E-cigarette Flavors Research Articles

"You have to vape to make it through": E-cigarette Outcome Expectancies among Youth and Parents.

Objectives: Outcome expectancies are central to explaining health behavior and have been shown to predict tobacco use. Research on outcome expectancies for e-cigarette use among youth is scarce but increasingly important given the growing rates of use, particularly of high-nicotine pod devices and the recent outbreak of e-cigarette related lung disease. Methods: In 2019, we conducted 3 focus groups with middle school youth (N=25), 5 with high school youth (N=38), and 4 with parents (N=27). Youth and parents were not related and groups included both users and non-users. Participants discussed reasons for e-cigarette use and bad and good things that might happen to a person who vapes. Results: Participants described positive and negative psychoactive/sensory, social, and health-related outcome expectancies. Both youth and parents mentioned stress relief and appearing older as positive outcome expectancies, and e-cigarette flavors, acting rebellious, and structural opportunities as other reasons for initiating e-cigarette use. Social consequences and health outcomes were negative outcome expectancies deterring use. Conclusions: Regulations and public communication campaigns can counteract the positive outcome expectancies (flavor regulation, providing stress reduction tips) and capitalize on negative ones (communicating negative health outcomes) to decrease youth e-cigarette use.

Comparative Reactive Oxygen Species (ROS) Content among Various Flavored Disposable Vape Bars, including Cool (Iced) Flavored Bars.

Studies have shown that aerosols generated from flavored e-cigarettes contain Reactive Oxygen Species (ROS), promoting oxidative stress-induced damage within pulmonary cells. Our lab investigated the ROS content of e-cigarette vapor generated from disposable flavored e-cigarettes (vape bars) with and without nicotine. Specifically, we analyzed vape bars belonging to multiple flavor categories (Tobacco, Minty Fruit, Fruity, Minty/Cool (Iced), Desserts, and Drinks/Beverages) manufactured by various vendors and of different nicotine concentrations (0–6.8%). Aerosols from these vape bars were generated via a single puff aerosol generator; these aerosols were then individually bubbled through a fluorogenic solution to semi-quantify ROS generated by these bars in H2O2 equivalents. We compared the ROS levels generated by each vape bar as an indirect determinant of their potential to induce oxidative stress. Our results showed that ROS concentration (μM) within aerosols produced from these vape bars varied significantly among different flavored vape bars and identically flavored vape bars with varying nicotine concentrations. Furthermore, our results suggest that flavoring chemicals and nicotine play a differential role in generating ROS production in vape bar aerosols. Our study provides insight into the differential health effects of flavored vape bars, in particular cool (iced) flavors, and the need for their regulation.

Racial Disparities of E-Cigarette Use Among US Youths: 2014‒2019.

Objectives To evaluate disparities in youth e-cigarette use patterns and flavor use by race/ethnicity over time. Methods We used data from the US 2014-2019 National Youth Tobacco Survey (NYTS) to examine trends in dual use (co-use of e-cigarettes and cigarettes or other tobacco products), occasional (≤ 5 days) versus frequent use (≥ 20 days) in the past 30 days, and flavor use among current (past-30-day) e-cigarette users (n = 13 178) across racial/ethnic groups (non-Hispanic Whites, non-Hispanic Blacks, Hispanics/Latinos, and non-Hispanic others). Results Among current e-cigarette users, dual use and occasional use decreased significantly from 2014 to 2019 across racial and ethnic groups except for non-Hispanic Blacks; frequent use and flavored e-cigarette use increased among non-Hispanic Whites, Hispanics/Latinos, and non-Hispanic others but not among non-Hispanic Blacks. In 2019, non-Hispanic Black e-cigarette users were more likely to report dual use (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI] = 1.5, 3.2; P < .001) and occasional use of e-cigarettes (AOR = 3.7; 95% CI = 2.3, 5.9; P < .001) but less likely to report frequent use (AOR = 0.2; 95% CI = 0.1, 0.4; P < .001) and flavored e-cigarette use (AOR = 0.4; 95% CI = 0.3, 0.5; P < .001) than their White peers. Conclusions Youth e-cigarette use patterns differed considerably across racial/ethnic groups, and tailored strategies to address disparities in e-cigarette use are needed. (Am J Public Health. 2021;111(11):2050-2058. https://doi.org/10.2105/AJPH.2021.306448).

