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Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users

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Rationale: The use of e-cigarettes has rapidly increased in the US and thousands of e-cigarette flavors are available. However, there remains a dearth of evidence on e-cigarette flavor use patterns among older e-cigarette users. Objectives: This longitudinal study examines changes in flavor use patterns in long-term e-cigarette users, assesses self-reported adverse reactions, and evaluates users' anticipated reaction to possible FDA e-cigarette flavor regulatory scenarios. Methods: The study population was 383 adult participants who completed two online e-cigarette surveys in 2012-2014 (baseline survey) and in 2017-2019 (follow-up survey). In both surveys participants were asked: "Thinking about your preferred liquid, what is the name of this liquid flavor", and to list all flavors used in the past 30 days. Flavor preference was classified using the Penn State Three-Step Flavor Classification method. Participants reported adverse events (open-ended description) with the associated flavor. Regulatory scenarios were presented and participants selected perceived actions from a list of 15 options. Results: Participants averaged 44±12 years; 86% were exclusive e-cigarette users and 13% reported "poly use" (i.e. e-cigarette and other tobacco product use). E-cigarette flavor preference migration occurred in all demographic groups: only 36-44% maintained a preference for their original flavor. Preference for tobacco and menthol or mint decreased over time (40% baseline, 22% follow-up); preference for fruit remained stable (23% baseline and follow-up), but chocolate/candy or other sweets preference significantly increased (16% baseline, 29% follow-up) and other flavors increased slightly. Migration to sweet flavors was more noticeable in younger adults (18-45 years); exclusive e-cigarette users more commonly preferred sweet flavors than poly-users (31% vs 19%). Flavor-associated adverse reactions, mainly respiratory irritations, were reported by 26 (6.9%) participants. Nearly 50% of the participants reported that they would "find a way" to buy their preferred flavor, or add flavoring agents themselves if non-tobacco flavors were banned. Conclusion: Flavor migration towards sweet flavors occurred in long-term e-cigarette users, a trend most pronounced in younger and exclusive e-cigarette users. The anticipated maintenance of access to flavors despite regulation suggests an element of e-cigarette-related dependence that requires further evaluation. The information could help clinicians understand the health impacts of e-cigarette flavors, develop appropriate strategies for smoking cessation, and inform the FDA to plan future regulations on e-cigarette flavors.
ORIGINAL RESEARCH
Changes in Flavor Preference in a Cohort of Long-Term Electronic
Cigarette Users
Ping Du
1,2
, Rebecca Bascom
1,2
, Tongyao Fan
1
, Ankita Sinharoy
1
, Jessica Yingst
1
, Pritish Mondal
3
, and
Jonathan Foulds
1
1
Department of Public Health Sciences,
2
Department of Medicine, and
3
Department of Pediatrics, Penn State University College of
Medicine, Hershey, Pennsylvania
ORCID IDs: 0000-0003-1329-790X (P.D.); 0000-0002-6911-196X (A.S.); 0000-0003-3028-668X (J.Y.); 0000-0001-7739-6320 (P.M.);
0000-0003-2296-0726 (J.F.).
Abstract
Rationale: The use of electronic cigarettes (e-cigarettes) has rapidly
increased in the United States, and thousands of e-cigarette avors are
available. However, there remains a dearth of evidence on e-cigarette
avor use patterns among older e-cigarette users.
Objectives: This longitudinal study examined changes in avor
use patterns in long-term e-cigarette users, assessed self-reported
adverse reactions, and evaluated usersanticipated reactions to
possible U.S. Food and Drug Administration e-cigarette avor
regulatory scenarios.
Methods: The study population was 383 adult participants who
completed two online e-cigarette surveys in 20122014 (baseline
survey) and in 20172019 (follow-up survey). In both surveys,
participants were asked, Thinking about your preferred liquid, what
is the name of this liquid avor?and to list all avors used in the past
30 days. Flavor preference was classied using the Penn State Three-
Step Flavor Classication method. Participants reported adverse
events (open-ended description) with the associated avor.
