Perceptions and use intentions of flavored versus unflavored tobacco products among young adults in Georgia: A cross-sectional study

Electronic cigarette (e-cigarette) use is common among youth, and there are concerns that e-cigarette use leads to future conventional cigarette use. We examined longitudinal associations between past-month cigarette and e-cigarette use to characterize the stability and directionality of these tobacco use trajectories over time. High school students (N = 808, 53% female) completed surveys across 3 waves (2013, 2014, and 2015) in 3 public schools in Connecticut. Using autoregressive cross-lagged models, we examined bidirectional relationships between past-month cigarette and e-cigarette use over time. Models were adjusted for covariates related to tobacco use (ie, sex, race/ethnicity, socioeconomic status, and use of other tobacco products). Past-month e-cigarette use predicted future cigarette use (wave 1-2: odds ratio [OR] = 7.08, 95% confidence interval [CI] = 2.34-21.42; wave 2-3: OR = 3.87, 95% CI = 1.86-8.06). However, past-month cigarette use did not predict future e-cigarette use (wave 1-2: OR = 2.02, 95% CI = 0.67-6.08; wave 2-3: OR = 1.90, 95% CI = 0.77-4.71). Additionally, frequency of cigarette and e-cigarette use increased over time. By wave 3, 26% of cigarette users and 20.5% of e-cigarette users reported using 21-30 days out of the past month. E-cigarette use was associated with future cigarette use across 3 longitudinal waves, yet cigarette use was not associated with future e-cigarette use. Future research needs to examine mechanisms through which e-cigarette use leads to cigarette use. E-cigarette regulation and prevention programs may help prevent future use of cigarettes among youth.

Heated tobacco products (HTPs) have expanded globally. IQOS, a global HTP leader, was launched in Israel in 2016 and the US in 2019. To inform tobacco control efforts, it is critical to understand who is likely to use HTPs in different countries with distinct regulatory and marketing contexts. Thus, we conducted a cross-sectional survey among adult (ages 18-45) online panelists in the US (n = 1128) and Israel (n = 1094), oversampling tobacco users, in the fall of 2021, and used multivariable regression to identify correlates of (1) ever using IQOS; (2) past-month vs. former among ever users; and (3) interest in trying IQOS among never users. Among US adults, correlates of ever use included being Asian (aOR = 3.30) or Hispanic (aOR = 2.83) vs. White, and past-month use of cigarettes (aOR = 3.32), e-cigarettes (aOR = 2.67), and other tobacco (aOR = 3.34); in Israel, correlates included being younger (aOR = 0.97), male (aOR = 1.64), and cigarette (aOR = 4.01), e-cigarette (aOR = 1.92) and other tobacco use (aOR = 1.63). Among never users, correlates of greater interest included cigarette and e-cigarette use in the US (β = 0.57, β = 0.90) and Israel (β = 0.88, β = 0.92). IQOS use prevalence was low (US: 3.0%; Israel: 16.2%) but represented in vulnerable subpopulations (younger adults, racial/ethnic minorities).

Flavored-Little-Cigar and Flavored-Cigarette Use Among U.S. Middle and High School Students