E-Cigarette Toxicology.

Since the spread of tobacco from the Americas hundreds of years ago, tobacco cigarettes and, more recently, alternative tobacco products have become global products of nicotine addiction. Within the evolving alternative tobacco product space, electronic cigarette (e-cigarette) vaping has surpassed conventional cigarette smoking among adolescents and young adults in the United States and beyond. This review describes the experimental and clinical evidence of e-cigarette toxicity and deleterious health effects. Adverse health effects related to e-cigarette aerosols are influenced by several factors, including e-liquid components, physical device factors, chemical changes related to heating, and health of the e-cigarette user (e.g., asthmatic). Federal, state, and local regulations have attempted to govern e-cigarette flavors, manufacturing, distribution, and availability, particularly to underaged youths. However, the evolving e-cigarette landscape continues to impede timely toxicological studies and hinder progress made toward our understanding of the long-term health consequence of e-cigarettes.

Cooling e-cigarette flavors and the association with e-cigarette use among a sample of high school students.

IntroductionE-liquid flavor is typically presented by flavor category (e.g. menthol, mint, fruit, dessert). Cooling sensations produced by flavor additives such as menthol enhance appeal of e-cigarettes among youth, but not all e-liquids that produce cooling sensations are labeled as menthol. Sensory experiences produced by flavors may allow for a new way to capture e-cigarette flavor use. This study aims to examine use of flavors that produce cooling sensations among youth and its association with e-cigarette use behaviors.MethodsA 2019 survey of high school students (n = 4875) examined use of e-cigarette flavors that produced cooling sensations (cooling flavors) among past 30-day e-cigarette users. E-cigarette use behaviors (flavor use, nicotine use, frequency of use) were examined between those who did and did not use cooling flavors. A binary logistic regression was used to examine associations between vaping frequency, nicotine (vs. non-nicotine) use, and vaping cooling flavors while controlling for demographics, number of flavors vaped in the past month, and vaping age of onset.Results51.6% (n = 473/916) of the analytic sample endorsed vaping cooling flavors. There were no demographic differences by vaping cooling flavors. Vaping cooling flavors was associated with vaping more frequently (AOR:1.04,95% CI:1.03,1.05) and vaping nicotine (AOR:2.37,95% CI:1.53,3.67).ConclusionVaping cooling flavors was associated with greater nicotine vaping and frequency of e-cigarette use. Assessing sensory experience, such as cooling, in addition to flavor category may more fully capture e-cigarette flavor use and its impacts on youth e-cigarette use behaviors.

First E-Cigarette Flavor and Device Type Used: Associations With Vaping Persistence, Frequency, and Dependence in Young Adults

Type of e-cigarette flavoring and device during first use might differentiate later e-cigarette use and dependence. This retrospective cross-sectional study examined associations of recalled first nicotine vaping device and flavor used with current vaping frequency/dependence. A young adult cohort from Los Angeles, California, USA completed web-based surveys (N = 2553). Using cross-sectional data from 971 reporting ever vaping nicotine, multivariable hurdle regressions tested associations between recalled first flavor (fruit/sweet, menthol/mint, other) and device (Juul, disposable, mod, box, pod, pen, other) vaped with past-30-day vaping status (yes/no) and frequency (1-30 days), and with any vaping dependence symptoms (yes/no) and count (1-10 symptoms). The most common first-flavor was sweet (71%); the most common first-device was a vape pen (37%), then Juul (22%). First-flavor of mint/menthol (vs. other; adjusted odds ratio [AOR]: 2.22[95% CI = 1.16 to 4.25]), and first-device mod (AOR = 2.40[95% CI = 1.34 to 4.31]) and non-Juul pod (2.64[95% CI = 1.41 to 4.92]) (vs. pen) were associated with past-30-day vaping, and twice as many vaping days (adjusted rate ratios [ARRs] range: 1.96-2.12; ps < .05). First flavor of mint/menthol (vs. other; AOR: 1.95[95% CI = 1.003 to 3.79) and first device mod, box, non-Juul pod, and other (AORs range: 2.36-4.01; ps < .05) were associated with nicotine dependence. First device Juul, mod, box, and non-Juul pod were also associated with more dependence symptoms (ARRs range:1.38-1.59; ps < .05). Exposure to mint/menthol and certain devices (mod, box, Juul, and non-Juul pods) at first e-cigarette use may be associated with more frequent e-cigarette use and nicotine dependence symptoms in young adulthood. Mint/menthol and certain devices warrant consideration in regulation of e-cigarettes based on product characteristics. Characteristics (flavor and device type) of first e-cigarette product used were associated with higher usage and more dependence. Pending replication with prospective designs, the findings suggest certain flavors (mint/menthol) and devices (pods, mods) merit consideration in regulation because of their possible link with continued use and dependence among young people.

