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R E S E A R C H Open Access
Changing patterns of first e-cigarette flavor
used and current flavors used by 20,836
adult frequent e-cigarette users in the USA
Christopher Russell
1*
, Neil McKeganey
1
, Tiffany Dickson
1
and Mitchell Nides
2
Abstract
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 purpose of the study was to assess the first e-cigarette flavor and current e-cigarette flavors used by a large
non-probabilistic sample of adult frequent users of e-cigarettes in the USA and assess how flavor preferences vary
by cigarette smoking status and time since first e-cigarette purchase.
Methods: An online survey assessed the first e-cigarette flavor and current e-cigarette flavors used by a non-probabilistic
sample of 20,836 adult frequent e-cigarette users in the USA. Differences in e-cigarette flavor preferences between current
smokers, former smokers, and never-smokers and trends in the first flavor used across time of e-cigarette use initiation
were assessed.
Results: The majority (n= 15,807; 76.4%) of sampled frequent e-cigarette users had completely substituted e-cigarettes
for conventional cigarettes—“switchers”—and were currently using rechargeable, refillable vaping devices. Among them,
the proportion of first e-cigarette purchases that were fruit-flavored increased from 17.8% of first purchases made before
2011 to 33.5% of first purchases made between June 2015 and June 2016. Tobacco-flavored first purchases almost
halved during this time (46.0% pre-2011 to 24.0% between 2015 and 2016). Fruit/fruit beverage (73.9 to 82.9% of
sampled users), dessert/pastry (63.5 to 68.5% of sampled users), and candy, chocolate, or sweets (48.7 to 53.4% of
sampled users) were the most popular currently used e-cigarette flavors. Tobacco and menthol flavors, the two most
popular flavors for initiating e-cigarette use prior to 2013, now rank as the 5th and 6th most popular currently used
e-cigarette flavors, respectively.
Conclusions: Adult frequent e-cigarette users in the USA who have completely switched from smoking cigarettes to
using e-cigarettes are increasingly likely to have initiated e-cigarette use with non-tobacco flavors and to have
transitioned from tobacco to non-tobacco flavors over time. Restricting access to non-tobacco e-cigarette flavors may
discourage smokers from attempting to switch to e-cigarettes.
Keywords: E-cigarettes, Flavors, E-liquids, Tobacco, Smoking, Cigarettes, Harm reduction, Vapers, Vaping
* Correspondence: russell@csures.org
1
Centre for Substance Use Research, 4.04 West of Scotland Science Park,
Kelvin Walkway, Glasgow G20 0SP, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Russell et al. Harm Reduction Journal (2018) 15:33
https://doi.org/10.1186/s12954-018-0238-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Tobacco harm reduction (THR) products and policies
aim to prevent or reduce harm by promoting substitu-
tion of combustible tobacco with less hazardous
non-combustible sources of nicotine to smokers who
are unable or unwilling to quit smoking in response
to conventional tobacco control measures [1]. Elec-
tronic cigarettes (e-cigarettes)—hand-held devices that
use battery power to heat a solution of propylene gly-
col, glycerol and often flavorings and nicotine, to pro-
duce an aerosol that the user inhales—have, in several
countries, rapidly grown in popularity among adults
as an alternative to smoking conventional cigarettes
[2–6]. E-cigarettes are now the most popular assisted
method of quitting smoking in the USA, used in 35%
of smokers’most recent quit attempts. [7]Bycom-
parison, nicotine patches or gums were used in 25%
of most recent quit attempts.
The ability to inhale e-cigarette vapor aerosol in a vast
and growing variety of “characterizing flavors”—a distin-
guishable taste or aroma, other than the taste or aroma
of tobacco—is thought to be a major feature accounting
for the appeal of e-cigarettes to adult smokers as an
alternative to continuing to smoke cigarettes. An esti-
mated 7700 unique e-liquid flavors were available for
purchase in 2014, comprising an assortment of fruit,
sweet, candy, dessert, food, and drink flavors. [8] Under
the Food and Drug Administration’s (FDA) final deem-
ing rule, decisions as to whether authorizing marketing
orders for flavored e-cigarette products would be appro-
priate for the protection of the public health must be
based on a weighing of the risks and benefits to both
users and non-users of tobacco products. FDA Commis-
sioner, Scott Gottlieb, has stated “it possible for flavors
to do both harm and good…On this issue, we see two
sides –on the one hand, we need to know the role that
flavors, including menthol, play in attracting youth to
initiate tobacco use. But on the other hand, we also need
to know whether…certain flavors may help adult
cigarette smokers switch to potentially less harmful
forms of nicotine delivery such as e-cigarettes”[9].
To this end, on March 21, 2018, FDA issued an ad-
vance notice of proposed rulemaking (ANPRM) to
obtain information related to the role that flavors play
in the population’s use of tobacco products. This
ANPRM is seeking data, research results, comments,
and other information about, among other things, the
extent to which certain flavors may attract youth to
initiate use of a tobacco product and the extent to
which certain flavors may help adult cigarette
smokers quit or reduce cigarette use and switch to
potentially less harmful products. FDA is seeking this
information to inform regulatory actions that FDA
might take with respect to flavored tobacco products
under the Federal Food, Drug, and Cosmetic Act
(“FD&C Act”), as amended by the Tobacco Control
Act.
Evidence from cross-sectional surveys of nationally
representative samples of US adults and
non-probabilistic surveys of dedicated e-cigarette users
suggests that smokers tend to initiate e-cigarette use
with tobacco-flavored e-cigarettes but transition to ex-
clusive or predominant use of non-tobacco flavored
products—particularly fruit, sweet, and dessert flavors—
with increased frequency and duration of e-cigarette use
[10,11]. Data from the Population Assessment of To-
bacco and Health (PATH) Study shows that the majority
of daily e-cigarette users were currently using
non-tobacco flavors and were significantly more likely
than moderate and infrequent e-cigarette users to have
initiated e-cigarette use with a non-tobacco flavor [10].
At the same time, daily e-cigarette use was associated
with higher odds of being a former smoker. Another
study found that most former smoking e-cigarette users
initiated e-cigarette use with non-tobacco flavors, while
initiation with tobacco flavors was more common for
dual users [11]. These data may indicate that smokers
who initiate e-cigarette use with a non-tobacco-flavored
e-cigarette are more likely to become daily e-cigarette
users, and in turn, more likely to quit smoking.