Regulatory scenarios were presented, and participants selected
perceived actions from among a list of 15 options.
Results: Participantsage averaged 44 612 years; 86% were exclusive
e-cigarette users, and 13% reported poly-use(i.e., e-cigarette and
other tobacco product use). E-cigarette avor preference migration
occurred in all demographic groups: only 3644% maintained a
preference for their original avor. Preference for tobacco and menthol
or mint decreased over time (40% baseline vs. 22% follow-up);
preference for fruit remained stable (23% baseline and follow-up), but
chocolate/candy or other sweets preference signicantly increased
(16% baseline vs. 29% follow-up), and other avors increased slightly.
Migration to sweet avors was more noticeable in younger adults (18
45 yr); exclusive e-cigarette users preferred sweet avors more
commonly than poly-users did (31% vs. 19%). Flavor-associated
adverse reactions, mainly respiratory irritations, were reported by 26
(6.9%) participants. Nearly 50% of the participants reported that they
would nd a wayto buy their preferred avor or add avoring agents
themselves if nontobacco avors were banned.
Conclusions: Flavor migration toward sweet avors occurred in
long-term e-cigarette users, a trend most pronounced in younger
and exclusive e-cigarette users. The anticipated maintenance of
access to avors despite regulation suggests an element of
e-cigaretterelated dependence that requires further evaluation.
This information could help clinicians understand the health
impacts of e-cigarette avors, develop appropriate strategies for
smoking cessation, and inform the U.S. Food and Drug
Administration to plan future regulation of e-cigarette avors.
Keywords: electronic cigarettes; avors; Food and Drug
Administration regulation
(Received in original form June 21, 2019; accepted in final form January 24, 2020 )
This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0
(http://creativecommons.org/licenses/by-nc-nd/4.0/). For commercial usage and reprints, please contact Diane Gern (dgern@thoracic.org).
Supported by the National Institute on Drug Abuse of the National Institutes of Health (NIH) and the Center for Tobacco Products of the U.S. Food and Drug
Administration (FDA) (P50-DA-036107) for the Penn State Tobacco Center of Regulatory Science. The content is solely the responsibility of the authors and does
not necessarily represent the official views of the NIH or the FDA.
Author Contributions: P.D., R.B., and J.F. designed this study. T.F. and A.S. administered the follow-up survey and analyzed the data. J.Y. helped design both
surveys and developed the Penn State Flavor Classification method. P.M. provided input on clinical implications. All authors contributed to the final manuscript.
Correspondence and requests for reprints should be addressed to Ping Du, M.D., Ph.D., Department of Medicine and Department of Public Health Sciences,
Penn State Hershey College of Medicine, 90 Hope Drive, A210, Hershey, PA 17033-0855. E-mail: pingdu@pennstatehealth.psu.edu.
This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org.
Ann Am Thorac Soc Vol 17, No 5, pp 573–581, May 2020
Copyright ©2020 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201906-472OC
Internet address: www.atsjournals.org
Du, Bascom, Fan, et al.: Long-Term E-Cigarette Flavor Preference Changes 573
Electronic cigarettes (e-cigarettes) are
battery-powered devices that vaporize a
nicotine- or nonnicotine-containing liquid
into aerosols for inhalation. Beginning in
2006, e-cigarettes were marketed as smoking
cessation aids without evidence and were
also used as substitutes for combustible
cigarettes in smoke-free zones (1).
E-cigarettes were not included in the U.S.
Food and Drug Administration (FDA)
regulations under the 2009 Family Smoking
Prevention and Tobacco Control Act
(Public Law 111-31), and they rapidly
evolved and gained popularity in the United
States (2). The National Health Interview
Survey indicated that 15.3% of U.S. adults
aged 18 years or older had used e-cigarettes
at least once in their lifetime and that 3.2%
of adults were using e-cigarettes on a daily
basis in 2018 (3, 4).
