Flavored Tobacco Use Research Articles

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

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

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

ObjectiveThis 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. MethodsParticipants 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. ResultsThose 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. ConclusionsExposure 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.

188 DIFFERENTIAL CHANGES IN YOUTH TOBACCO USE BEFORE AND AFTER IMPLEMENTATION OF MASSACHUSETTS’ STATEWIDE FLAVOR RESTRICTION POLICY

OBJECTIVES/GOALS: This study examined youth tobacco use, disaggregated by sexual and gender minority (SGM) identity and race, in Massachusetts before and after the state implemented a flavored tobacco restriction. We assessed if the policy differentially impacted groups that have had higher rates of flavored tobacco use (i.e., SGM and African Americans [AAs]). METHODS/STUDY POPULATION: Data for this analysis came from the 2019 and 2021 Massachusetts Youth Risk Behavior Survey (YRBS), a biennial, national survey conducted among high school students, provided by the Massachusetts Department of Elementary and Secondary Education. Changes in current use of cigarettes and e-cigarettes between 2019 and 2021 were examined for the entire sample and by SGM identity and race/ethnicity. Current cigarette use and current e-cigarette use were defined as reporting any use of the product in the past 30 days. We received confirmation from the IRB that because the data are de-identified and available to the public, this research is considered Not Human Subjects Research. RESULTS/ANTICIPATED RESULTS: Between 2019 and 2021, current cigarette use and current e-cigarette use decreased for the entire sample (3.78% to 2.79% and 27.69% to 15.74%, respectively). Decreases were also observed after disaggregating results, but smaller changes were observed among minoritized groups (i.e., SGM and AAs), particularly for e-cigarettes. Current e-cigarette use decreased 25.56% among individuals identifying as SGM (28.14% to 20.95%) compared to a 49.33% decrease among non-SGM individuals (27.63% to 14.0%). Among all races, AAs had the lowest prevalence of current e-cigarette use in 2019 (15.10%), but also saw the lowest percentage decrease (17.68%). Among whites, current e-cigarette use decreased 45.75% from 32.33% in 2019 to 17.54% in 2021. DISCUSSION/SIGNIFICANCE: After implementation of Massachusetts’ flavored tobacco restriction, current cigarette and e-cigarette use declined among Massachusetts youth overall and among groups that have been most affected by flavored tobacco. However, minoritized groups (i.e., SGMs, AAs) had lower percentage decreases compared to non-minoritized groups.

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

PurposeThis 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. MethodsCross-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. Results88.1% 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. DiscussionDespite 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.

Variation in adults' use of flavored tobacco products by sales restrictions in California jurisdictions.

State and local policies prohibiting the sales of flavored tobacco have been effective in curtailing retail availability and sales of products across the United States. Less is known about the use of flavored tobacco which could vary as a function of type of ordinance, product category, policy implementation, and other factors. The 2019-2020 California Health Interview Surveys were used to estimate flavored and non-flavored tobacco use among adults (n=43,681) residing in a California jurisdiction with a comprehensive (n=48), partial (n=35), or no flavored tobacco sales restriction (FTSR) (n=427). Multinomial logistic regression models, which accounted for clustering within jurisdictions (n=510), were separately developed for outcomes corresponding to use of any tobacco, non-cigarette tobacco products (NCTPs), electronic nicotine delivery systems, and conventional cigarettes. Individual-level effects of policy on tobacco use were estimated due to the overlap between the survey periods and effective policy dates. Approximately 22% of Californians were subject to a partial or comprehensive FTSR by December 31, 2020. Accounting for potential confounders, residents of jurisdictions with a comprehensive FTSR (vs. no ban) had 30% lower odds of using any flavored tobacco. The strongest and only statistically significant association by product category was exposure to a comprehensive FTSR and use of a flavored NCTP (aOR=0.4 (0.2, 0.8); p=0.008). Null or positive associations were primarily observed between a partial FTSR and flavored tobacco use, as well as associations between any FTSR and non-flavored tobacco use. Recent passage of a statewide ban in California will close gaps from the patchwork of local policies and eliminate most partial FTSR exemptions. However, state law still exempts the sales of some flavored tobacco products (e.g., hookah), leaving jurisdictions the option of enacting comprehensive FTSRs that may be more effective than partial FTSRs in reducing use of flavored tobacco.