A separate analysis of PATH data found that young
adult (aged 18–34) cigarette smokers at wave 1 (2013/
14) who were using one non-tobacco/menthol flavor or
multiple non-tobacco/menthol flavors in an e-cigarette
at wave 2 (2014/15) were 2.5 and 3 times more likely to
have quit or reduced smoking in the past year, respect-
ively, compared to non-e-cigarette users [12]. Dedicated
e-cigarette users who are also former smokers report
that switching between flavors within the same day is
common and that regular use of multiple e-liquid flavors
was associated with significantly higher odds of having
quit smoking [13]. E-cigarette flavor preferences also
appear to vary by age and smoking status. In a nationally
representative survey, young US adult (18–29 years)
and older US adult (≥30 years) former smokers who
had become exclusive e-cigarette users were signifi-
cantly more likely than dual users of conventional
cigarettes and e-cigarettes to have initiated e-cigarette
use with a non-tobacco flavor (65.7 vs. 47.3%) [11]. Both
former-smoking exclusive e-cigarette users and dual
users reported significantly higher rates of current use of
a non-tobacco-flavor—72.5 and 72.9%, respectively—
compared to initiation, suggesting adult e-cigarette users
gravitate towards the use of non-tobacco flavors as
e-cigarette use continues, with only around one in
ten adult current e-cigarette users using tobacco fla-
vored e-cigarettes. Younger adults were significantly
more likely to be currently using fruit (74%) and
Russell et al. Harm Reduction Journal (2018) 15:33 Page 2 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
candy and dessert (50%) flavors than were older
adults (47 and 27%, respectively). Older adults were
significantly more likely than younger adults to be using
tobacco-flavored e-cigarettes (13 vs. 1%). Additionally,
exclusive e-cigarette users were more likely than dual
users to endorse “liking of flavors”as a reason for current
e-cigarette use (69.8 vs. 48.9%), suggesting the use of
non-tobacco flavors may be positively associated with
smokers’likelihood of transitioning to exclusive
e-cigarette use.
Despite evidence of a potential role of non-tobacco
e-cigarette flavors in helping adults to quit or reduce
cigarette smoking, the same concerns that led the US
Congress to ban the sale of cigarettes with characterizing
flavors in 2009 now exist for e-cigarettes. In particular,
concerns have been raised that fruit and sweet e-liquid
flavors will attract youth and non-smokers to e-cigarette
use, that use of flavored e-cigarettes will habituate youth
to the effects of nicotine, and in turn, youth who would
otherwise not have smoked in the absence of flavored
e-cigarettes will “graduate”to use of more harmful to-
bacco products, such as cigarettes, that deliver nicotine
more efficiently [14]. These concerns are borne from
data that show the majority of youth and young adults
who have ever tried an e-cigarette started their use with
fruit or sweet flavors rather than a tobacco flavor and
that rates of use of flavored tobacco products are higher
among youth and young adults than among older adults
[15–18]. Other research suggests adolescents’intentions
to try using e-cigarettes are linked to the availability of
non-tobacco flavors [19,20]. Concerns have also been
raised about the long-term health effects of inhalation of
e-cigarette flavorings [13].
While the Tobacco Control Act does not ban the sale
of flavored e-cigarette products, it does not pre-empt
state and local governments from restricting or banning
the sale of these products. The city of Chicago, for ex-
ample, in 2013 adopted an ordinance that prohibited the
sale of flavored tobacco products, including menthol cig-
arettes and e-cigarettes, within 500 ft of schools [21]. In
June 2017, the city of San Francisco became the first US
city to sign into law an ordinance prohibiting the sale of
all flavored tobacco products, including all flavors of
e-liquid except tobacco flavor [22]. This ordinance came
into effect in April 2018, though the fate of the ordin-
ance will be decided by San Francisco voters after a peti-
tion drive by R.J. Reynolds Tobacco Company gained
enough signatures to put the ordinance on a ballot in
San Francisco County on June 5, 2018 [23]. Both the
Chicago and San Francisco ordinances were adopted as
precautionary measures in the absence of an established
scientific basis for estimating that restricting the use and
availability of e-cigarettes in characterizing flavors would
be appropriate for the benefit and protection of the
public health. The ANPRM recently announced by FDA
represents the first steps to establishing a scientific basis
for the regulation of flavors in tobacco products, includ-
ing e-cigarettes, that weighs the risks and benefits of
flavored e-cigarettes to the population as a whole, in-
cluding their appeal to, use by, and effect of the tobacco
use behaviors of current users, former users, and
non-users of tobacco products.
The present study sought to obtain information on the
flavor preferences of frequent e-cigarette users for two
main reasons. First, frequent e-cigarette users should be
at greater risk of being harmed by and addicted to
e-cigarettes compared to infrequent users and former
users. Understanding the extent to which different fla-
vors are used by this sub-group, and the effect that fre-
quent use of different flavors has on cigarette smoking,
is therefore of great importance to assessing the likeli-
hood that frequent use of different e-cigarette flavors is
likely to add or reduce risk of harm to users. Second,
much of what is known about the flavor preferences of
e-cigarette users is based on surveys of nationally repre-
sentative samples that are largely comprised of infre-
quent e-cigarette users. The extent to which the flavor
preferences of infrequent e-cigarette users apply to fre-
quent e-cigarette users is unclear.
Assessing the first use and current use of flavored
e-cigarettes and e-liquids among current smokers,
former smokers, and never smokers who currently use
e-cigarettes on a frequent basis can therefore help in-
form the potential population health impact of these
products. The purpose of the present study was to assess
the first e-cigarette flavor and current e-cigarette flavors
used by a large non-probabilistic sample of adult fre-
quent users of e-cigarettes in the USA.
Methods
Recruitment materials
A study invitation called for individuals aged 18 years or
older, living in the USA, who have ever used an
e-cigarette, even a single puff, to complete a 20-min on-
line survey about their current and past use of
e-cigarettes and conventional tobacco cigarettes.
“E-cigarette use”was defined as “use of any cigalike,
pre-filled device, eGo-style vaping device, Mod-style
vaping device, or advanced personal vaporizer.”The
study invitation clarified that people who smoke ciga-
rettes, used to smoke cigarettes, or have never smoked
cigarettes were equally welcome to complete the survey.
The invitation contained a web-link to the survey home-
page. Data collection ran from May 1 to June 30 2016.
No financial or other incentive was offered in exchange
for participation. A favorable ethical opinion of this study
was given by the University of Strathclyde Research
Ethics Committee.
Russell et al. Harm Reduction Journal (2018) 15:33 Page 3 of 14
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Recruitment strategies
The population of interest in this study was adults
(aged 18 years and older) living in the USA who were
frequent users of an e-cigarette or personal vaporizer,
with “frequent use”defined as use on at least 20 of
the past 30 days. It was hypothesized that frequent
e-cigarette use would be the predominant use fre-
quency among adults who are actively engaged in dis-
cussion, advocacy, and events related to vaping and
vapor products. Participant recruitment was therefore
conducted in two ways.
First, a survey invitation was emailed to members of
four US-based organizations with large memberships of
e-cigarette/vapor product users: Consumer Advocates
for Smoke-Free Alternatives Association (CASAA),
Smoke-Free Alternatives Trade Association (SFATA),
the American Vaping Association (AVA), and Not Blow-
ing Smoke (NBS). According to their websites, the broad
mission of these organizations is to raise public aware-
ness and education around tobacco harm reduction,
provide smokers and non-smokers with scientific infor-
mation about the relative risks associated with use of
different tobacco and nicotine-containing products,
and advocate for adults who want to use vapor prod-
ucts as an alternative to continuing to use combust-
ible tobacco products. The study investigators did not
request, have sight of, or have access to any organization’s
membership list. Reminder emails were sent after 7 and
14 days.
Second, the survey invitation was posted by account
administrators to the social media accounts (e.g., Face-
book, Twitter, Instagram) belonging to CASAA, SFATA,
AVA, and NBS and to a number of social media plat-
forms (e.g., Facebook, Twitter, Reddit, Instagram) and
e-cigarette discussion forums (e.g. E-Cigarette Forum,
Planet of the Vapes) that are dedicated to vaping-related
discussion.
