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Flavor of first e-cigarette purchased by time since first e-cigarette purchase: frequent e-cigarette users (n = 20,641/20,676)
Source publication
Background:
Understanding the role that flavors play in the population's use of e-cigarettes and the impact that flavored e-cigarette products have on the population's use of more harmful tobacco products, like conventional cigarettes, has been identified by the US Food and Drug Administration (FDA) as a public health research priority. The purpos...
Context in source publication
Context 1
... of first e-cigarette flavor purchased at all time points of e-cigarette use initiation (p < 0.001 for all). Tobacco flavor was the most popular first flavor pur- chased by those who initiated e-cigarette use ≥ 5 years ago and between 3 and 5 years ago but declined among those who initiated e-cigarette use 1-3 years ago and in the past 12 months (Fig. 1). First e-liquid purchases that were menthol/mint-flavored had also steadily declined, from being ranked second most common first flavor prior to 2011 to being ranked fourth in the past 12 months. Since 2013, fruit-flavored e-liquids have replaced tobacco-flavored e-liquids as the most popular flavors with which participants had ...
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Purpose
To investigate sleep quantity as a moderator of vaping and self-reported suicidality among adolescents.
Design
Cross-sectional. Setting: United States high schools.
Sample
10,520 high-school students with complete data on the primary outcome of suicide attempt in the past year (76.9% response rate).
Measures
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E-cigarettes are a highly popular nicotine replacement therapy in the process of smoking cessation. Despite this, research on the effects of E-vapours to human health remains limited. The popularity of vaping and mass production of cheap E-liquids has led to compromised safety regulations, with contaminants such as heavy metals and alkaloids detect...
Citations
... Unlike most NRT products, ENDS are available with a broad range of e-liquid flavors and nicotine concentrations, giving smokers a range of choices to potentially substitute cigarettes [5][6][7][8] . Smokers who try ENDS have the option to change nicotine concentrations and flavors over time 7,9,10 . ...
... When smokers switch to ENDS, observational data suggests that they tend to initially choose tobacco flavors, but long-term users are likely to report choosing fruity flavors 7,9,10 . The flavor preferences may change over time and users may use different flavors concurrently [10][11][12] . ...
... Flavor variety may even help ex-smokers remain abstinent 9,10 , as some studies reported that limiting flavors may drive them back to smoking cigarettes or dissuade smokers from switching to ENDS 9,13,14 . ENDS users who use e-liquids with nicotine, quit smoking more successfully than those who use e-liquids without nicotine [15][16][17] . ...
INTRODUCTION
Many tobacco smokers try to quit with electronic nicotine delivery systems (ENDS or e-cigarettes). We aimed to describe e-liquid flavors and nicotine concentration use over 6 months in a prospective cohort of smokers willing to quit with ENDS.
METHODS
We included 622 participants from the intervention group of the Efficacy, Safety and Toxicology of ENDS randomized controlled trial. Participants were adult smokers smoking at least five cigarettes a day. They received free ENDS and a choice of 6 e-liquid flavors in 4 nicotine concentrations and smoking cessation counseling. We tracked flavor choice and nicotine concentration at 1, 2, 4, and 8 weeks, and at 6 months, after the target quit date, comparing participants who reported only vaping (exclusive e-cigarette users) to those who vaped and smoked (dual users) over the last 7 days. We applied multivariable regression models to compute adjusted risk ratios (ARR).
RESULTS
At Week 1, 66% (n=409) were exclusive e-cigarette users, and 21% (n=129) were dual users. At Month 6, 43% (n=266) were exclusive e-cigarette users, and 16% (n=102) were dual users. While flavor choices were similar at Week 1, at 6 months, exclusive e-cigarette users reported using more fruity flavors than dual users (31% vs 22%, ARR=2.10; 95% CI: 1.21–3.66). The nicotine concentration used initially was similar in both groups and diminished over time. At 6 months, exclusive e-cigarette users used a lower mean nicotine concentration than dual users (6.3 vs 8.2 mg/mL, difference= -1.55; 95% CI: -2.84 – -0.25 mg/mL).
