2], and investigation into intermediate measures may provide insight on potential mechanisms of action underlying overall clinical trial findings. A randomized controlled trial in the United Kingdom among cigarette quit attempters found e-cigarette use to be more beneficial for quitting compared to nicotine replacement therapy use, with greater treatment adherence in the e-cigarette treatment arm compared to the nicotine replacement therapy treatment arm, and with fruit-flavored e-cigarettes most popular among participants [4] These findings may not reflect what happens in the real world or among the U.S population, and no e-cigarettes have been approved by the FDA as a cessation aid in the U.S. At the population level in the U.S, e-cigarette flavor use has been found to be associated with frequency of e-cigarette use in general [5], as has e-cigarette device type use, with users of open systems (i.e., refillable tanks) generally using more frequently than users of closed systems (i.e., disposables, devices with cartridges), and with users of open systems more likely to use non-tobacco flavors (e.g., fruit, candy) [6]. Kasza et al found that e-cigarette flavor use was not associated with making a subsequent attempt to quit cigarette smoking [11], suggesting that the overall association found by Friedman and Xu may be driven by those making a quit attempt

Objectives

Methods

Results

Discussion

Conclusion