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

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. 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. 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. 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. 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.

Use of Traditional Smokeless, Snus, and Dissolvable Tobacco Among U.S. Youth

Snus, dissolvable, and traditional smokeless tobacco product use is often amalgamated in youth epidemiologic research despite differences across these products. Prevalence, trends, and correlates of U.S. youth use across different classes of oral tobacco products are unknown. Using 2011-2020 National Youth Tobacco Survey (N=193,933) data, the authors tested for cross-year linear and quadratic trends in the weighted prevalence of ever and current use of traditional smokeless tobacco, snus, and dissolvable tobacco. Multivariable logistic regressions estimated the demographic and tobacco use factors associated with the use of different oral tobacco products in 2020. Analyses were conducted in 2022. During 2011-2020, there were declines in the prevalence of ever use of traditional smokeless tobacco (11.0% to 5.6%; linear trend, p<0.0001) and snus (5.2% to 2.4%; p<0.0001) but no change in ever dissolvable tobacco use (0.8%-1.2%). In 2020, an estimated 1,546,000 U.S. youth ever used traditional smokeless tobacco (7.7% high school, 3.0% middle school), 662,000 ever used snus (high school: 3.5%, middle school: 1.0%), and 326,000 ever used dissolvables (high school: 1.5%, middle school: 0.8%). In 2020, females and non-Hispanic Blacks and Hispanics had lower smokeless or snus ever use odds than males and non-Hispanic Whites, respectively, whereas sexual minorities (than heterosexuals) or those speaking a language other than English at home were more likely to report ever use of dissolvable tobacco. Flavored tobacco use was common, particularly for dissolvable current users (72.8% used any flavor). Differences in the epidemiology of oral tobacco use across product types among U.S. youth suggest that oral tobacco products should be disaggregated in future research and policy strategies.

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

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

Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study

PurposeDescribe racial/ethnic patterns of flavored tobacco use to illuminate equity implications of flavored tobacco policies. MethodsUsing data on US young adults (ages 18–34; n = 8,114) in the Population Assessment of Tobacco and Health Study Wave 5 (2018–2019) and survey-weighted logistic regression, we estimated any flavors (regular brand) and mint/menthol (vs. other flavors) use by race/ethnicity among cigarette, e-cigarette, cigar, blunt, hookah, smokeless tobacco, and any tobacco product users. ResultsAny flavored tobacco use was common and was significantly higher for Black (75.1%; OR: 1.4; 95% CI: 1.2, 1.7) and Hispanic/Latinx (77.2%; OR: 1.4; 95% CI: 1.1, 1.7) users than White users (73.5%). The most pronounced difference across products was in menthol cigarette use between Black and White smokers (OR: 4.5; 95% CI: 3.5, 5.9). Among flavored product users, mint/menthol use was significantly higher for Latinx blunt and hookah users. DiscussionRacial/ethnic disparities in flavored tobacco use include and extend beyond menthol cigarettes. Comprehensive flavored tobacco restrictions that include mint/menthol and non-cigarette products will likely have more equitable impact.