Cigarette Use Before and After the 2009 Flavored Cigarette Ban

Widely marketed flavored tobacco products might appeal to nonusers and could be contributing to recent increases in tobacco product use. We assessed flavored product use among current tobacco users; and measured associations between flavored product use and dependence among US adults. Data were from the 2014-2015 Tobacco Use Supplement to the Current Population Survey, a cross-sectional household-based survey of US adults ≥18 years (n = 163 920). Current users of cigarettes, cigars, pipes, hookahs, smokeless tobacco, and electronic cigarettes (e-cigarettes) were asked whether their usual product was menthol or came in any characterizing flavors. Proportions of flavored product users were computed nationally and by state and demographic characteristics. Tobacco dependence was assessed with two proxy measures: daily use and use ≤30 minutes after waking. Associations between flavored product use and tobacco dependence were examined using logistic regression adjusted for sex, age, race/ethnicity, and multi tobacco product use. An estimated 41.0% of current users of any tobacco product usually used a flavored product during 2014-2015. The proportion ranged from 22.5% (Maine) to 62.1% (District of Columbia). By product, the proportion ranged from 28.3% (cigars) to 87.2% (hookah). Flavored product use was associated with: daily tobacco product use among current e-cigarette users (adjusted odds ratio [AOR] = 1.71), cigar smokers (AOR = 1.42), and cigarette smokers (AOR = 1.13); and tobacco product use ≤30 minutes after waking among current cigar smokers (AOR = 1.80), and cigarette smokers (AOR = 1.11). Restricting sales of flavored tobacco products and implementation of proven population-level tobacco control interventions could help reduce tobacco product use among US adults. During 2014-2015, flavored tobacco products were widely used by US adults with variations across states and demographic characteristics. Use of flavored e-cigarettes, flavored cigars, and menthol cigarettes were associated with daily tobacco use: use of flavored cigars and menthol cigarettes were associated with tobacco use within 30 minutes after waking. These findings suggest associations between flavor use and increased tobacco dependence. Prohibiting sale of flavored products can reduce access to those products, and could help reduce tobacco dependence and promote cessation behaviors among current tobacco product users.

IntroductionIn December 2022, a California law banned the retail sale of most flavored tobacco products (including e-cigarettes). This investigation evaluates adolescents’ use of flavored tobacco before and after enactment.Aims and MethodsThe Teens Nicotine and Tobacco Project included online surveys of California adolescents (age 12–17) in 2022 (N = 5127) and 2023 (N = 5015) that assessed past 30-day use of various tobacco products, flavored product use, and perceived access to flavored e-cigarettes. Eight focus groups conducted in 2023 and 2024 (total N = 35) queried flavored tobacco experiences and perceptions.ResultsAmong participants who used specific products, the prevalence of flavored product use declined for cigarettes (2022: 72.0%; 2023: 57.2%), cigars (2022: 87.2%; 2023: 67.4%), and smokeless tobacco (2022: 93.1%; 2023: 83.1%) but not for e-cigarettes (2022: 91.0%; 2023: 90.7%) or hookah (2022: 88.1%; 2023: 85.6%; the flavor law exempted some hookah sales). In 2023, 10.2% of all participants used any flavored tobacco product (2022: 10.0%), primarily flavored e-cigarettes (2022: 8.6%; 2023: 8.8%). In 2023, 22.0% of all participants were aware of the statewide flavor ban, including 44.1% of participants who reported tobacco use. Few focus group participants were aware of the statewide law or perceived difficulties accessing flavored e-cigarettes.ConclusionsShortly following a statewide flavor ban, adolescent use of flavored cigarettes, cigars, and smokeless tobacco declined, but flavored e-cigarette use was unchanged. More time for implementation and enforcement may be needed to see full policy impact.ImplicationsThese findings suggest that a statewide flavored tobacco policy in California was followed shortly by declines in adolescent use of some flavored tobacco products. Additional time for implementation and enforcement, along with potential further actions, such as greater restrictions on online sales, could be necessary to curb youth access to flavored e-cigarettes.

<h3>Introduction</h3> Modified risk tobacco product (MRTP) claims for heated tobacco products (HTPs) that convey reduced exposure compared with conventional cigarettes may promote product initiation and transition among young people. We assessed the effects of a hypothetical MRTP claim for HTPs on young adults’ intention and perceptions of using HTPs and whether these effects differed by their current cigarette and e-cigarette use. <h3>Methods</h3> We embedded a randomised between-subjects experiment into a web-based survey administered among a cohort of 2354 Southern California young adults (aged 20–23) in 2020. Participants viewed depictions of HTPs with an MRTP claim (n=1190) or no claim (n=1164). HTP use intention and HTP-related harm and use perceptions relative to cigarettes and e-cigarettes were assessed. <h3>Results</h3> Overall, participants who viewed versus did not view the claim did not differ in HTP use intention (28.5% vs 28.7%) but were more likely to perceive HTPs as less harmful than cigarettes (11.4% vs 7.0%; p&lt;0.001). The experimental effect on HTP use intention did not differ among past 30-day cigarette smokers versus non-smokers (interaction adjusted OR (AOR)=0.78, 95% CI 0.36 to 1.76) but differed among past 30-day e-cigarette users versus non-users (interaction AOR=1.67, 95% CI 1.02 to 2.68). <h3>Discussion</h3> The hypothetical MRTP claim may lower young adults’ HTP harm perceptions compared with cigarettes but may not change HTP use intention overall or differentially for cigarette smokers. The larger effect on HTP use intention among e-cigarette users than non-users raises the question of whether MRTP claims may promote HTP use or HTP and e-cigarette dual use among young e-cigarette users.