Survey procedure
Clicking the link in the study advertisement routed
the individual to the study information page, which
described the purpose of the survey, the names and
contact details of the study investigators, information
about who is eligible to take part and how survey
data will be used, assurances of participant anonymity
and confidentiality, and the source of funding for this
study. Individuals who satisfied eligibility criteria and
gave informed consent to participate began the sur-
vey. Participants were asked to answer the survey as
fully as possible but informed that they were free to
skip any questions they did not wish to answer. Du-
plicate survey entries were identified as either those
with the same e-mail address or those with the same
IP address, state, gender, and age.
Survey measures
Chronology of initiation, cessation, and re-initiation of
cigarette smoking and e-cigarette use
Questions assessed the prevalence of ever use, current
use, and frequent use of combustible cigarettes and
e-cigarettes, and the chronological order in which partic-
ipants had started, stopped, and re-started use of com-
bustible cigarettes and e-cigarettes. On the basis of
responses to these questions, participants were first clas-
sified as either (i) a frequent e-cigarette user—used an
e-cigarette on ≥20 of the past 30 days–or (ii) an infre-
quent e-cigarette user–used an e-cigarette on 0–19 of
the past 30 days.
Frequent e-cigarette users were then further classified
as one of the six types of cigarette smoker. These six
classifications, referred to as Tobacco Use Pathway
Groups (TUPs), represent all the transitions an individ-
ual may conceivably make between cigarette smoking
and frequent e-cigarette use and the chronological order
in which these transitions occur. The criteria used to
classify frequent e-cigarette users into each TUP are
shown in Table 1.
Demographic characteristics
Questions assessed participants’age, gender, census re-
gion, educational attainment, and employment status.
First and current device, flavor, and nicotine
concentration
Participants were asked the format, flavor, and nicotine
concentration of the first e-cigarette/e-liquid they pur-
chased for personal use, the format of the device used
most often now, currently used e-cigarette/e-liquid fla-
vors, and the nicotine concentration of e-cigarettes/
e-liquids used most often now. Participants reported the
approximate time of their first e-cigarette purchase; for
the analysis, data were categorized as “≥5 years ago”
(coded as 1), “3 to 5 years ago”(coded as 2), “1 to 3 years
ago”(coded as 3), and “less than 12 months ago”(coded
as 4). Questions also assessed weekly consumption of
disposable e-cigarettes, pre-filled cartridges, or volume
(mLs) of e-liquid, depending on the format of the device
currently used most often. Current users of rechargeable
devices with a refillable tank were also asked the coil
resistance and typical wattage at which they used their
current device, if applicable.
Statistical analysis
All analyses were performed in four exclusive smoking
status groups (switchers, dual users, former smoker
e-cigarette users, and never smoker e-cigarette user);
two groups (former smokers-turned-dual users and
never smokers-turned-dual users) were excluded from
analyses due to extremely low cell sizes. Descriptive
Russell et al. Harm Reduction Journal (2018) 15:33 Page 4 of 14
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statistics—mean (SD) or number (%)—are reported
for demographic variables. Chi-square (χ
2
) tests com-
pared the prevalence of first e-cigarette flavor pur-
chased, separately for each time period of first
e-cigarette purchase. Cross-tabulations and chi-square
tests compared the prevalence of first e-cigarette pur-
chases that were flavored to taste like “tobacco”ver-
sus “fruit/fruit beverage”between different TUP
groups. Logistic regression analyses were conducted
to evaluate the association between the first
e-cigarette purchases that were flavored to taste like
“tobacco”versus “fruit/fruit beverage”and TUPs and
time period of first e-cigarette purchase. Similar ana-
lyses were conducted for current use of tobacco and
fruit/fruit beverage flavored e-cigarettes. The analyses
were adjusted for age and gender, and the time period
of first e-cigarette purchase was entered in the model
as an ordinal scale variable to estimate the change in
odds of tobacco and fruit/fruit beverage flavored first
e-cigarette purchases associated with each change in
time period from ≥5 years (reference group: coded as
1) to less than 12 months ago (coded as 4). A pvalue
< 0.05 was considered statistically significant, and all
analyses were conducted in SPSS v24.
Results
Participants
After removal of 286 duplicate entries, 758 entries from
individuals not living in the USA (Canada n=289; UK
n= 291; country of residence not specified n= 178),
and 396 entries from individuals who did not indicate
where they found out about the survey, a sample of
22,411 US-based, adult (≥18 years), ever-users of
e-cigarettes was retained for preliminary analysis.
Within this sample, 20,836 (92.9%) respondents were
frequent e-cigarette users at the time of survey. The
distribution of these 20,836 respondents across the six
TUPs is shown in Table 2. Demographic characteristics
of the frequent e-cigarette users, stratified by Tobacco
Use Pathway Group, are summarized in Table 3. Demo-
graphic characteristics are not reported for former
smokers-turned-dual users or never smokers-turned-dual
users due to low cell sizes. Thus, the analyses of flavor
preferences were confined to 20,676 participants.
E-cigarette device format currently used
The majority of frequent e-cigarette users in each
TUP group reported current main use of a recharge-
able e-cigarette device with a refillable tank/reservoir
Table 1 Criteria for classification of frequent e-cigarette users into six Tobacco Use Pathway (TUP) groups
Num. TUP group label TUP group definition
1 Switchers A lifetime smoker (≥100 cigarettes smoked) who smoked cigarettes regularly prior to initiating e-cigarette use
and had quit smoking completely (no smoking in the past 30 days) at the time of survey and was a frequent
e-cigarette user at the time of survey.
2 Dual users of cigarettes and
e-cigarettes
A lifetime smoker (≥100 cigarettes smoked) who smoked cigarettes regularly prior to initiating e-cigarette use
and was a current smoker (smoked in the past 30 days) and a frequent e-cigarette user at the time of survey.
3 Former smoker-turned-dual
users
A lifetime smoker (≥100 cigarettes smoked) who had quit smoking completely prior to initiating e-cigarette
use and was a current smoker (smoked in the past 30 days) and a frequent e-cigarette user at the time of
survey.
4 Former-smoker e-cigarette
users
A lifetime smoker (≥100 cigarettes smoked) who had quit smoking completely prior to initiating e-cigarette
use and has not re-initiated regular smoking since initiating e-cigarette use and was a frequent e-cigarette user
at the time of survey.
5 Never-smoker-turned-dual
users
A lifetime never-smoker (< 100 cigarettes smoked) who was not smoking at the point of his/her first use of an
e-cigarette and was a current smoker and a frequent e-cigarette user at the time of survey.
6 Never-smoker e-cigarette
users
A lifetime never-smoker (< 100 cigarettes smoked) who was not smoking at the point of his/her first use of an
e-cigarette and was not a current smoker at the time of survey and was a frequent e-cigarette user at the time
of survey.