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

ObjectiveTobacco use remains disproportionately common among adults with internalizing problems. The rising prevalence of flavored tobacco use among this population may be a contributing factor. Using data from Wave 4 of the Population Assessment of Tobacco and Health Study, this study examined differences across adult ever tobacco users by severity of internalizing problems, in initiation of tobacco use with a flavored product and past 30-day (current) flavored tobacco use (n = 27,425).Severity of internalizing problems was measured using the Global Appraisal of Individual Needs–Short Screener Internalizing Disorder Screener. Tobacco use variables included initiation with or current use of a flavored product, assessed separately for each product. Weighted chi-square tests and multivariable modified Poisson regression models were used to examine the associations between severity of internalizing problems and each outcome. ResultsControlling for covariates, ever users with severe internalizing problems were more likely to have initiated with flavors for cigarettes (adjusted prevalence ratio [aPR]: 1.16, 95% confidence interval [CI]: 1.09,1.24), cigarillos (aPR: 1.09, 95% CI: 1.03, 1.16), electronic nicotine products (aPR: 1.08, 95% CI: 1.03, 1.13) and smokeless tobacco (aPR: 1.15, 95% CI: 1.04, 1.27), relative to those with low internalizing problems. Ever users with severe internalizing problems were more likely to currently use a flavored tobacco product for cigarettes (aPR: 1.15, 95% CI: 1.07, 1.24) and cigarillos (aPR: 1.15, 95% CI: 1.04, 1.28). ConclusionsFlavored tobacco use seems disproportionately common among tobacco users with severe internalizing problems, across a variety of measures.

Longer-Term Impact of the Flavored Tobacco Restriction in Two Massachusetts Communities: A Mixed-Methods Study.

In response to high rates of youth tobacco use, many states and localities are considering regulations on flavored tobacco products. The purpose of this study was to assess whether flavored tobacco restrictions (FTRs) in Massachusetts curb youth tobacco use over time and whether a dose-response effect of length of policy implementation on tobacco-related outcomes exists. Using a quasiexperimental design, two municipalities with a FTR (adopting municipalities) were matched to a comparison municipality without a FTR. Surveys were administered before (December 2015) and after (January and February 2018) policy implementation to high school students in these municipalities (more than 2000 surveys completed at both timepoints). At follow-up, adopting municipalities had a policy in place for 1 and 2 years, respectively. In 2019, focus groups were conducted with high school students in each municipality. Increases seen in current tobacco use from baseline to follow-up were significantly smaller in adopting municipalities compared to the comparison (-9.4% [-14.2%, -4.6%] and -6.3% [-10.8%, -1.8%], respectively). However, policy impact was greater in one adopting municipality despite shorter length of implementation. Focus groups indicated reasons for differential impact, including proximity to localities without FTRs. Restrictions implemented in adopting municipalities had positive impacts on youth tobacco awareness and use 1-2 years postimplementation. Policy impact varies depending on remaining points of access to flavored tobacco, as such policy effectiveness may increase as more localities restrict these products. In response to high rates of youth flavored tobacco use (including flavored vape products), federal, state, and localities have passed FTRs that reduce availability of flavored tobacco in youth-accessible stores. Previous research has found that FTRs may curb youth tobacco use in the short-term; however, the long-term effectiveness remains unknown.This is the first study to show FTRs can curb youth tobacco use and reduce youth awareness of tobacco prices and brands even 2 years after policy passage. Municipality-specific factors, including proximity to localities without FTRs, may attenuate policy impact, highlighting the importance of widespread policy adoption.

Heated tobacco product use among US adolescents in 2019: The new tobacco risk.

INTRODUCTIONThere is growing public health concern about adolescent use of heated tobacco products (HTPs) after the US Food and Drug Administration approved the leading HTPs, IQOS, as a modified risk tobacco product. Extending the previous studies examining the correlates of HTP use among adolescents, this study aims to investigate potential risk factors for HTP use among US adolescents, including the use of multiple tobacco and flavored tobacco products.METHODSWe analyzed the 2019 National Youth Tobacco Survey (n=19018) and conducted a series of logistic regression models on awareness and use of HTPs as a function of tobacco use status (none, single, dual/poly) and past 30 days flavored tobacco use (e.g. menthol cigarette use, flavored e-cigarettes), controlling for sociodemographics.RESULTSIn multivariable analyses, awareness of HTPs was associated with usual menthol cigarette use (AOR=1.77; 95% CI: 1.23–2.53) and past 30 days flavored tobacco use (AOR=1.44; 95% CI: 1.16–1.80). Risk factors for ever HTP use included single (AOR=2.52; 95% CI: 1.19–5.33) and dual/poly tobacco use (AOR=4.94; 95% CI: 2.56–9.54), usual menthol cigarette use (AOR=2.50; 95% CI: 1.66–3.76), and past 30 days flavored tobacco use (AOR=1.61; 95% CI: 1.07–2.44). Risk factors for current HTP use included single (AOR=10.84; 95% CI: 6.72–17.49) and dual/poly tobacco use (AOR=31.96; 95% CI: 17.79–57.43), and usual menthol cigarette use (AOR=2.50; 95% CI: 1.63–3.85).CONCLUSIONSThis study documents HTP use in adolescents and contributes insight and urgency into prioritizing at-risk adolescents for interventions, including current users of other tobacco products and flavored tobacco users.