Background The e-cigarette industry has targeted low- and middle-income countries and young adults, suggesting the particular susceptibility of populations at the intersection. This study assessed e-cigarette perceptions, use, and use intention among college students in Georgia, an LMIC with high smoking rates. Methods We analyzed 2023 cross-sectional survey data among 225 students (Mage = 21.68, SD = 3.43; 56.4% female) at a large medical university in Tbilisi, Georgia. Multivariable regression analyses assessed sociodemographics, tobacco use, and e-cigarette perceptions in relation to past-month e-cigarette use and next-year use intentions. Results Past-month use of cigarettes and e-cigarettes was 44.9% and 23.3%, respectively. The most common sources of initial exposure were friends/family (72.2%), followed by media (25.6%). The most common reasons for initiation were curiosity (49.6%), friends’ use (28.5%), cigarette cessation (15.5%), and lower perceived risk versus cigarettes (2.4%). Past-month e-cigarette use was associated with past-month cigarette use (p < .001), being more informed about e-cigarettes (p = .001), and more favorable e-cigarette perceptions (p = .009). Greater next-year e-cigarette use intent was associated with past-month e-cigarette use and perceiving e-cigarettes as less of a public health problem (p = .029). Discussion Enhanced regulatory and educational efforts must address e-cigarette use and related factors among young adults in Georgia and countries with similar contexts.

Background: Electronic dance music (EDM) party attendees are at high risk for use of various illegal drugs; however, little is known about their tobacco use. Understanding tobacco use patterns in this population at high risk for illegal drug use can inform multi-product interventions. Objectives: 954 EDM party attendees (ages 18–40) were surveyed in New York City in 2017. We estimated prevalence of use of cigarettes, hookah, cigars, other tobacco, and e-cigarettes and delineated correlates of current (past-month) use using bivariable and multivariable models. Results: Past-month use of cigarettes (36.2%), e-cigarettes (15.6%), cigars (12.5%), and hookah (11.7%) in particular was prevalent. In multivariable models, females were less likely to use e-cigarettes than males (adjusted prevalence ratio [aPR] = 0.63, p = .030), and those who attended graduate school were less likely to use cigarettes (aPR = 0.55, p = .003) and/or e-cigarettes (aPR = 0.33, p = .026). Past-year ecstasy/MDMA/Molly use was a risk factor for past-month use of cigarettes (aPR = 1.38, p = .013) and/or cigars (aPR = 1.61, p = .032), and past-year cocaine use was a risk factor for past-month use of cigarettes (aPR = 1.80, p < .001), cigars (aPR = 1.80, p = .013), other tobacco products (aPR = 3.05, p = .003), and/or e-cigarettes (aPR = 2.39, p = .003). 55.4% of ecstasy users and 60.3% of cocaine users were current cigarette smokers, but use of other products among users of these drugs was less prevalent (9.8–27.9%). Conclusions: Results suggest that current tobacco use is prevalent in this population who is also at high risk for use of drugs such as ecstasy and cocaine. Prevention and cessation efforts need to target tobacco users in this scene while incorporating components addressing illegal drug use.