Table 2 Classification of 20,836 US adult frequent e-cigarette users into six Tobacco Use Pathway Groups (TUPs)
Num. TUP group N% of total sample % of frequent EC users
1 Switchers 15,807 70.5 75.9
2 Dual users of cigarettes and e-cigarettes 1330 5.9 6.4
3 Former smoker-turned-dual users 129 0.6 0.6
4 Former-smoker e-cigarette users 2483 11.1 11.9
5 Never-smoker-turned-dual users 31 0.1 0.1
6 Never-smoker e-cigarette users 1056 4.7 5.1
Russell et al. Harm Reduction Journal (2018) 15:33 Page 5 of 14
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Table 3 Demographic characteristics of 20,676 US adult frequent e-cigarette users classified into four Tobacco Use Pathway (TUP)
groups
Switchers
(n= 15,807)
Dual users
(n= 1330)
Former smoker
e-cigarette users
(n= 2483)
Never smoker
e-cigarette users
(n= 1056)
Total
(n= 20,676)
Variable N(%) N(%) N(%) N(%) N(%)
Age group
18–25 1714 (10.8) 264 (19.8) 587 (23.6) 579 (54.8) 3144 (15.2)
26–35 4165 (26.4) 378 (28.4) 784 (31.6) 199 (18.8) 5526 (26.7)
36–45 4382 (27.7) 305 (22.9) 543 (21.9) 118 (11.2) 5348 (25.9)
46–55 3193 (20.2) 237 (17.8) 336 (13.5) 92 (8.7) 3858 (18.7)
56–65 1910 (12.1) 124 (9.3) 192 (7.7) 58 (5.5) 2284 (11.0)
66–75 421 (2.7) 19 (1.4) 41 (1.7) 9 (0.9) 490 (2.4)
75+ 19 (0.1) 3 (0.2) 0 (0.0) 1 (0.1) 23 (0.1)
Total 15,804 (100.0) 1330 (100.0) 2483 (100.0) 1056 (100.0) 20,673 (100.0)
Gender
Male 11,173 (71.0) 904 (68.1) 1866 (75.5) 806 (76.9) 14,749 (71.6)
Female 4513 (28.7) 420 (31.6) 594 (24.0) 234 (22.3) 5761 (28.0)
Transgender 51 (0.3) 4 (0.3) 12 (0.5) 8 (0.8) 75 (0.4)
Total 15,737 (100.0) 1328 (100.0) 2472 (100.0) 1048 (100.0) 20,585 (100.0)
Census region-division
Northeast 2511 (15.8) 228 (17.1) 470 (18.9) 163 (15.5) 3372 (16.3)
New England 686 (4.3) 51 (3.8) 109 (4.4) 43 (4.1) 889 (4.3)
Middle Atlantic 1825 (11.5) 177 (13.3) 361 (14.5) 120 (11.4) 2483 (12.0)
Midwest 3710 (23.5) 355 (26.7) 547 (22.0) 250 (23.7) 4862 (23.6)
East North Central 2547 (16.1) 254 (19.1) 408 (16.4) 174 (16.5) 3383 (16.4)
West North Central 1163 (7.4) 101 (7.6) 139 (5.6) 76 (7.2) 1479 (7.2)
South 6161 (39.0) 469 (26.7) 857 (34.5) 337 (31.8) 7824 (37.8)
South Atlantic 3074 (19.4) 250 (18.8) 451 (18.2) 162 (15.3) 3937 (19.0)
East South Central 1241 (7.9) 95 (7.1) 162 (6.5) 71 (6.7) 1569 (7.6)
West South Central 1846 (11.7) 124 (9.3) 244 (9.8) 104 (9.8) 2318 (11.2)
West 3085 (21.8) 251 (18.9) 522 (21.1) 259 (24.6) 4117 (19.9)
Mountain 1195 (7.6) 100 (7.5) 200 (8.1) 83 (7.9) 1578 (7.6)
Pacific 1890 (12.0) 151 (11.4) 322 (13.0) 176 (16.7) 2539 (12.3)
No answer 340 (2.2) 27 (2.0) 87 (3.5) 47 (4.5) 501 (2.4)
Total 15,807 (100.0) 1330 (100.0) 2483 (100.0) 1056 (100.0) 20,676 (100.0)
Employment (hours paid work pw)
35+ hours 11,014 (69.9) 824 (62.1) 1718 (69.5) 549 (52.2) 14,105 (68.5)
15–35 h 1320 (8.4) 142 (10.7) 263 (10.6) 231 (22.0) 1956 (9.5)
0–15 h 320 (2.0) 47 (3.5) 55 (2.2) 50 (4.8) 472 (2.3)
0 h 3092 (19.6) 313 (23.6) 435 (17.6) 221 (21.0) 4061 (19.7)
Total 15,746 (100.0) 1326 (100.0) 2471 (100.0) 1051 (100.0) 20,594 (100.0)
Highest education level
Less than high school 77 (0.5) 11 (0.8) 17 (0.7) 5 (0.5) 110 (0.5)
Some high school, no diploma 380 (2.4) 50 (3.8) 81 (3.3) 44 (4.2) 555 (2.7)
GED 1019 (6.5) 107 (8.1) 160 (6.5) 26 (2.5) 1312 (6.4)
High school graduate, diploma 2944 (18.6) 270 (20.3) 619 (25.0) 347 (32.9) 4180 (20.2)
Russell et al. Harm Reduction Journal (2018) 15:33 Page 6 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
(switchers = 85.7%; dual users = 87.9%; former smoker
e-cigarette users = 81.6%; and never smoker e-cigarette
users = 79.8%). Current main use of an e-cigarette kit
(rechargeable with pre-filled cartridges) was less than 1%
in all TUP groups, and current main use of disposable
e-cigarettes was essentially zero in all TUP groups.
First e-liquid flavor purchased
The lengths of time since participants made their first
e-cigarette are summarised in Table 4. Chi-square tests
indicated statistically significant differences in the preva-
lence 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 initiated e-cigarette use. The
proportion of first e-cigarette purchases that were des-
sert/pastry-flavored had also increased consistently, from
being ranked fifth most common first flavor prior to 2011
to being ranked third in the past 12 months (Table 4).
Figures 2and 3show that, in each of the four TUP
groups, the proportion of first e-liquid purchases
that were tobacco-flavored had declined over time,
while the proportion of first e-liquid purchases that
were fruit-flavored had increased over time. The
lowest prevalence of tobacco-flavored first e-cigarette
purchases was observed among former smoker
e-cigarette users and never smoker e-cigarette users
(Fig. 2). Since 2011, the highest rate of fruit-flavored
first e-cigarette purchases has consistently been
among never smoker e-cigarette users.
Chi-square tests indicated a statistically significant
difference in the prevalence of tobacco flavor initiation
between TUP groups overall (p< 0.001) and statistically
significant differences between TUP groups within each
time period of e-cigarette use initiation (all ps < 0.001).
The proportions of switchers and dual users who initi-
ated e-cigarette use with a tobacco-flavored product
were similar in all four time periods. For fruit/fruit bev-
erage flavors, statistically significant differences were
observed overall (p< 0.001) and for each time point
of e-cigarette use initiation (p= 0.006 for > 5 years,
p< 0.001 for all other time points). The proportions
of switchers and dual users who initiated e-cigarette
use with a fruit-flavored e-cigarette were similar except
among those who initiated e-cigarette use 5 or more
years ago.