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.

The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults

ObjectiveFlavors play an important role in the initiation and use of tobacco products. The FDA, states, and cities have been implementing or considering banning flavored e-cigarettes or any flavored tobacco products. This study empirically assessed the impact of one of the first comprehensive bans of all flavored tobacco products other than tobacco-flavored e-cigarettes among young adults in San Francisco, California. MethodsUsing Amazon Mechanical Turk, a sample of San Francisco residents aged 18–34 who previously used tobacco products (N = 247) were surveyed about their tobacco use both before and after the ban. Descriptive statistics and regression models were applied. ResultsThe prevalence of overall flavored tobacco use decreased from 81% and 85% to 69% and 76% for 18–24 years and 25–34 years old, respectively. The prevalence of flavored e-cigarettes decreased from 57% and 56% to 45% and 48% for 18–24 years and 25–34 years old, respectively. The prevalence of cigars uses reduced as well. However, cigarette smoking increased, although not statistically significant among 25–34 years old. 66% of participants did not support the ban and 65% believed the ban had not been enforced completely. Most users reported being able to obtain flavored tobacco products in multiple ways despite the ban. ConclusionsThese findings suggest that comprehensive local flavor bans, by themselves, cannot sharply reduce the availability or use of flavored tobacco products among residents. Nevertheless, local bans can still significantly reduce overall e-cigarette use and cigar smoking but may increase cigarette smoking.

Short-Term Impact of a Flavored Tobacco Restriction: Changes in Youth Tobacco Use in a Massachusetts Community

To counter the high prevalence of flavored tobacco use among youth, many U.S. localities have passed policies that restrict youth access to these products. This study aims to evaluate the short-term impact of a flavored tobacco restriction policy on youth access to, and use of, flavored tobacco products in a Massachusetts community. A community with the policy (Lowell) was matched to a community without the policy (Malden) with similar demographics, retailer characteristics, and point-of-sale tobacco policies. Product inventories were assessed in tobacco retailers in the 2 communities, and surveys were administered to high school-aged youth in those communities. Inventories and surveys were conducted around the time the policy took effect in October 2016 (baseline) and approximately 6 months later (follow-up); all data were analyzed in 2017. Chi-squared tests and difference-in-difference models were used to estimate the impact of the policy on flavored tobacco availability and youth perceptions and behaviors related to flavored tobacco use. Flavored tobacco availability decreased significantly in Lowell from baseline to follow-up periods by 70 percentage points (p<0.001), whereas no significant changes in flavored tobacco availability were seen in Malden. In addition, current use of both flavored and non-flavored tobacco decreased in Lowell, but increased in Malden from baseline to follow-up; these changes were significantly different between communities (flavored tobacco: -5.7%, p=0.03; non-flavored tobacco: -6.2%, p=0.01). Policies that restrict the sale of flavored tobacco have the potential to curb youth tobacco use in as few as 6 months.