The availability of e-cigarette avors has
also increased rapidly: About 242 new avors
were added to the market each month and
more than 7,500 e-cigarettes avors have
become available since 2012 (5). In the PATH
(Population Assessment of Tobacco and
Health) study, a longitudinal study of tobacco
use based on a national representative sample
of U.S. population aged 12 years or older,
65% of young adults aged 1824 years and
50% of adults aged 25 years and older who
had ever used e-cigarettes started with
avored e-cigarettes (6). In a 2017 press
release, the American Thoracic Society
voiced a concern that avored e-cigarettes
were attracting people to initiate e-cigarette
use (7, 8). Evidence also suggested that
experimentation with avored e-cigarettes
might result in initiating combustible
cigarette smoking (9). These results focused
on e-cigarettes as an on-rampfor
nonsmokers.
The rapid increase of avored
e-cigarette use has raised a great public
health concern for nicotine addiction,
subsequent initiation of cigarette smoking,
and unforeseen adverse health effects (10).
In 2016, the FDA deeming ruleextended
its authority to regulate e-cigarette
products (11), but because e-cigarette
products are relatively new in the United
States, more evidence is needed to better
understand the health impacts of e-cigarette
avors. Previous e-cigarette avor studies
mainly addressed avor use experience in
young people in cross-sectional analysis and
showed a popularity of fruit avors in the
majority (9, 12). Nontobacco avors seemed
more appealing to young adults (1829 yr)
(9), but among adults aged 30 years and
older or smokers who attempted to reduce
or quit smoking, avor use patterns were
inconsistent across studies. In a large online
survey of adult frequent e-cigarette users in
the United States, use of tobacco avors
(both at e-cigarette initiation and current
use) has largely decreased over time, and
fruit avor was the most commonly used
avor (13). The PATH study also indicated
the changing pattern of increasing fruit
avor use in all users, but tobacco-associated
avors (tobacco and menthol or mint) were
still common in adult users aged 25 years
and older (14, 15).
Another group of interest is older adult
smokers who become e-cigarette users, either
as exclusive e-cigarette users or as poly-users
(e-cigarettes and other tobacco products,
mainly involving combustion cigarettes).
However, avor use is understudied in this
group, and very limited longitudinal studies
have been conducted to examine avor use
in older adult users (16, 17). Even in the
rst wave of the PATH study, only a small
sample of exclusive everyday e-cigarette
users (N= 156) was identied (18). Also,
there is a dearth of evidence on avor use
patterns in relation to long-term e-cigarette
use behaviors (13, 17, 19, 20).
From 2012 to 2014, we surveyed a
large group of e-cigarette users to examine
their e-cigarette use behaviors, and 1,863
participants consented to participate in
future research. In 2017, we resurveyed this
cohort to assess how their e-cigarette use
behaviors had changed over time (21). In
this study, we wanted to examine 1) changes
in e-cigarette avor use patterns (both
preference and use) over time, 2)avor
preferences among different age groups, and
3) changes in avor preference by e-cigarette
use behaviors. We also asked participants to
identify adverse reactions after the use of
specicavors and to anticipate how they
would react to potential FDA e-cigarette
avor regulations.
Methods
Study Population and Data Collection
Our 20122014 baseline online e-cigarette
survey included over 7,000 adult
respondents who had used e-cigarettes at
least 30 days in their lifetime and were aged
18 years or older (22). We recruited study
participants through various online sources
(e.g., WebMD [www.webmd.com] or
E-Cigarette Forum [www.e-cigarette-
forum.com]) and invited them to complete
an online survey of e-cigarette use and other
tobacco product use. At that time, a total
of 1,863 survey respondents provided
their contact information and agreed to
participate in future research. In January
2017, we recontacted these study
participants by sending a unique link to
each individuals e-mail address, inviting
them to complete a follow-up survey.
We administered the online follow-up
survey and collected data using Penn
State Research Electronic Data Capture
(REDCap), which is a secure, web-based
application designed to support data capture
for research studies in over 600 U.S.
academic institutions (23). We used an
implied consent for this follow-up survey
and did not offer compensation for
participation. This study was approved
by the Penn State College of Medicine
Institutional Review Board.