Logistic regression analysis (Table 5) showed that odds
of a tobacco-flavored first e-cigarette purchase reduced
with the recency of the first e-cigarette purchase, from
“> 5 years ago”to “in the past 12 months.”Additionally,
switchers and dual users were each four times more
likely than never smoker e-cigarette users to have initi-
ated e-cigarette use with a tobacco-flavored product;
Table 3 Demographic characteristics of 20,676 US adult frequent e-cigarette users classified into four Tobacco Use Pathway (TUP)
groups (Continued)
Switchers
(n= 15,807)
Dual users
(n= 1330)
Former smoker
e-cigarette users
(n= 2483)
Never smoker
e-cigarette users
(n= 1056)
Total
(n= 20,676)
Variable N(%) N(%) N(%) N(%) N(%)
Some college, no degree 5496 (34.8) 462 (34.8) 812 (32.8) 336 (31.9) 7106 (34.4)
Associate degree—voc./occup. 1736 (11.0) 119 (9.0) 269 (10.9) 83 (7.9) 2207 (10.7)
Associate degree—academic 1070 (6.8) 78 (5.9) 149 (6.0) 63 (6.0) 1360 (6.6)
Bachelor’s degree 2325 (14.7) 178 (13.4) 287 (11.6) 105 (10.0) 2895 (14.0)
Master’s degree 513 (3.2) 37 (2.8) 64 (2.4) 35 (3.3) 649 (3.1)
Professional school degree 131 (0.8) 9 (0.7) 10 (0.4) 7 (0.7) 157 (0.8)
Doctorate degree 95 (0.6) 8 (0.6) 11 (0.4) 3 (0.3) 117 (0.6)
Total 15,786 (100.0) 1329 (100.0) 2479 (100.0) 1054 (100.0) 20,648 (100.0)
Vape advocacy group membership
CASAA 10,442 (66.1) 694 (52.2) 1620 (65.2) 500 (47.3) 13,256 (64.1)
SFATA 1512 (9.6) 60 (4.5) 313 (12.6) 107 (10.1) 1992 (9.6)
NBS 3126 (19.8) 221 (16.6) 640 (25.8) 302 (28.6) 4289 (20.7)
AVA 1432 (9.1) 108 (8.1) 307 (12.4) 117 (11.1) 1964 (9.5)
Russell et al. Harm Reduction Journal (2018) 15:33 Page 7 of 14
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former smoker e-cigarette users were 2.3 times more
likely than never smoker e-cigarette users to have initi-
ated e-cigarette use with a tobacco-flavored product.
Conversely, the odds of initiating e-cigarette use with
fruit-flavored product increased with the recency of the
first e-cigarette purchase. Switchers, dual users, and
former smoker e-cigarette users were all significantly less
likely than never smoker e-cigarette users to have initi-
ated e-cigarette use with fruit-flavored products.
Currently used e-liquid flavors
The most popular currently used e-cigarette flavors
within each TUP group were fruit/fruit beverage
followed by dessert/pastry and candy/chocolate/sweets
(Fig. 4). Approximately 4 in 10 participants were cur-
rently using e-cigarettes containing a blend of two or
more flavors. Rates of current use of tobacco-flavored
e-liquids were low in all four groups. Once the most
popular flavors at the point of first purchase of an
e-cigarette, tobacco and menthol/mint-flavored e-liquids
were the fifth and sixth most popular currently used fla-
vors by switchers and dual users.
The highest rate of current use of tobacco-flavored
e-liquid was reported by those who initiated e-cigarette
use ≥5 years ago; the lowest rate of current use of
tobacco flavor was reported by those who initiated
e-cigarette use in the past 12 months (Fig. 5). The high-
est rate of current use of fruit/fruit beverage flavors was
among those who initiated e-cigarette use in the past
12 months; the lowest rate of current use of fruit/fruit
beverage flavors was among those who initiated
e-cigarette use ≥5 years ago. A similar effect of time since
first e-cigarette purchase was found for current use of des-
sert/pastry flavors and for candy/chocolate/sweets flavors.
Logistic regression analysis (Table 6) showed that,
compared to first purchases made > 5 years ago, odds of
current use of tobacco-flavored e-liquid decreased with
recency of first e-cigarette purchase, with the lowest rate
of current use of tobacco-flavored e-liquid observed
among those who purchased their first e-cigarette in the
past 12 months. As was observed for tobacco-flavored
first e-cigarette purchases, switchers, dual users, and
former smoker e-cigarette users all had significantly
higher odds of current use of tobacco-flavored e-liquid
compared to never smoker e-cigarette users, though
these odds for current use of tobacco-flavored products
were considerably smaller than the odds for initiating
use with a tobacco-flavored product. Conversely, odds of
current use of fruit/fruit beverage flavors were observed
to increase with the recency of a participant’s first
Fig. 1 Flavor of first e-cigarette purchased by time since first e-cigarette purchase: frequent e-cigarette users (n= 20,641/20,676)
Table 4 Time since first e-cigarette purchase, stratified by Tobacco Use Pathway (TUP) group
TUP group Time since first e-cigarette purchase
≥5 years 3–5 years 1–3 years < 12 months Total
N(%) N(%) N(%) N(%) N
Switchers 2576 (16.3) 5567 (35.3) 5230 (33.1) 2406 (15.2) 15,779
Dual users 142 (10.7) 334 (25.1) 483 (36.3) 370 (27.8) 1329
Former smoker e-cigarette users 281 (11.3) 788 (31.8) 901 (36.3) 510 (20.6) 2480
Never smoker e-cigarette users 55 (5.2) 225 (21.4) 405 (38.4) 368 (34.9) 1053
Time since first e-cigarette purchase recorded in June 2016
Russell et al. Harm Reduction Journal (2018) 15:33 Page 8 of 14
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e-cigarette purchase, with the highest odds of current
use of fruit-flavored product observed among those
who purchased their first e-cigarette in the past
12 months. Though the odds of current use of a
fruit-flavored product had increased over time in all
groups, switchers, dual users, and former smoker
e-cigarette users were significantly less likely than
never smoker e-cigarette users to be current users of
fruit-flavored products.
Discussion
This study assessed first and current use of tobacco and
non-tobacco e-cigarette flavors by a non-probabilistic
sample of 20,836 adults in the USA who were using
e-cigarettes on a frequent basis, of whom 15,807 (75.9%)
had completely switched from smoking cigarettes to
using e-cigarettes. Results indicated that adults who have
completely switched from smoking cigarettes to using
e-cigarettes in the past 5 years are increasingly likely to
have initiated e-cigarette use with vapor products not
flavored to taste like tobacco. E-cigarette flavors that are
not available through cigarettes—particularly fruit, des-
sert, and pastry flavors—were found to have increasingly
replaced tobacco and menthol as the preferred flavors
with which adult smokers, former smokers, and never
smokers have initiated e-cigarette use.