Perceptions of the IQOS Heated Tobacco Product on Twitter in the United States

After the approval of the sales of IQOS in the United States market, discussions about IQOS have become active on social media. Twitter is a popular social media platform to understand public opinions toward IQOS. This study aims to explore public perceptions toward IQOS on Twitter in the United States. IQOS-related tweets from the United States between November 19, 2019, and August 24, 2020, were collected using a Twitter streaming application programming interface (API). Sentiment analysis was performed to determine whether the public perceptions toward IQOS were positive, neutral, or negative. In addition, topics discussed in these tweets were manually coded. From November 2019 to August 2020, the number of tweets discussing IQOS was relatively constant except for a peak starting from July 7, 2020, which lasted for 4 days. Among IQOS tweets with positive sentiments, the most popular topic is “IQOS is safer than cigarettes,” followed by “IQOS helps quit smoking.” Among tweets with negative sentiments, the most popular topic is “illegal marketing/selling to youth,” followed by “health risks/fire hazards.” “FDA approval/regulation” is the most popular topic for tweets with neutral sentiments. After the announcement of the United States Food and Drug Administration (FDA) enforcement policy on unauthorized flavored e-cigarette products on January 2, 2020, the proportion of tweets with positive attitudes toward IQOS significantly increased, while the proportion of negative tweets significantly decreased. Our study showed that the public perception of IQOS in the United States became more positive after the FDA enforcement policy on flavored e-cigarettes. While many Twitter users thought IQOS is safer than cigarettes and helps quit smoking, some Twitter users complained about the illegal marketing and health risks of IQOS. These findings provide useful information on future tobacco regulations.

Impact of flavours, device, nicotine levels and price on adult e-cigarette users’ tobacco and nicotine product choices

IntroductionTo understand the impact of e-cigarette devices, flavours, nicotine levels and prices on adult e-cigarette users’ choices among closed-system and open-system e-cigarettes, cigarettes and heated tobacco products (HTPs).MethodsOnline discrete choice...

Characteristics of e-Cigarette Use Behaviors Among US Youth, 2020

Comprehensive surveillance of e-cigarette use behaviors among youth is important for informing strategies to address this public health epidemic. To characterize e-cigarette use behaviors among US youth in 2020. The 2020 National Youth Tobacco Survey, a nationally representative, cross-sectional, school-based survey of middle school (grades 6-8) and high school (grades 9-12) students, was conducted from January 16, 2020, to March 16, 2020. A total of 14 531 students from 180 schools participated in the 2020 survey, yielding a corresponding student-level participation rate of 87.4% and school-level participation rate of 49.9%. The overall response rate, a product of the school-level and student-level participation rates, was 43.6%. Current (past 30-day) e-cigarette use. Self-reported current e-cigarette use behaviors (frequency of use, usual e-cigarette brand, and access source) by school level and flavored e-cigarette use and flavor types among current e-cigarette users by school level and device type. Prevalence estimates were weighted to account for the complex survey design. Overall, 14 531 students completed the survey, including 7330 female students and 7133 male students with self-reported grade level and sex. In 2020, 19.6% (95% CI, 17.2%-22.2%) of high school students and 4.7% (95% CI, 3.6%-6.0%) of middle school students reported current e-cigarette use. Among them, 38.9% (95% CI, 35.2%-42.6%) of high school users and 20.0% (95% CI, 16.0%-24.8%) of middle school users reported e-cigarette use on 20 to 30 days within the past 30 days. Among current users, JUUL was the most commonly reported usual brand (high school: 25.4%; 95% CI, 18.8%-33.4%; middle school: 35.1%; 95% CI, 27.9%-43.1%). Among current users, the most common source of obtaining e-cigarettes was from a friend (high school: 57.1%; 95% CI, 52.6%-61.4%; middle school: 58.9%; 95% CI, 51.4%-66.1%). Among current users, 84.7% (95% CI, 82.2%-86.9%) of high school students and 73.9% (95% CI, 66.9%-79.8%) of middle school students reported flavored e-cigarette use. Fruit-flavored e-cigarettes were the most commonly reported flavor among current exclusive e-cigarette users of prefilled pods or cartridges (67.3%; 95% CI, 60.9%-73.0%), disposable e-cigarettes (85.8%; 95% CI, 79.8%-90.3%), and tank-based devices (82.7%; 95% CI, 68.9%-91.1%), followed by mint-flavored e-cigarettes. These results suggest that although current e-cigarette use decreased during 2019 to 2020, overall prevalence, frequent use, and flavored e-cigarette use remained high. Continued actions are warranted to prevent and reduce e-cigarette use among US youth.