CONCLUSIONS
After 6 months, exclusive e-cigarette users used more fruity-flavored e-liquids and chose a lower mean nicotine concentration than dual users.
... Merke Epidemiologische Arbeiten zeigen eine aromenbedingte gesteigerte Attraktivität für E-Zigaretten [27] und einen Trend weg vom Tabakgeschmack hin zu fruchtigen und süßen Aromen [28], wobei geschlechtsspezifische Unterschiede bestehen. ...
Zusammenfassung
Hintergrund Fast alle E-Zigaretten enthalten Aromastoffe, die das Produkt attraktiver machen. Bei der Bewertung von E-Zigaretten in Bezug auf die Gesundheit spielten Aromen bisher eine untergeordnete Rolle.
Methode Selektive Literaturrecherche in PubMed, ergänzt durch rechtliche Bestimmungen zur Nutzung von Aromen in E-Zigaretten.
Ergebnisse Aromen erleichtern den Einstieg in den E-Zigarettenkonsum und haben eine konsumfördernde Wirkung. Durch tieferes Inhalieren werden die Nikotinaufnahme und die Aufnahme toxischer Substanzen aus dem E-Zigaretten-Liquid gesteigert. Für einige Aromen wurden pathologische Wirkungen, additiv zu anderen toxischen Bestandteilen der E-Zigarette, nachgewiesen. Für die große Mehrzahl der in E-Zigaretten enthaltenen Aromen liegen bisher keine toxikologischen Analysen vor.
Schlussfolgerungen Die nachgewiesene konsumfördernde Wirkung und die aus präklinischen Daten extrapolierbaren Gesundheitsrisiken sind bedeutsam für die politische Diskussion eines Verbots von Aromen auch für E-Zigaretten, analog zu dem bereits geltenden Verbot von Aromen in Tabakerzeugnissen.
... This massive volume of interactions has made it an important resource for investigating public perceptions and discussions on various topics, including health and lifestyle behaviors like vaping. For instance, researchers analyzed thousands of tweets to investigate attitudes toward e-cigarette flavors and found that preferences for certain flavors, such as fruit/fruit beverage, dessert/pastry, and candy, chocolate, or sweets, might be associated with continued e-cigarette use [23]. Twitter has also been employed to study the perceived health impacts of vaping [24]. ...
Amid a potential menthol ban, electronic cigarette (e-cigarette) companies are incorporating synthetic cooling agents like WS-3 and WS-23 to replicate menthol/mint sensations. This study examines public views on synthetic cooling agents in e-cigarettes via Twitter data. From May 2021 to March 2023, we used Twitter Streaming Application Programming Interface (API), to collect tweets related to synthetic cooling agents with keywords such as ‘WS-23,’ ’ice,’ and ’frozen.’ The deep learning RoBERTa (Robustly Optimized BERT-Pretraining Approach) model that can be optimized for contextual language understanding was used to classify attitudes expressed in tweets about synthetic cooling agents and identify e-cigarette users. The BERTopic (a topic modeling technique that leverages Bidirectional Encoder Representations from Transformers) deep-learning model, specializing in extracting and clustering topics from large texts, identified major topics of positive and negative tweets. Two proportion Z-tests were used to compare the proportions of positive and negative attitudes between e-cigarette users (vapers) and non-e-cigarette-users (non-vapers). Of 6,940,065 e-cigarettes-related tweets, 5,788 were non-commercial tweets related to synthetic cooling agents. The longitudinal trend analysis showed a clear upward trend in discussions. Vapers posted most of the tweets (73.05%, 4,228/5,788). Nearly half (47.87%, 2,771/5,788) held a positive attitude toward synthetic cooling agents, which is significantly higher than those with a negative attitude (19.92%,1,153/5,788) with a P-value < 0.0001. The likelihood of vapers expressing positive attitudes (60.17%, 2,544/4,228) was significantly higher (P < 0.0001) than that of non-vapers (14.55%, 227/1,560). Conversely, negative attitudes from non-vapers (30%, 468/1,560) were significantly (P < 0.0001) higher than vapers (16.2%, 685/4,228). Prevalent topics from positive tweets included “enjoyment of specific vape flavors,” “preference for lush ice vapes,” and “liking of minty/icy feelings.” Major topics from negative tweets included “disliking certain vape flavors” and “dislike of others vaping around them.” On Twitter, vapers are more likely to have a positive attitude toward synthetic cooling agents than non-vapers. Our study provides important insights into how the public perceives synthetic cooling agents in e-cigarettes. These insights are crucial for shaping future U.S. Food and Drug Administration (FDA) regulations aimed at safeguarding public health.