Fig. 2 Proportion of e-cigarette first purchases that were flavored to taste like tobacco stratified by time since first e-cigarette purchase and
Tobacco Use Pathway (TUP) group
Fig. 3 Proportion of first e-cigarette purchases that were flavored to taste like fruit/fruit beverage stratified by time since first e-cigarette purchase
and Tobacco Use Pathway (TUP) group
Russell et al. Harm Reduction Journal (2018) 15:33 Page 9 of 14
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Table 5 Logistic regression analysis of the association between first e-cigarette purchases that were tobacco-flavored and fruit/fruit
beverage-flavored and Tobacco Use Pathway Group and time of first e-cigarette purchase
Variable BOR 95% CI p
Tobacco-flavored FEP
TUP group
Never smoker e-cigarette users (referent)
Switchers 1.39 4.03 3.26–4.97 < 0.001
Dual users 1.42 4.14 3.26–5.26 < 0.001
Former smoker e-cigarette users 0.85 2.33 1.85–2.93 < 0.001
Time of FEP
> 5 years (referent)
< 12 months −1.04 0.35 0.32–0.40 < 0.001
1–3 years −0.80 0.45 0.41–0.49 < 0.001
3–5 years −0.46 0.63 0.58–0.69 < 0.001
Fruit/fruit beverage-flavored FEP
TUP group
Never smoker e-cigarette users (referent)
Switchers −0.85 0.43 0.38–0.49 < 0.001
Dual users −0.90 0.41 0.34–0.48 < 0.001
Former smoker e-cigarette users −0.55 0.58 0.50–0.67 < 0.001
Time of FEP
> 5 years (referent)
< 12 months 0.89 2.43 2.16–2.72 < 0.001
1–3 years 0.79 2.21 1.99–2.46 < 0.001
3–5 years 0.57 1.76 1.59–1.96 < 0.001
TUP Tobacco Use Pathway, FEP First E-cigarette purchase
Fig. 4 E-cigarette/e-liquid flavors currently used by 20,676 US adult frequent e-cigarette users stratified by Tobacco Use Pathway (TUP) group
Russell et al. Harm Reduction Journal (2018) 15:33 Page 10 of 14
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Between 2011 and 2016, the proportion of first
e-cigarette purchases that were flavored to taste like a
fruit had almost doubled, while tobacco-flavored first
e-cigarette purchases had almost halved. These data
suggest a transition in flavor preference at e-cigarette use
initiation over time, from tobacco to non-tobacco flavors,
which is consistent with data from a US nationally repre-
sentative survey that found both former-smoking exclu-
sive e-cigarette users and dual users reported significantly
higher rates of current use of a non-tobacco-flavor—72.5
and 72.9%, respectively—compared to initiation [11]. The
proportions of switchers and dual users who initiated
e-cigarette use with fruit flavors did not significantly differ
among those who initiated e-cigarette use after 2011. This
finding contrasts with the data from a US nationally repre-
sentative survey that showed former smokers who had
become exclusive e-cigarette users were significantly more
likely than dual users of conventional cigarettes and
e-cigarettes to have initiated e-cigarette use with a
non-tobacco flavor (65.7 vs. 47.3%) [11]. One potential
explanation for these contrasting findings is the different
frequencies of e-cigarette use in the samples analyzed; the
majority of individuals in the US nationally representative
sample were likely to have been infrequent e-cigarette
users—i.e., used an e-cigarette on less than 20 of the past
30 days—whereas the present study included only
frequent users. The present findings therefore indicate
that switchers and dual users were equally likely to have
initiated e-cigarette use with fruit-flavored e-cigarettes at
any time after 2011, but both have been increasingly likely
to have initiated e-cigarette use with a fruit-flavored
e-cigarette.
Current e-cigarette use among participants was domi-
nated by use of non-tobacco flavors, mainly fruit/fruit
beverage, dessert/pastry, and/or candy/chocolate/sweets
flavors. Once the most popular first flavors purchased by
switchers and dual users, tobacco and menthol/mint
currently rank as the 5th and 6th most commonly used
flavors. Comparable odds of current use of fruit/fruit
beverage flavor were observed in switchers, dual users,
and never smoker e-cigarette users. These findings
suggest both that non-tobacco flavors are comparably
attractive to smokers who may or may not intend to quit
smoking as they are to non-smokers and that
non-tobacco flavors are not more strongly associated
with dual use (i.e., continuing to smoke) than they are
with quitting smoking. Given that the taste of increas-
ingly preferred e-cigarette flavors such as fruits, desserts,
and pastries are very different from the taste of a con-
ventional cigarette, the increasing likelihood that adults
will initiate e-cigarette use and currently use an
e-cigarette use with a non-tobacco flavor could have the
Table 6 Logistic regression analysis of the association between current use of tobacco-flavored e-liquids and fruit/fruit beverage-
flavored e-liquids and Tobacco Use Pathway Group and time of first e-cigarette purchase
Variable BOR 95% CI p
Current use of tobacco flavor
Never smoker e-cigarette users (referent)
Switchers 0.78 2.18 1.69–2.81 < 0.001
Dual users 0.97 2.63 1.97–3.51 < 0.001
Former smoker e-cigarette users 0.43 1.54 1.16–2.03 < 0.001
Time of FEP
> 5 years (referent)
< 12 months −0.84 0.43 0.38–0.50 < 0.001
1–3 years −0.82 0.44 0.39–0.49 < 0.001
3–5 years −0.39 0.68 0.61–0.76 < 0.001
Current use of fruit-fruit beverage flavor
Never smoker e-cigarette users (referent)
Switchers −0.45 0.64 0.54–0.75 < 0.001
Dual users −0.36 0.70 0.57–0.86 < 0.001
Former smoker e-cigarette users −0.35 0.70 0.59–0.85 < 0.001
Time of FEP
> 5 years (referent)
< 12 months 0.49 1.62 1.46–1.81 < 0.001
1–3 years 0.47 1.61 1.46–1.77 < 0.001
3–5 years 0.28 1.32 1.20–1.45 < 0.001
TUP Tobacco Use Pathway, FEP First E-cigarette purchase
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beneficial effects of discouraging a return to smoking
among adults who switch to e-cigarettes and discour-
aging non-smoking e-cigarette users from initiating
cigarette use.
The positive association observed between the use of
fruit flavor and time of first e-cigarette purchase sug-
gests it is likely that future frequent e-cigarette use will
be increasingly initiated with the use of non-tobacco
flavors, regardless of the individual’s smoking history.
Judgements on whether authorizing marketing of fla-
vored e-cigarettes would be appropriate for the benefit
and protection of the public health should account for
the possibility that adults who have switched completely
from smoking cigarettes to using e-cigarettes in
non-tobacco flavors may not have attempted to switch
to e-cigarettes, or perceived themselves as able to switch,
had e-cigarettes only been available in the flavors that
are available through conventional cigarettes. A tobacco
regulatory policy that maintains adult smokers’access to
the existing market of non-tobacco flavors, and enables
manufacturers to innovate existing flavors, could in-
crease the popularity and effectiveness of e-cigarettes as
a substitute for cigarette smoking.
A low rate of first use of an e-cigarette that was
tobacco-flavored by those who had quit smoking com-
pletely prior to their first use of an e-cigarette was ob-
served. A possible explanation for this is that these
individuals, having already quit smoking completely,
wished to resume using nicotine by inhalation but did
not wish to taste a tobacco flavor that has, for them,
historically functioned as a conditioned stimulus for
smoking thoughts and memories, and in turn, cravings.