Measures
Survey questions. In both the baseline and
follow-up surveys, we asked participants
about their typical e-cigarette use behaviors
and the frequency of their e-cigarette use
over the past 30 days and over the past
7 days. In the follow-up survey, we asked
participants to recall their avor use when
they rst initiated e-cigarette use.
To assess the participantspreferred
e-cigarette avors, we included an open-
ended question in both surveys. The
baseline survey asked, What is your favorite
avor, and what brand of avored liquid do
you prefer?and the follow-up survey asked,
Thinking about your preferred liquid, what
is the name of this liquid avor?
We also asked participants to report
avor-associated adverse reactions in the
follow-up survey: Have you had a bad
reaction to a particular e-cig liquid avor,
including an allergic reaction?”“If yes,
please describe the reaction(open-ended
question), and, What avor were you using
at that time?(open-ended question).
Regarding FDA regulatory scenarios, we
rst asked participants if they believed that
the FDA should regulate e-cigarettes, and
then we let them select their anticipated
actions from among a list of 15 options
under the scenarios if your preferred avor
were bannedand if all nontobacco
avorings, including your preferred avor,
were banned.
ORIGINAL RESEARCH
574 AnnalsATS Volume 17 Number 5 |May 2020
Variable denitions. On the basis of
answers to the open-ended questions about
preferred e-cigarette avors at baseline and
follow-up, we used the Penn State Three-
step Flavor Classication method to
determine the preferred avor for each
participant and categorized the avors into
the following groups: tobacco, menthol or
mint, clove or spice, fruit, alcoholic drink,
chocolate/candy or other sweets, beverage,
and all other avors (24). We divided the
study participants into four age groups
based on their age at follow-up: 1830 years,
3145 years, 4660 years, and 61 years and
older. We dened current exclusive
e-cigarette usersas those who had used
e-cigarettes in the last 30 days and used only
e-cigarettes in the past 7 days, and we
dened current poly-usersas those who
had used both e-cigarettes and any other
tobacco products in the past 7 days. The
few participants who reported not using
e-cigarettes in the past 7 days were excluded
from analysis because of a small sample size.
We previously reported e-cigarette
related dependence among adult users,
scaling from low to high dependency based
on a validated measure, the Penn State
Electronic Cigarette Dependence Index
(PSECDI) (21, 22). In this study, we
reassessed e-cigaretterelated dependence
using the PSECDI in both surveys. We
calculated the PSECDI according to
individualsresponses to 10 questions
referring to their typical e-cigarette use
behaviors. The PSECDI ranged from
0to20toindicateusersdependence
levels on their e-cigarettes (no dependence=
03; low dependence = 48; medium
dependence = 912; and high
dependence >13).
Statistical Analysis
We used the follow-up survey data retrieved
in March 2019 and linked each participants
follow-up survey data with his/her baseline
survey data. We calculated means and
percentages to describe participants
sociodemographic characteristics,
e-cigarette use behavior, and avor use at
baseline and follow-up. We then compared
the overall changes in the preferred avor
between baseline and follow-up and changes
within and across age groups. We also
compared avor preference among
exclusive e-cigarette users and poly-users at
baseline and follow-up. We used a two-
sided, paired ttest for continuous variables
and the McNemar test or chi-square tests for
categorical variables and accepted statistical
differences at two-sided Pvalues less than
0.05. We also used the Cochran-Armitage
trend test two-sided Pvalues to examine the
differences in avor preference across age
groups at baseline and follow-up. We
performed the statistical analysis using SAS
version 9.4 software (SAS Institute).
Results
Characteristics of the Study
Population
A total of 742 baseline survey participants
answered the follow-up survey. Compared
with the nonrespondents, the follow-
up survey respondents had higher
socioeconomic status and were more likely
to report that the most important reason to
use an e-cigarette was to quit smoking or
avoid relapse (30.6% vs. 24.5%; P= 0.004)
(see Table E1 in the online supplement).