... Merke Epidemiologische Arbeiten zeigen eine aromenbedingte gesteigerte Attraktivität für E-Zigaretten [27] und einen Trend weg vom Tabakgeschmack hin zu fruchtigen und süßen Aromen [28], wobei geschlechtsspezifische Unterschiede bestehen. ...
Zusammenfassung
Hintergrund Fast alle E-Zigaretten enthalten Aromastoffe, die das Produkt attraktiver machen. Bei der Bewertung von E-Zigaretten in Bezug auf die Gesundheit spielten Aromen bisher eine untergeordnete Rolle.
Methode Selektive Literaturrecherche in PubMed, ergänzt durch rechtliche Bestimmungen zur Nutzung von Aromen in E-Zigaretten.
Ergebnisse Aromen erleichtern den Einstieg in den E-Zigarettenkonsum und haben eine konsumfördernde Wirkung. Durch tieferes Inhalieren werden die Nikotinaufnahme und die Aufnahme toxischer Substanzen aus dem E-Zigaretten-Liquid gesteigert. Für einige Aromen wurden pathologische Wirkungen, additiv zu anderen toxischen Bestandteilen der E-Zigarette, nachgewiesen. Für die große Mehrzahl der in E-Zigaretten enthaltenen Aromen liegen bisher keine toxikologischen Analysen vor.
Schlussfolgerungen Die nachgewiesene konsumfördernde Wirkung und die aus präklinischen Daten extrapolierbaren Gesundheitsrisiken sind bedeutsam für die politische Diskussion eines Verbots von Aromen auch für E-Zigaretten, analog zu dem bereits geltenden Verbot von Aromen in Tabakerzeugnissen.
... This approach allows participants to tailor their own gratifying "nicotine experience" by selecting the C-F NA that aligns with their preferences. By doing so, we anticipate not only fostering a transition to the latest technology but also facilitating the reduction of cigarette smoking and bolstering long-term prevention of relapse [38][39][40][41][42]. It is worth highlighting that this aspect of personal choice is notably absent in studies of harm reduction. ...
Background
Although the detrimental effects of conventional combustible cigarettes on oral health and dental esthetics are well known, there is limited information about the long-term impact of combustion-free nicotine alternatives (C-F NA) such as e-cigarettes or heated tobacco products.
Objective
This multicenter, prospective, 3-parallel-arm randomized controlled trial will investigate whether switching from combustible cigarettes to C-F NA will lead to measurable improvements in oral health parameters and dental esthetics over 18 months in adult smokers with limited gum disease.
Methods
Regular smokers not intending to quit and without clinical signs of periodontitis will be randomly assigned (1:4 ratio) to either standard of care with brief cessation advice (control group; arm A) or C-F NA use (intervention group; arm B). The study will also include a reference group of never smokers (reference group; arm C). The primary end point is the change in the Modified Gingival Index (MGI) score from baseline between the control arm (arm A) and the intervention arm (arm B) at the 18-month follow-up. In addition, the study will analyze the within- and between-group (arms A, B, and C) changes in MGI assessment, plaque imaging, dental shade quantitation, tooth stain scores, and oral health–related quality of life questionnaires measured at each study time point. All participants will attend a total of 7 clinic visits: screening, enrollment, and randomization (visit 0); baseline visit—day 14 (visit 1); day 90 (visit 2); day 180 (visit 3); day 360 (visit 4); and day 540 (visit 5). This multicenter study will be conducted in 4 dental clinics in 4 countries. The statistical analysis will involve descriptive statistics for continuous and categorical data. Primary end points will undergo tests for normality and, based on distribution, either a 2-sided t test or Mann-Whitney U test. Linear mixed model with random factors center and study arms by center will also be applied. Secondary end points, including MGI assessment and quality of life, will be subjected to similar tests and comparisons. Only if one value of the parameter MGI is missing after day 1, the last available observation will be carried forward. The analysis will be performed on the substituted data. Secondary parameters will not have missing value replacement.