To the extent that this explains part of these former
smokers’reasons for initiating e-cigarette use with
non-tobacco flavored e-cigarettes/e-liquids, then restrict-
ing access to non-tobacco flavors may remove a method
that many former smokers have found effective for
attenuating nicotine cravings and preventing relapse to
smoking, and so in turn, increase the likelihood that
former smokers will resume cigarette smoking to satisfy
nicotine cravings.
This study also identified rapid changes in patterns of
e-cigarette use over time that highlight the need for
policymakers and researchers to continually update their
understanding of smokers’changing preferences for
using e-cigarettes of different styles, formats, and per-
formance capabilities. There is also a need for research
to better understand smokers’objections and barriers to
switching to e-cigarettes and other proven and poten-
tially less harmful sources of nicotine, and to respond
with policies that are more likely to rationalize a switch
away from conventional cigarettes, both among those
who are open to giving up smoking if offered an appeal-
ing alternative to cigarettes and to those who appear to
be hardened against ever stopping smoking.
Above all, there is a need to continually study the
effect on adult and youth smoking rates of legislation
and regulatory frameworks that either maintain or re-
strict access to a diverse variety of e-cigarette products
that reflect users’heterogeneity of preferences in terms
of esthetic appeal (the look and feel of the device),
sensory appeal (the taste and smell of vapor), and
pharmacological appeal (the speed and efficiency of
nicotine delivery).
Study limitations
The conclusions of this study are limited in several ways.
First, the sample is not representative of the general US
adult population nor was the study designed or intended
to estimate the prevalence or frequency of e-cigarette
use and cigarette smoking in the general US adult popu-
lation. The study aimed to elicit data on patterns of use
Fig. 5 E-cigarette/e-liquid flavors currently used by 20,611 US adult frequent e-cigarette users stratified by time since first e-cigarette purchase
Russell et al. Harm Reduction Journal (2018) 15:33 Page 12 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
by a specific sub-group of US adult e-cigarette user—
those who are using e-cigarettes on a daily or near-daily
basis. The recruitment methods were therefore biased
towards outlets where such sub-group of e-cigarette user
was most likely to be found, and so conclusions there-
fore do not represent the flavor preferences or patterns
of e-cigarette use of US adults who are using e-cigarettes
only experimentally or infrequently, patterns which to-
gether account for approximately 79% of all e-cigarette
use in the USA [24]The flavor preferences and patterns
of e-cigarette use reported by the present sample of
frequent e-cigarette users may more closely represent
those of the 21.3% of current e-cigarette users in the
USA who use e-cigarettes daily [24]. Conclusions about
changing flavor preferences are also unlikely to be
applicable to US adults who do not frequently use
rechargeable, refillable devices, as there is evidence that
preferences for tobacco and menthol flavors vary be-
tween users of closed-system and open system devices.
A consumer representative survey of 2000 US
e-cigarette users, for example, found that 84% of users
of advanced tanks (refilled with open liquid) currently
used non-tobacco flavors compared to 54% of users of
rechargeable cigalikes (reloaded with prefilled cartridges)
[25]. Users of advanced tanks were significantly less
likely than users of rechargeable “cigalikes”to be using
tobacco (16 vs 46%) or menthol (18 vs. 25%) flavors and
significantly more likely to be using fruit (36 vs. 15%)
and sweet (11 vs. 4%) flavors. These self-reported
device-specific data closely approximate distributor
shipment to retail data for February 2016 [26], which
show tobacco and menthol flavors accounted for 67% of
the total volume of cartridges shipped to retail in 2016
compared to 50% of the total volume of liquids shipped
to retail. Lastly, the study conclusions may not apply to
frequent e-cigarette users who do not engage with
e-cigarette advocacy groups and online forums.
Another limitation is the study’s reliance on accurate
self-reporting of the nature and timing of behaviors that
may have occurred up to several years ago. Additionally,
the cross-sectional design and non-probabilistic sam-
pling method prevent conclusions about the relative
effectiveness of tobacco versus non-tobacco flavored
e-cigarettes for producing smoking cessation. Finally,
participants in this study were not asked to identify the
flavors they were using at the point at which they
stopped smoking and so were not asked how frequently
they were using each flavor at the point at which they
stopped smoking.
Conclusions
This study identified an increasing popularity of
non-tobacco flavors and declining popularity of tobacco
flavors by over 15,000 adult frequent e-cigarette users
who formerly smoked cigarettes. The findings suggest
that access to a variety of non-tobacco flavored e-liquid
may be important for encouraging and assisting adults
to use e-cigarettes in place of conventional cigarettes.
Restricting the availability of non-tobacco flavors could
reduce adult smokers’interest in switching to
e-cigarettes or rationalize a return to cigarette smoking
among frequent e-cigarette users whose journey towards
smoking abstinence started with, progressed to, and is
being sustained by frequent use of e-cigarettes contain-
ing non-tobacco flavors. A tobacco products regulatory
framework that balances adult smokers’increasingly
common preference to try to quit smoking by using
e-cigarettes that do not taste like cigarettes, with mea-
sures that reduce the appeal and use of e-cigarettes by
non-smokers and youth, may accelerate the US progress
towards the end of the tobacco smoking epidemic that
causes the premature death of approximately 480,000
Americans each year [27].
Abbreviations
ANPRM: Advanced Notice of Proposed Rule Making; AVA: American Vaping
Association; CASAA: Consumer Advocates for Smoke-free Alternatives
Association; FD&C: Food, Drug and Cosmetic Act; FDA: US Food and Drug
Administration; FEP: First E-cigarette purchase; NBS: Not Blowing Smoke;
PATH: Population Assessment of Tobacco and Health; SFATA: Smoke Free
Alternatives Trade Association; THR: Tobacco harm reduction; TUP: Tobacco
Use Pathway; US: United States
Acknowledgements
The authors are grateful to Julie Woessner and Alex Clark (Consumer
Advocates for Smoke-free Alternatives Association), Stefan Didak and Danielle
Bloss (Not Blowing Smoke), Gregory Conley (American Vaping Association),
Cynthia Cabrera (Cating Group), and the Board of the Smoke-Free Alterna-
tives Trade Association, without whose assistance this study would not have
been possible. Above all, the authors wish to thank the 22,411 individuals
who participated in this study—their time and contributions are greatly
appreciated.
Funding
Fontem Ventures, a company that makes e-cigarettes, and a wholly owned
subsidiary of Imperial Brands PLC (formerly Imperial Tobacco) provided
funding for this study. Fontem Ventures had no input or control over the
study design, implementation, data analysis, interpretation, or reporting of
findings. The authors alone are responsible for the contents, production, and
decision to submit this manuscript.
Availability of data and materials
The datasets analyzed in the current study are available from the
corresponding author on reasonable request.
Authors’contributions
CR and NM conceived of the study. CR, NM, and MN developed the
questionnaire. CR and TD performed the statistical analysis. CR, NM, TD, and
MN helped to draft the manuscript. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
A favorable ethical opinion of this study was given by the University of
Strathclyde Research Ethics Committee. Participants were presented with an
Informed Consent Form and gave consent to participate online.