Limited longitudinal research has examined differential interpersonal and intrapersonal correlates of young adult use and use frequency of cigarettes, e-cigarettes, and cannabis. This study aimed to address these limitations. We analyzed five waves of longitudinal data (2018-2020) among 3006 US young adults (Mage = 24.55, 44% male, 32% sexual minority, ~30% racial/ethnic minority). Two-part latent growth models examined likelihood of past-month cigarette, e-cigarette, and cannabis use (binary part) and days used (continuous part) and identified predictors (depressive symptoms, personality traits, adverse childhood experiences [ACEs], parental use) of baseline use and changes over time. Regarding baseline past-month use (27% cigarettes, 38% e-cigarettes, 39% cannabis), depressive symptoms, ACEs, and parental substance use predicted use outcomes (i.e., likelihood, frequency) for each product; extraversion predicted cigarette and e-cigarette use outcomes; openness predicted e-cigarette and cannabis use outcomes; conscientiousness negatively predicted cigarette and cannabis use outcomes; and agreeableness negatively predicted cannabis use frequency. Regarding longitudinal changes, conscientiousness predicted accelerated increase of cigarette use frequency at later timepoints; depressive symptoms predicted increases in likelihood of e-cigarette use but the association weakened over time; and parental cannabis use predicted decreased cannabis use frequency but the association weakened over time. Young adult substance use interventions should target high-risk subgroups and focus on distinct factors impacting use, including chronic, escalating, and decreasing use. This study advances the literature regarding distinct predictors of different substance use outcomes and provides unique data to inform interventions targeting young adult cigarette, e-cigarette, and cannabis use.

Although a few countries have banned flavored cigarettes (except menthol), flavors in most tobacco products remain unregulated across the globe. We conducted a systematic review of qualitative studies examining perceptions of and experiences with flavored non-menthol tobacco products. Of 20 studies on flavored tobacco products included in our qualitative systematic review, 10 examined hookah, six examined e-cigarettes, two examined little cigars and cigarillos (LCCs), and three examined other tobacco products, including cigarettes. The majority of studies, regardless of product type, reported positive perceptions of flavored tobacco products, particularly among young adults and adolescents. In six studies that assessed perceptions of harm (including hookah, LCCs, and other flavored tobacco products), participants believed flavored tobacco products to be less harmful than cigarettes. In studies that examined the role of flavors in experimentation and/or initiation (including three studies on e-cigarettes, one hookah study and one LCC study), participants mentioned flavors as specifically leading to their experimentation and/or initiation of flavored tobacco products. Given that many countries have not yet banned flavors in tobacco products, these findings add to existing research on why individuals use flavored tobacco products and how they perceive harm in flavored tobacco products, providing further support for banning non-menthol flavors in most tobacco products.

ObjectiveThis systematic review examines the impact of non-menthol flavours in tobacco products on tobacco use perceptions and behaviours among youth, young adults and adults.Data sourcesEnglish-language peer-reviewed publications indexed in 4...

INTRODUCTIONCOVID-19 impacted cigarette and e-cigarette use behaviors among some individuals. This study examined COVID-19 factors and prior substance use as predictors of cigarette and e-cigarette cessation and initiation among US young adults from before to during the COVID-19 pandemic.METHODSWe analyzed data from Wave 3 (Sept–Dec 2019) and Wave 5 (Sept–Dec 2020) of a 2-year, 5-wave longitudinal study of young adults across six US metropolitan areas. We examined COVID-19 news exposure, perceived smoking and e-cigarette use risk, and prior substance use, as predictors of cigarette and e-cigarette cessation and initiation, respectively.RESULTSOf W3 cigarette users (n=516), 37.8% (n=195) quit cigarettes at W5; predictors of cessation included younger age, fewer days of W3 past-month cigarette use, and no W3 e-cigarette use. Of W3 e-cigarette users (n=687), 38.7% (n=266) quit e-cigarettes at W5; predictors included greater COVID-19 news exposure, fewer days of W3 past-month e-cigarette use, and no W3 cigarette use. Of W3 cigarette non-users (n=1693), 5.0% (n=85) initiated cigarettes at W5; predictors of initiation included younger age, lower perceived smoking risk, lifetime cigarette and e-cigarette use, and W3 e-cigarette use. Of W3 e-cigarette non-users (n=1522), 6.3% (n=96) initiated e-cigarettes at W5; predictors included younger age, less news exposure, lifetime cigarette and e-cigarette use, and W3 cigarette use.CONCLUSIONSThese findings underscore the need to address cigarette and e-cigarette co-use and related risk perceptions in prevention and cessation interventions.