Results
Participant recruitment began in October 2021, and enrollment was completed in June 2023. Results will be reported in 2025.
Conclusions
This will be the first study to provide key insights into oral health benefits or risks associated with using C-F NA in smokers who are seeking alternatives to cigarette smoking.
Trial Registration
ClinicalTrials.gov NCT04649645; https://clinicaltrials.gov/ct2/show/NCT04649645
International Registered Report Identifier (IRRID)
DERR1-10.2196/53222
... 6 Flavours increase product appeal, 6 e-cigarette initiation and regular use 7 and facilitate the transition from combustible cigarettes to e-cigarettes. 8 Flavours also pose potential risks, as they mask the harshness of the tobacco taste 9 and reduce perceptions of the harm of e-cigarettes. 10 Moreover, some disposable flavoured e-cigarettes, such as 'milk tea cups' and 'coke cups' that imitate the taste and packaging of milk tea and Coca-Cola, have gained popularity among Chinese youth. ...
Background
China has banned all flavoured e-cigarettes to reduce e-cigarette use among young people, but little is known about the views and reactions of people who use e-cigarettes. This study explored the perceptions of, and responses by, young adults who use e-cigarettes to the flavour ban.
Methods
Semistructured interviews were conducted with 25 Chinese young adults aged 18–25 years who had used e-cigarettes daily in the past 3 months. Thematic analysis was used to analyse the interview data.
Findings
Four themes were identified from the data: (1) understanding of the public health benefits, (2) resistance to and misperceptions of the flavour ban, (3) circumvention of the flavour ban and (4) acceptance of the flavour ban. Some participants expressed support for the ban due to perceived public health benefits, while others who resisted the ban emphasised their right to choose preferred flavours and questioned the rationale behind the policy. Participants responded to the flavour ban by utilising a variety of adaptive strategies, including purchasing flavoured e-cigarettes through illegal channels or exploring alternative ways to obtain flavours. Those who complied with the ban responded with different strategies, including switching back to combustible cigarettes, using tobacco-flavoured e-cigarettes, or quitting vaping.
Conclusions
The findings suggest the need for comprehensive regulatory measures, including stringent enforcement measures, transparent health communication and vigilant monitoring of e-cigarette manufacturers’ tactics, to reduce e-cigarette use among young adults.
... There has been considerable debate regarding the role of ENDS flavors in facilitating switching away from cigarettes (Farsalinos et al., 2013;Ward-Peterson & Maziak, 2019). Some observational studies suggest that participants using ENDS in nontobacco flavors are more likely to switch than those using tobacco flavors (Chen, 2018;Friedman & Xu, 2020;Gendall & Hoek, 2021;Glasser et al., 2020;Gravely et al., 2020;Jones et al., 2019;Li et al., 2021;Mok et al., 2023), and that adults who smoke cigarettes often transition from tobacco to nontobacco flavors as they switch (Du et al., 2020;Russell et al., 2018), whereas other studies have not found significant associations between use of flavored ENDS and switching or quit attempts (Kasza, Edwards, Gravely, et al., 2021;Liber et al., 2023;Lindson et al., 2023;Schneller et al., 2019). U.S. adults who smoke and purchased JUUL products predominantly used nontobacco flavors, but evidence on the association of flavors and switching is mixed Russell et al., 2019aRussell et al., , 2019b. ...