Vaping, SARS-CoV-2, and Multisystem Inflammatory Syndrome: A Perfect Storm.

The use of electronic cigarettes (e-cigarettes) and vaping among adolescents has risen exponentially in the last decade. E-cigarette flavors has driven adolescents to use these convenient, USB-like devices, designed to create a desired social image, while being seemingly unaware of the serious health consequences of their behavior. Vaping impacts protective pulmonary barriers by attenuating the mucociliary clearance and by increasing peribronchial inflammation and fibrosis. The recent SARS-CoV-2 (COVID-19) pandemic has been characterized by a plethora of unusual disease presentations. Among them, a unique presentation seen exclusively in children and adolescents was multisystem inflammatory syndrome (MIS-C). Seventy percent of adolescents who had MIS-C also had acute respiratory distress syndrome (ARDS), and we speculate that there may exist common denominator that links MIS-C and adolescents: the use of e-cigarettes. The virus targets the angiotensin converting receptor (ACE receptor), and studies have shown nicotine-based e-cigarettes or vaping cause oxidative stress and resulting in the upregulation of ACE2, which might worsen ARDS in MIS-C. Our mini-review highlights that adolescents using e-cigarette have alterations in their pulmonary defenses against SARS-CoV-2: an upregulation of the ACE2 receptors, the primary target of SARS-CoV-2. Their compromised immune system makes them more uniquely vulnerable to Covid-19 related MIS-C, increasing their risk for ARDS and related morbidities. Currently, studies have shown an association between MIS-C and vaping, we speculate that adolescents who vape/smoke might be especially vulnerable to serious respiratory symptoms if they develop a hyper-inflammatory state MIS-C.

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.

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.

A machine learning approach to identify correlates of current e-cigarette use in Canada

Aim: Popularity of electronic cigarettes (i.e. e-cigarettes) is soaring in Canada. Understanding person-level correlates of current e-cigarette use (vaping) is crucial to guide tobacco policy, but prior studies have not fully identified these correlates due to model overfitting caused by multicollinearity. This study addressed this issue by using classification tree, a machine learning algorithm. Methods: This population-based cross-sectional study used the Canadian Tobacco, Alcohol, and Drugs Survey (CTADS) from 2017 that targeted residents aged 15 or older. Forty-six person-level characteristics were first screened in a logistic mixed-effects regression procedure for their strength in predicting vaper type (current vs. former vaper) among people who reported to have ever vaped. A 9:1 ratio was used to randomly split the data into a training set and a validation set. A classification tree model was developed using the cross-validation method on the training set using the selected predictors and assessed on the validation set using sensitivity, specificity and accuracy. Results: Of the 3,059 people with an experience of vaping, the average age was 24.4 years (standard deviation = 11.0), with 41.9% of them being female and 8.5% of them being aboriginal. There were 556 (18.2%) current vapers. The classification tree model performed relatively well and suggested attraction to e-cigarette flavors was the most important correlate of current vaping, followed by young age (&lt; 18) and believing vaping to be less harmful to oneself than cigarette smoking. Conclusions: People who vape due to flavors are associated with very high risk of becoming current vapers. The findings of this study provide evidence that supports the ongoing ban on flavored vaping products in the US and suggests a similar regulatory intervention may be effective in Canada.