Competing interests
In the past 3 years, the employer of CR, NM, and TD, the Centre for
Substance Use Research, has received funding from several e-cigarette
Russell et al. Harm Reduction Journal (2018) 15:33 Page 13 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
manufacturers to conduct research on tobacco harm reduction, specifically,
on factors that encourage and discourage smokers from switching to using
e-cigarettes. In the past 3 years, MN has received funding from several
e-cigarette manufacturers to conduct pharmacokinetic/pharmacodynamic
studies of their products with smokers and vapers, as well as biomarker
studies on smokers who switch to vaping.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Substance Use Research, 4.04 West of Scotland Science Park,
Kelvin Walkway, Glasgow G20 0SP, UK.
2
Los Angeles Clinical Trials, 4116 W.
Magnolia Blvd, Suite 100, Burbank, CA 91505, USA.
Received: 18 April 2018 Accepted: 31 May 2018
References
1. Royal College of Physicians. Harm reduction in nicotine addiction: helping
people who can’t quit. A report by the Tobacco Advisory Group of the
Royal College of Physicians. London: RCP; 2007.
2. Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United
States, 2014. NCHS data brief, no. 217. Hyattsville: National Center for Health
Statistics; 2015.
3. Tan AS, Bigman CA. E-cigarette awareness and perceived harmfulness
prevalence and associations with smoking-cessation outcomes. Am J Prev
Med. 2014;47:141–9.
4. Adkison SE, O'Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery
systems: international tobacco control four-country survey. Am J Prev Med.
2013;44:207–15.
5. Action on Smoking and Health. Use of electronic cigarettes (vapourisers)
among adults in Great Britain. Action on Smoking and Health. 2017.
Accessed 2 June 2017 at: http://ash.org.uk/information-and-resources/fact-
sheets/use-of-e-cigarettes-among-adults-in-great-britain-2017/
6. Office for National Statistics. Adult smoking habits in Great Britain: 2015.
ONS 2016. Accessed 26 August 2016 at: https://www.ons.gov.uk/
peoplepopulationandcommunity/healthandsocialcare/
healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2015
7. Caraballo RS, Shafer PR, Patel D, Davis KC, McAfee TA. Quit methods used
by US adult cigarette smokers, 2014–2016. Prev Chronic Dis. 2017;14:160600.
https://doi.org/10.5888/pcd14.160600.
8. Zhu S-H, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-
cigarettes and counting: implications for product regulation. Tob Control.
2014;23(Suppl 3):iii3–9.
9. Maloney, J. FDA chief: menthol, tobacco flavors could do both ‘harm and
good’. Wall Street J. 2017. at: https://www.wsj.com/articles/fda-chief-
menthol-tobacco-flavors-could-do-both-harm-and-good-1508432700.
Accessed 5 Jan 2018
10. Coleman, B.N., Rostron B., Johnson, S.E. et al.. Electronic cigarette use among
US adults in the Population Assessment of Tobacco and Health (PATH)
Study, 2013–2014. Tob Control. 2017. . doi: https://doi.org/10.1136/
tobaccocontrol-2016-053462. [Epub ahead of print]. pii: tobaccocontrol-
2016-053462.
11. Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use:
characterizing youth, young adult and adult users. Prev Med Reports.
2017;5:33–40.
12. Chen JC. Flavored e-cigarette use and cigarette smoking reduction and
cessation—a large national study among young adult smokers. Subt Use
Misuse. 2018:1–15. https://doi.org/10.1080/10826084.2018.1455704.
[Epub ahead of print]
13. Farsalinos K, Romagna G, Tsiapras D, et al. Impact of flavour variability on
electronic cigarette use experience: an internet survey. Int J Environ Res
Public Health. 2013;10:7272–82.
14. U.S. Department of Health and Human Services: E-cigarette use among
youth and young adults. A report of the surgeon general.Atlanta.
Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2016.
15. Harrell MB, Weaver SR, Loukas A, Creamer M, Marti CN, Jackson CD,
Heath JW, Nayak P, Perry CL, Pechacek TF, Eriksen MP. Flavored
e-cigarette use: characterizing youth, young adult, and adult users.
Prev Med Rep. 2016;5:33–40.
16. Krishnan-Sarin S, Morean ME, Camenga DR, Cavallo DA, Kong G. E-cigarette
use among high school and middle school adolescents in Connecticut.
Nicotine Tob Res. 2015 Jul;17(7):810–8.
17. Dai H, Hao J. Flavored electronic cigarette use and smoking among youth.
Pediatrics 2016 Dec;138(6). pii: e20162513.
18. Corey CG, Ambrose BK, Apelberg BJ, King BA. Flavored tobacco product use
among middle and high school students—United States, 2014. MMWR
Morb Mortal Wkly Rep. 2015 Oct 2;64(38):1066–70.
19. Pepper JK, Ribisl KM, Brewer NT. Adolescents’interest in trying flavoured
e-cigarettes. Tob Control. 2016 Nov;25(Suppl 2):ii62–6.
20. Vasiljevic M, Petrescu DC, Marteau TM. Impact of advertisements promoting
candy-like flavoured e-cigarettes on appeal of tobacco smoking among
children: an experimental study. Tob Control. 2016 Dec;25(e2):e107–12.
21. Emanuel, R. Amendment of chapter 4-64 of municipal code by adding new
section 4-64-098 regarding flavored tobacco products and amending
section 4-64-180 C.o. Chicago,Editor Accessed 1 July 2017 at: https://www.
scribd.com/document/190761077/Amendment-of-Chapter-4-64-of-
Municipal-Code-by-adding-new-Section-4-64-098-regarding-flavored-
tobacco-products-and-amending-Section-4-64-180
22. Cohen, M. et al. Oridnance No. 140–17: Ordinance amending the Health
Code to prohibit tobacco retailers from selling flavored tobacco products,
including menthol cigarettes. at: https://sfgov.legistar.com/View.ashx?M=
F&ID=5303550&GUID=8D715199-F0C9-48F1-9752-D7E66F16C90C.
Accessed 15 July 2017.
23. Tyler C. San Fransisco voters to decide fate of flavored tobacco ban. ABC7
News. at: http://abc7news.com/politics/san-francisco-voters-to-decide-fate-
of-flavored-tobacco-ban/2379516/. Accessed 11 Dec 2017.
24. Delnevo CD, Giovenco DP, Steinberg MB, et al. Patterns of electronic
cigarette use among adults in the United States. Nicotine Tob Res.
2016;18:715.
25. ECigIntelligence. U.S. vaping habits and patterns: an ECigIntelligence survey.
2017. at: http://ecigintelligence.com/product/u-s-vaping-habits-and-
patterns-an-ecigintelligence-survey/. Accessed 1 July 2017.
26. Management Science Associates. Distributor shipment to retail data
managed by Management Science Associates: Retail shipment data through
25
th
February 2017. Data provided by Management Science Associates.
27. Centers for Disease Control and Prevention. Burden of Tobacco Use in the
U.S. at: https://www.cdc.gov/tobacco/campaign/tips/resources/data/
cigarette-smoking-in-united-states.html. Accessed 5 Feb 2017.
Russell et al. Harm Reduction Journal (2018) 15:33 Page 14 of 14
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