Observational studies show high rates of switching away from cigarettes among adult purchasers of JUUL-brand electronic nicotine delivery system (ENDS); data are needed to evaluate switching with JUUL in randomized general population trials. The association of ENDS flavor availability and switching is pertinent. This study assessed switch rates and smoking reduction among participants randomized to use JUUL in a choice of flavors or tobacco-only, compared to a condition provided smoking-cessation materials. U.S. adults who smoke cigarettes (N = 837; Mage [SD] = 45.99 years [11.48]; 18.76 cigarettes/day [SD = 7.86]; 50.2% female) from an address-based representative panel were randomized to receive JUUL for 6 months (5.0% nicotine; only Virginia Tobacco [N = 285] or choice of flavors [N = 281]), or smoking-cessation materials (quit advice [QA]; N = 271). Self-reported past 30-day smoking and cigarette consumption were assessed at 1, 3, and 6 months. Repeated-measure regressions assessed differences in smoking outcomes between groups. Only 2% of participants were planning to quit smoking within 30 days. Across the 6-month intervention, participants randomized to JUUL (vs. QA) had 6.57-fold greater odds of reporting past 30-day switching (95% CI [3.72−11.63]). Participants in the JUUL (vs. QA) group smoked 27% fewer cigarettes/day versus baseline (Rate Ratio [95% CI] = 0.73 [0.68−0.77]). Over half (51.8%) of the Virginia Tobacco group used other flavors (36.7% nontobacco flavors), contaminating randomized flavor-conditions. JUUL flavor groups did not differ in smoking outcomes (p > .48). Use of JUUL products may support complete switching away from cigarettes, including among those not ready to quit smoking. Results suggest a preference for nontobacco-flavored ENDS among adults who smoke, although smoking outcomes did not differ by flavor.
... The patterns of e-cigarette flavor use observed herein are in agreement with a cross-sectional study examining the responses of more than 20,000 participants from the USA [15]. Additionally, a recent longitudinal study examined changes in flavor use patterns in long-term vapers over a period of 5 years and found a transition to sweet flavors with a significant reduction in the use of tobacco, menthol, and mint flavors [16]. ...
Background
Flavored e-cigarettes remain a controversial topic with regulators planning or already implementing restrictions worldwide. In this study, we examined patterns of flavor use in e-cigarettes among a convenience sample of US adult vapers.
Methods
Participants aged ≥ 18 years who reported ever using an e-cigarette were included in the study (N = 69,233) and responded to an online questionnaire. Their smoking status was recorded as well as patterns of flavor use at e-cigarette use initiation, at the time of the survey and at the time of smoking cessation (for participants who used to smoke and were using e-cigarettes at the time of quitting).
Results
The most popular flavors at e-cigarette use initiation were fruit (82.8%), followed by dessert/pastry/bakery (68.6%) and candy/chocolate/sweet (52.2%). Slightly higher prevalence of using fruit and dessert/pastry/bakery flavors was observed in those who never smoked compared to those who were currently and formerly smoking. Tobacco flavors were used by 20.8% of the participants and was by far the least prevalent among participants who never smoked. Similar patterns were observed with participants’ choices at the time of the survey, but tobacco flavor use was substantially reduced (7.7%). Only 2.1% reported tobacco as the single most often used flavor. The most prevalent flavor at the time of quitting smoking was again fruit (83.3%), followed by dessert/pastry/bakery (68.0%) and candy/chocolate/sweet (44.5%). These flavors were considered the most helpful for quitting smoking. Tobacco flavor use at the time of smoking cessation was reported by 15.0%, while 9.3% considered it helpful for quitting smoking.
Conclusion
Non-tobacco flavors were popular among the US adult vapers who participated in the study, and were popular choices at the time of quitting smoking for those who formerly smoked. Tobacco flavor use prevalence was low and was further reduced over time. Regulators should consider the flavor choice of adult consumers, especially those who quit smoking, when preparing legislation on flavored e-cigarettes.
... 93 such as fruit/fruit beverage, dessert/pastry, and candy, chocolate, or sweets, might be associated 94 with continued e-cigarette use [22]. Twitter has also been employed to study the perceived health 95 impacts of vaping [23]. ...