Seven states have policies restricting the sale of flavored e-cigarettes. Limited evidence exists regarding these policies' association with the use of tobacco products across age groups. To evaluate associations of e-cigarette flavor restriction policies with e-cigarette and cigarette use by age group over multiple years. In this cross-sectional study, annual state-level prevalences of e-cigarette and cigarette use in the US between 2015 and 2023 were separately estimated among youths (high school age) using data from the Youth Risk Behavior Survey (YRBS) and young adults (ages 18-24 years) and adults (ages ≥25 years) using the Behavioral Risk Factor Surveillance System (BRFSS). Six policy states had multiple years of postpolicy data available; other states were control states. Associations between policy and prevalence of e-cigarette and cigarette use in each postpolicy year were estimated annually using difference-in-differences analysis, setting 2019 as the prepolicy year and 2020 to 2023 as postpolicy years. Statewide policy restricting sales of non-tobacco flavored e-cigarettes. State annual prevalence of past 30-day (YRBS) and current (BRFSS) e-cigarette and cigarette use. Prevalence data were obtained for 186 (YRBS) and 386 (BRFSS) state-years for e-cigarettes and 191 (YRBS) and 456 (BRFSS) state-years for cigarettes. In recent years, e-cigarette use prevalence decreased among youths (eg, the change in mean prevalence from 2019 to 2023 was 24.1% to 14.0% for policy states and 24.6% to 17.2% for control states) but increased in control states among young adults (eg, mean prevalence, 17.0% in 2019 to 20.4% in 2023). Cigarette use prevalence decreased in policy and control states, although policy states exhibited lower prepolicy prevalence and attenuated postpolicy decreases (eg, mean prevalence, 6.7% in 2019 to 3.8% in 2023 among young adults) relative to control states (eg, mean prevalence, 12.1% in 2019 to 6.3% in 2023 among young adults). Flavor policies were associated with reduced e-cigarette use among young adults in 2022 (average treatment effect among the treated [ATT], -6.7 percentage points; 95% CI, -1.3 to -12.1 percentage points) and adults aged 25 years or older in 2023 (ATT, -1.2 percentage points; 95% CI, -2.0 to -0.4 percentage points) and increased cigarette use among youths in 2021 (ATT, 1.8 percentage points; 95% CI, 0.7 to 2.9 percentage points) and young adults in 2021 (ATT, 3.7 percentage points; 95% CI, 2.2 to 5.2 percentage points), 2022 (ATT, 2.7 percentage points; 95% CI, 1.4 to 4.1 percentage points), and 2023 (ATT, 3.2 percentage points; 95% CI, 0.9 to 5.5 percentage points). In this study, flavor restriction policies were associated with some reductions in e-cigarette use but also unintended increases in cigarette use, highlighting a need for further work evaluating potential substitution outcomes and prevention of tobacco use among youths.

In 2020, Massachusetts became the first state in the USA to restrict the sale of flavoured tobacco products. One demographic group that is disproportionately impacted by flavoured tobacco use is young people. This study explored how Massachusetts' flavour restriction impacted young adults and the ways that flavoured tobacco products were acquired after policy implementation. Between January and March 2024, we conducted 15 virtual, semistructured qualitative interviews with young adults (aged 19-29) who were living in Massachusetts and who reported ever using a flavoured tobacco product. The interview guide included questions about personal tobacco use, awareness of the flavour restriction policy and accessing flavoured tobacco products. After interviews were transcribed and coded, themes were identified. Only 1 out of 15 participants believed that it would be hard for them to acquire flavoured tobacco products with Massachusetts' policy in place. Social sources were a common way participants reported getting flavoured tobacco products and one-third of participants mentioned seeing them sold on social media platforms. Snapchat was the most frequently reported platform; participants described the 'easy' process of connecting with sellers on Snapchat and how 'openly' people listed the products they had for sale. Despite Massachusetts implementing a comprehensive flavoured tobacco restriction (FTR), young adults report being able to access flavoured tobacco products with ease. Snapchat was the social media platform that participants brought up frequently to find people selling flavoured tobacco products. Preventing the sale of flavoured tobacco products through Snapchat and other social sources will be critical for Massachusetts' FTR to have its intended impact.