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

Flavors in tobacco products may appeal to young and inexperienced users. To examine among youth (aged 12-17 years), young adults (aged 18-24 years), and adults (aged ≥25 years) the prevalence of first use of flavored tobacco products among new tobacco users and the association between first flavored use of a given tobacco product and tobacco use 1 year later, including progression of tobacco use. This cohort study represents a longitudinal analysis of data from the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative study with data collected in 2013 to 2014 (wave 1) and 2014 to 2015 (wave 2). Participants were noninstitutionalized individuals, including 11 996 youth and 26 447 adults, in selected households who participated in both waves of the PATH Study. Data analysis was conducted from July 2016 to June 2019. Prevalence of tobacco product use at wave 2. The mean (SE) age of the participants was 14.5 (0.0) years for youth, 21.1 (0.0) years for young adults, and 50.3 (0.0) for adults. Most youth (71.9%; 95% CI, 69.7%-74.0%) and young adults (57.6%; 95% CI, 54.9%-60.3%) who were new users of tobacco products over the 10- to 13-month follow-up period used flavored products. First use of a menthol or mint or other flavored cigarette documented at wave 1 was positively associated with past 12-month and past 30-day cigarette use in all age groups at wave 2 compared with first use of a nonflavored cigarette (youth, flavored cigarette, past 12-month use adjusted prevalence ratio [aPR], 1.14 [95% CI, 1.05-1.25] and past 30-day use aPR, 1.15 [95% CI, 1.00-1.31]; youth, menthol or mint cigarette, past 12-month use aPR, 1.18 [95% CI, 1.08-1.29] and past 30-day use aPR, 1.19 [95% CI, 1.04-1.37]; young adult, flavored cigarette, past 12-month use aPR, 1.09 [95% CI, 1.04-1.15] and past 30-day use aPR, 1.13 [95% CI, 1.06-1.21]; young adult menthol or mint cigarette, past 12-month use aPR, 1.10 [95% CI, 1.05-1.16] and past 30-day use aPR, 1.15 [95% CI, 1.07-1.23]; adult flavored cigarette, past 12-month use aPR, 1.10 [95% CI, 1.05-1.15] and past 30-day use aPR, 1.09 [95% CI, 1.04-1.14]; adult menthol or mint cigarette, past 12-month use aPR, 1.13 [95% CI, 1.08-1.18] and past 30-day use aPR, 1.12 [95% CI, 1.07-1.17]). Among young adults, first use of flavored e-cigarettes (aPR, 2.05; 95% CI, 1.61-2.61), any cigars (aPR, 1.60; 95% CI, 1.26-2.02), cigarillos (aPR, 1.49; 95% CI, 1.08-2.05), filtered cigars (aPR, 3.69; 95% CI, 2.08-6.57), hookah (aPR, 1.91; 95% CI, 1.23-2.98), and any smokeless tobacco (aPR, 1.54; 95% CI, 1.08-2.20) was prospectively associated with current regular use of those products at wave 2 compared with first nonflavored use. Among adults aged 25 years and older, first use of flavored e-cigarettes (aPR, 1.60; 95% CI, 1.41-1.82), any cigars (aPR, 1.56; 95% CI, 1.29-1.87), cigarillos (aPR, 1.29; 95% CI, 1.01-1.64), filtered cigars (aPR, 1.79; 95% CI, 1.25-2.54), hookah (aPR, 5.66; 95% CI, 2.04-15.71), and any smokeless tobacco (aPR, 1.55; 95% CI, 1.32-1.82) was prospectively associated with current regular use of those products at wave 2 compared with first nonflavored use. In this longitudinal cohort study, flavors in tobacco products were associated with youth and young adult tobacco experimentation. First use of a flavored tobacco product may place youth, young adults, and adults at risk of subsequent tobacco use.

Flavored tobacco use is associated with dual and poly tobacco use among adolescents