Amid a potential menthol ban, electronic cigarette (e-cigarette) companies are incorporating synthetic cooling agents like WS-3 and WS-23 to replicate menthol/mint sensations. This study examines public views on synthetic cooling agents in e-cigarettes via Twitter data. From May 2021 to March 2023, we used Twitter Streaming API, to collect tweets related to synthetic cooling agents with keywords such as ‘WS-23,’ 'ice,' and 'frozen.' Two deep learning roBERTa models, classified attitudes expressed in tweets about synthetic cooling agents and identified e-cigarette users. The BERTopic deep-learning model identified major topics of positive and negative tweets. Two proportion Z-tests were used to compare the proportions of positive and negative attitudes between e-cigarette users (vapers) and non-e-cigarette-users (non-vapers). Of 6,940,065 e-cigarettes related tweets, 5,788 non-commercial tweets related to synthetic cooling agents. The longitudinal trend analysis showed a clear upwards trend in discussions. Vapers posted most of the tweets (73.05%, 4,228/5,788). Nearly half (47.87%, 2,771/5,788) held a positive attitude toward synthetic cooling agents, which is significantly higher than those with a negative attitude (19.92%,1,153/5,788) with a P-value < 0.0001. The likelihood of Vapers expressing positive attitudes (60.17%, 2,544/4,228) was significantly higher (P < 0.0001) than that from non-vapers (14.55%, 227/1,560). Conversely, negative attitudes from non-vapers (30%, 468/1,560) was significantly (P < 0.0001) higher than vapers (16.2%, 685/4,228). Prevalent topics from positive tweets included “enjoyment of specific vape flavors,” “preference for lush ice vapes,” and “liking of minty/icy feelings.” Major topics from negative tweets included “disliking certain vape flavors” and “dislike of others vaping around them.” On Twitter, vapers are more likely to have a positive attitude toward synthetic cooling agents than non-vapers. Our study provides important insights into how the public perceives synthetic cooling agents in e-cigarettes, insights that are crucial for shaping future FDA regulations aimed at safeguarding public health.
... The flavoring compounds used in EC e-liquids are generally considered safe (GRAS) for ingestion and are used extensively in the food industry. However, there are concerns about EC flavoring toxicity when inhaled using EC (Farsalinos et al., 2013;Khlystov and Samburova, 2016;Kim et al., 2018;Leigh et al., 2016;Lucas et al., 2020;Madison et al., 2019;Russell et al., 2018;Sundar et al., 2016) because the evidence for safety following inhalation has not been extensively investigated. Several primary research articles report potential adverse health effects on pulmonary cells from exposure to flavoring compounds in e-liquids, including but not limited to growth inhibition, cytotoxicity, apoptosis, reactive oxygen species (ROS) generation, and mitochondrial dysfunction (see Effah et al., 2022, for an extensive review). ...
Electronic cigarettes (ECs) are considered a less hazardous alternative to tobacco smoking but are not harmless. Growing concerns about the safety profiles of flavors in e-liquids underpin the need for this study. Here, we screened 53 nicotine-free flavored e-liquids (across 15 flavor categories) across a 3-point concentration range (0.25%, 0.5%, and 1% v/v) in a high-throughput fashion in human bronchial epithelial (HBEC-3KT) submerged cell cultures to identify 'toxic hits' using in vitro endpoint assays comprising cell count, cell viability, and lactate dehydrogenase (LDH). We observed significant, dose-dependent adverse effects only with cinnamon, vanilla tobacco, and hazelnut e-liquids compared to media-only and PG/VG vehicle controls. Hence, we further analyzed these three flavors for their effects on HBEC-3KT proliferation, mitochondrial health, and oxidative stress. A significant decrease in cell proliferation after 36h was observed for each e-liquid toxic hit compared to media-only and PG/VG controls. Hazelnut (at all concentrations) and vanilla tobacco (1%) increased cytoplasmic reactive oxygen species generation compared to media-only and PG/VG controls. Conversely, all three flavors at 0.5% and 1% significantly decreased mitochondrial membrane potential compared to PG/VG and media-only controls. Chemical analysis revealed that all three flavors contained volatile organic compounds. We hypothesized that the cytotoxicity of cinnamon might be mediated via TRPA1; however, TRPA1 antagonist AP-18 (10 μM) did not mitigate these effects, and cinnamon significantly increased TRPA1 transcript levels. Therefore, pathways mediating cinnamon's cytotoxicity warrant further investigations. This study could inform public health authorities on the relative health risks assessment following exposure to EC flavor ingredients.