Effect of Exposure to e-Cigarettes With Salt vs Free-Base Nicotine on the Appeal and Sensory Experience of Vaping

Alkaline free-base nicotine is bitter and a respiratory irritant. High-nicotine electronic cigarette (e-cigarette) products contain acid additives that change nicotine from a free-base to a protonated salt chemical form, which could improve the sensory experience of vaping, particularly among never smokers unaccustomed to inhaling free-base nicotine. To determine whether exposure to e-cigarettes with salt vs free-base nicotine formulations improves the appeal and sensory experience of vaping e-cigarettes and whether nicotine formulation effects differ by e-cigarette flavor and ever combustible cigarette smoking status. Single-visit double-blind within-participant randomized clinical trial was conducted in an academic medical center outpatient clinical research facility in Southern California. Participants were 119 individuals with past 30-day e-cigarette or combustible cigarette use aged 21 years or older recruited from November 2019 to March 2020. Participants self-administered standardized puffs of each 10 differently flavored e-cigarette solutions using a pod-style device. Each flavor was administered in salt (benzoic acid added) and free-base (no benzoic acid) nicotine formulations with commensurate nicotine concentrations (mean, 23.6 mg/mL). The 20 solutions were administered in randomly assigned sequences. Immediately after puffing each solution, participants rated appeal and sensory attributes. Self-reported appeal (mean of like, dislike [reverse-scored], and willingness to use again ratings) and 4 sensory attributes (sweetness, smoothness, bitterness, and harshness; analyzed individually) on visual analog scales with not at all and extremely anchors (range, 0-100). Of the 119 participants; 39 (32.8%) were female. The mean (SD) age was 42.1 (14.4) years; 105 (88.2%) were ever combustible cigarette smokers, and 66 (55.5%) were current e-cigarette users. Salt vs free-base nicotine formulations produced higher ratings of appeal (salt vs free-base mean difference effect estimate: b = 12.0; 95% CI, 9.9-14.1; P < .001), sweetness (b = 9.3; 95% CI, 7.1-11.4; P < .001), and smoothness (b = 17.4; 95% CI, 15.2-19.6; P < .001) and lower ratings of bitterness (b = -13.3; 95% CI, -15.4 to -11.2; P < .001) and harshness (b = -21.0; 95% CI, -23.2 to -18.7; P < .001). Nicotine formulation effects largely generalized across different flavors and the smoothness-enhancing and harshness-reducing effects of nicotine salt were stronger in never vs ever cigarette smokers. In this randomized clinical trial of adult current nicotine or tobacco product users, controlled exposure to e-cigarette puffs with salt vs free-base nicotine formulations appeared to increase product appeal and improve the sensory experience of vaping, particularly among never smokers. Regulatory policies limiting acid additives in e-cigarettes might reduce the appeal of high-nicotine e-cigarettes among populations deterred from vaping e-cigarettes that emit harsh aerosol. ClinicalTrials.gov Identifier: NCT04399031.

Exploring in vitro to in vivo extrapolation for exposure and health impacts of e-cigarette flavor mixtures

In vitro to in vivo extrapolation (IVIVE) leverages in vitro biological activities to predict corresponding in vivo exposures, therefore potentially reducing the need for animal safety testing that are traditionally performed to support the hazard and risk assessment. Interpretation of IVIVE predictions are affected by various factors including the model type, exposure route and kinetic assumptions for the test article, and choice of in vitro assay(s) that are relevant to clinical outcomes. Exposure scenarios are further complicated for mixtures where the in vitro activity may stem from one or more components in the mixture. In this study, we used electronic cigarette (EC) aerosols, a complex mixture, to explore impacts of these factors on the use of IVIVE in hazard identification, using open-source pharmacokinetic models of varying complexity and publicly available data. Results suggest in vitro assay selection has a greater impact on exposure estimates than modeling approaches. Using cytotoxicity assays, high exposure estimates (>1000 EC cartridges (pods) or > 700 mL EC liquid per day) would be needed to obtain the in vivo plasma levels that are corresponding to in vitro assay data, suggesting acute toxicity would be unlikely in typical usage scenarios. When mechanistic (Tox21) assays were used, the exposure estimates were much lower for the low end, but the range of exposure estimate became wider across modeling approaches. These proof-of-concept results highlight challenges and complexities in IVIVE for mixtures.

#FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans

Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. People took to Twitter to voice their opposition, referencing the phrase "Flavors Save Lives." This study documented the emerging themes pertaining to "Flavors Saves Lives" over a 12-month period. The study period was from May 1, 2019, to May 1, 2020. A stratified sampling procedure supplied 2500 tweets for analysis. Posts were classified by one or more of the following themes: (1) Political Referendum; (2) Institutional Distrust; (3) Individual Rights; (4) Misinformation; (5) THC Vaping is the Real Problem; (6) Smoking Cessation; (7) Adult Use; and (8) Not a Bot. The temporal pattern of tweets over the year was examined. Political Referendum (76.5%) and Institutional Distrust (31.3%) were the most prominent themes, followed by Not a Bot (11.0%), Individual Rights (10.4%), Adult Use (8.0%), Smoking Cessation (6.6%), Misinformation (5.9%), and THC Vaping is the Real Problem (3.5%). Total tweet frequencies increased in September 2019 and peaked in November 2019 before returning to relatively low numbers. Political Referendum and Institutional Distrust were consistently the most prevalent themes over time. Twitter posts with the phrase "Flavors Save Lives" commonly discussed voting against political incumbents and mentioned distrust of government representatives. Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans. These data may be valuable for designing tobacco control information campaigns in the future. (a) Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. (b) This study content analyzed Twitter posts with the phrase "Flavors Save Lives" from a 12-month period to understand opposition to flavor restrictions. (c) Twitter posts commonly discussed voting against political incumbents and mentioned distrust of government representatives. (d) Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans, and contribute to a more comprehensive assessment of different sub-population's responses to current and proposed tobacco control information policies.

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

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

Adults’ E-Cigarette Flavor Use and Cigarette Quit Attempts: Population Assessment of Tobacco and Health Study Findings

Prevalence of use of e-cigarettes among youth 1 Cullen KA Gentzke AS Sawdey MD et al. E-cigarette use among youth in the United States, 2019. JAMA. 2019; 322: 2095-2103https://doi.org/10.1001/jama.2019.18387 Crossref PubMed Scopus (383) Google Scholar and adults 2 Creamer MR Wang TW Babb S et al. Tobacco product use and cessation indicators among adults - United States, 2018. MMWR Morb Mortal Wkly Rep. 2019; 68: 1013-1019https://doi.org/10.15585/mmwr.mm6845a2 Crossref PubMed Scopus (448) Google Scholar in the U.S. continues to rise, and flavored tobacco product use is associated with initiation and subsequent use of tobacco products. 3 Villanti AC Johnson AL Glasser AM et al. Association of flavored tobacco use with tobacco initiation and subsequent use among U.S. youth and adults, 2013-2015. JAMA Netw Open. 2019; 2e1913804 https://doi.org/10.1001/jamanetworkopen.2019.13804 Crossref PubMed Scopus (46) Google Scholar However, little data exist on whether flavored e-cigarettes are associated with cigarette-cessation behaviors, 4 National Academies of Sciences Engineering and MedicinePublic Health Consequences of e-Cigarettes. The National Academies Press, Washington, DC2018https://doi.org/10.17226/24952 Google Scholar including attempting to quit cigarette smoking and quit success among those who attempt to quit, 5 Kasza KA Edwards KC Tang Z et al. Correlates of tobacco product cessation among youth and adults in the USA: findings from the PATH study waves 1-3 (2013-2016). Tob Control. 2020; 29: s203-s215https://doi.org/10.1136/tobaccocontrol-2019-055255 Crossref PubMed Scopus (20) Google Scholar although Buu et al. 6 Buu A Hu YH Piper ME Lin HC The association between e-cigarette use characteristics and combustible cigarette consumption and dependence symptoms: results from a national longitudinal study. Addict Behav. 2018; 84: 69-74https://doi.org/10.1016/j.addbeh.2018.03.035 Crossref PubMed Scopus (29) Google Scholar found that among exclusive cigarette smokers, using flavored e-cigarettes 1 year later was associated with lower quantity of cigarette smoking. This study uses U.S. nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study to report on e-cigarette flavor use among adult past 30–day dual users of e-cigarettes and cigarettes and to longitudinally evaluate the relationship between flavor use and attempting to quit cigarette smoking approximately 1 year later.