ObjectivesThis study examines the relationships between flavored tobacco use and single, dual, and poly tobacco product use, among adolescents. Given the increased use of flavored tobacco products, it is vital to understand if flavored products are associated with dual and poly tobacco product use. MethodsData were obtained from the 2017 National Youth Tobacco Survey. Participants were 2042 adolescent past 30-day tobacco users. Multivariable multinomial logistic regression models were used to assess the relationship between flavored tobacco use and past 30-day single, dual, and poly (three or more) tobacco product use. Two analyses were conducted using different categories as referent groups to allow for a comprehensive examination of the relationship between all groups. Covariates included sex, grade level, race/ethnicity and exposure to tobacco marketing. ResultsApproximately half of all adolescent tobacco users (45.7%) reported use of more than one product. The majority of adolescent tobacco users reported using flavors (69.4%). Flavored tobacco use was significantly correlated with a greater risk of dual (RRR: 2.09) and poly (RRR: 5.54) tobacco use, relative to single product use, controlling for covariates. Similarly, flavored tobacco use was significantly correlated with a greater risk of poly (RRR: 2.66) tobacco use, relative to dual tobacco use, controlling for covariates. ConclusionsA positive relationship was observed for flavored tobacco use and multiple tobacco product use. Findings suggest the need to consider stronger regulations of flavored tobacco products. Similarly, as most adolescent tobacco users reported using flavors, findings suggest the need to emphasize flavored tobacco use in prevention and education programs.

WITHDRAWN: Flavored Tobacco Use is Associated with Dual and Poly Tobacco Use among Adolescents

WITHDRAWN: Flavored Tobacco Use is Associated with Dual and Poly Tobacco Use among Adolescents

Flavored Tobacco Use Among U.S. Adults by Age Group: 2013–2014

Objective: This study sought to assess patterns of flavored tobacco product (FTP) use and their associations with (1) susceptibility to smoke cigarettes among young adults aged 18–29 who have never smoked; (2) quit attempts in the past 12 months among current cigarette users by age group (18–29, 30–49, and 50+). Methods: We used the 2013–2014 National Adult Tobacco Survey (n = 75,233) to estimate the prevalence of single-, dual-, and poly-use of FTP (menthol cigarettes, e-cigarettes, cigars, regular pipes/hookahs, and smokeless). Logistic regression models were performed to examine the associations between FTP use and smoking behaviors. Results: Among current tobacco users, young adults aged 18–29 (72.7%) had a higher prevalence of FTP use than other age groups (30–49: 51.7% and 50+: 37.9%). For FTP use within each age group, dual- and poly-FTP use was most popular among young adults aged 18–29 and menthol cigarette use was most popular among older adults aged 50+. Compared with not using any tobacco products, FTP use was associated with higher odds of susceptibility to cigarette smoking among young adult never smokers (single FTP use: aOR =5.5, CI: 4.2–7.3; dual/poly FTP use: aOR =10.7, CI: 6.2–18.4). FTP use was not associated with quit attempts among current cigarettes users aged under 50, while dual/poly-FTP use was associated with higher odds of quit attempts among current cigarette users aged 50 + (aOR =1.7, CI: 1.2–2.4). Conclusions: This study shows the heterogeneity of FTP use among adults by age group and demonstrates its associations with susceptibility to cigarette smoking among young adult never smokers.

Flavored Tobacco Products in the United States: A Systematic Review Assessing Use and Attitudes.

We systematically reviewed research examining use of and attitudes toward nonmenthol-flavored tobacco products to provide information relevant to a decision to regulate these products in the future. To identify eligible studies, we searched PubMed, CINHAL, Embase, LILACS, and PsycINFO on September 19, 2013, without date restrictions. We obtained additional studies via gray literature searches, expert contacts, and hand-searching citations of included articles. We included participants of all ages. We conducted a qualitative synthesis for included studies. The 32 studies included in this review exhibited substantial heterogeneity and were of varied methodological quality. Findings from observational, experimental, and quasiexperimental studies suggest that flavored tobacco use is associated with young age and that consumers may perceive flavored products more favorably than nonflavored products. Evidence from qualitative studies indicates that flavoring in tobacco is viewed favorably by users and nonusers of these products. The Food and Drug Administration has expressed interest in regulating flavored tobacco products. This systematic review strengthens the evidence base relating to this issue by synthesizing the literature from the United States on the use of and attitudes toward flavored tobacco. To address gaps in the literature, more research is needed to understand how flavoring impacts tobacco use over time. The evidence base would further be strengthened with the collection of brand-, flavor-, and product-specific data.