Promotion of Disposable Electronic Cigarette Flavors and Topics on Twitter.

Disposable electronic cigarettes (e-cigarettes) became popular among youth after the Food and Drug Administration (FDA) implemented an enforcement policy to restrict the sale of cartridge-based flavored e-cigarettes starting from February 2020 in the United States (US). We aimed to examine the flavors and topics related to disposable e-cigarettes on Twitter. The Twitter dataset, which includes 1489 tweets, was collected by the Tweepy streamapplication programming interface (API) using a keyword query from March to September 2020. The disposable e-cigarette flavors were curated from both online stores and collected tweets. Topics related to disposable e-cigarettes on Twitter were manually coded. Distributions of topics were compared between tweets from the US and tweets from non-US countries. The temporal analysis results showed a slight increase in the number of discussions over the study period. Strawberry, mango, watermelon, and mint were the most popular flavors of disposable e-cigarettes mentioned on Twitter. Almost all the tweets (97.11%) were commercial tweets, which were dominated by topics related to the product and flavor promotions. The US tweets focused more on product and flavor promotions and less on price promotions compared to non-US tweets. Our results suggest that companies exploited the limitations of legislation to promote flavors on Twitter, which could undermine public health and young people’s finances if they get hooked on addictive products.

Consumer Preferences for E-cigarette Flavor, Nicotine Strength, and Type: Evidence from Nielsen Scanner Data.

Many countries regulate e-cigarette attributes such as flavors and nicotine strength. Despite a large literature on consumer preferences for e-cigarette attributes, none used consumer-level longitudinal purchase data. We therefore use a unique large dataset on U.S. adults' e-cigarette purchases as to gain insight into real-world consumer choices and purchasing patterns. A total of 7098 purchase transactions, made by 1239 households on e-cigarette from various retail outlets for 2013 through 2017, were collected from Nielsen scanner data. We then apply an innovative multinomial logit model to examine which factors affected adult choices over 23 e-cigarettes products broken down by eight brands, three flavors, three nicotine strength levels, and two types. We found that tobacco flavor, medium nicotine strength (12< mg/ml ≤18), or disposables lead to higher adult purchases and such preference can vary over cigarette smoking status, purchase frequency, gender, race, and age. Specifically, smokers tend to purchase tobacco flavor, non-smokers or female vapers tend to purchase medium strength, and infrequent vapers tend to purchase disposables. Vapers are quite responsive to e-cigarette prices and also display loyalty (inertia) to e-cigarette brands, flavor, and nicotine strength. When modeled together, e-cigarette flavors, strength, type, price, and previous choice were all found to influence vapers' current purchase decision in the actual retail environment. The evidence presented here indicates that the impacts of certain restrictions on e-cigarette attributes, such as a flavor ban or maximum level of nicotine content, might have heterogeneous impacts on adults.

The danger of flavor: E-cigarettes, social media, and the interplay of generations

This study evaluates the effects of social media advertisements of e-cigarettes on consumer perceptions. We first use netnographic data to explore e-cigarette comments (n = 1900) and next conduct an experimental study on a randomized sample of cigarette consumers (n = 525) to assess the effects of e-cigarette features (i.e., flavor) and social influence (i.e., social tie and popularity of the advertisement) on consumer beliefs. Our findings show that the influence of e-cigarette flavor on perceived relative risk and negative beliefs has an opposite pattern for generation X consumers versus millennials. Millennials perceive cherry-flavored e-cigarettes as less risky, and perceive tobacco-flavored e-cigarettes as less risky when they are associated with close social ties. Our mixed methods study contributes to the marketing and public health disciplines by uncovering health-related perceptions and beliefs as outcomes of e-cigarette flavor and social influence. It also contributes empirically by showing the differential influences of close and far social ties.