Regarding e-cigarette use behaviors,
the respondents were less likely than
nonrespondents to report waking at night to
use e-cigarettes (8.2% vs. 16.6%; P,0.0001)
or believing it was hard to quit e-cigarettes
Table 1. Characteristics at baseline and at follow-up (N= 383)
Characteristics Baseline Follow-Up PValue*
Sociodemographics
Age, yr, mean (SD; range) 40.8 (12.4;
1871)
44.6 (12.3;
2275)
Sex, M, n(%) 257 (67.1)
Race, white, n(%) 360 (94.0)
Education level, college or higher, n(%) 171 (44.7) 164 (45.2) 0.31
Full-time employed, n(%) 256 (66.8) 238 (65.6) 0.74
Income .$2,500/mo, n(%) 225 (62.5)
Current e-cigarette use behaviors
Exclusive e-cigarette use, n(%) 300 (83.6) 308 (85.8) 0.53
Poly-use (e-cigarettes 1any other tobacco
products), n(%)
56 (15.6) 47 (13.1) 0.40
Daily e-cigarette use in the past 28 d or 30 d (SD)
342 (89.3) 345 (90.1) 0.64
Mean e-cigarettes use times per day (SD) 25.1 (34.7) 20.7 (23.1) 0.02
Mean PSECDI (SD) 8.6 (3.4) 8.2 (3.9) 0.03
E-cigarette avor use behaviors
Median number of avors ever used (interquartile
range)
NA 10 (1050)
Number of avors used on a regular basis NA
One 4 (1.8)
Two or three 127 (57.5)
Four or more 90 (40.7)
Preferred avor
Tobacco 102 (26.6) 43 (11.2) <0.0001
Menthol or mint 52 (13.6) 42 (11.0) 0.09
Fruit 91 (23.8) 89 (23.2) 0.84
Chocolate/candy or other sweets 63 (16.5) 113 (29.5) <0.0001
Beverage 29 (7.6) 25 (6.5) 0.53
Clove or spice 16 (4.2) 24 (6.3) 0.16
Alcoholic drink 10 (2.6) 12 (3.1) 0.65
All other avors 20 (5.2) 35 (9.1) 0.03
Having had a bad reaction to liquid avor(s),
yes vs. no
NA 26 (6.9)
Ever used popcorn-avored e-cigarette liquid or
any e-cigarette avor containing diacetyl
NA 90 (23.7)
Ever used cinnamon-avored e-cigarette liquid
or any e-cigarette avor containing
cinnamaldehyde or 2-methoxicinnamaldehyde
NA 121 (31.8)
Definition of abbreviations: NA = questions were not comparable in the baseline survey; PSECDI = Penn
State Electronic Cigarette Dependence Index; SD = standard deviation.
Boldface indicates statistical significance (P,0.05).
*Paired ttest or McNemar test Pvalues to examine changes in characteristics between baseline and
follow-up surveys.
In the baseline survey, participants were asked to report the number of e-cigarette use days in the past
28 days; in the follow-up survey, participants were asked to report the number of e-cigarette use days
in the past 30 days.
ORIGINAL RESEARCH
Du, Bascom, Fan, et al.: Long-Term E-Cigarette Flavor Preference Changes 575
(33.4% vs. 38.2%; P= 0.04). There was also a
higher proportion of exclusive e-cigarette
users among the respondents than among
the nonrespondents (76.0% vs. 66.6%;
P,0.0001).
We excluded 359 participants because
of missing values in avor use behaviors,
e-cigarette use behaviors, or other tobacco
product use and participants with
inconsistent responses in age and sex
between the baseline and follow-up surveys
(Figure E1). The nal analytic population
was 383 participants with a mean follow-up
period of 3.7 years (standard deviation, 0.7;
range, 26 yr). The majority of the study
participants in both surveys were white
(94.0%) and male (67.1%) and had similar
education levels and employment status
(Table 1). The study population at follow-up
averaged 44.6 (612.3) years old (age range,
2275 yr).
Current E-Cigarette Use Behaviors
In both the baseline and follow-up surveys,
study participants reported using
e-cigarettes over 95% of the days of the
previous month. A majority of the study
participants used e-cigarettes exclusively in
the past 7 days (85.8% at follow-up), with
concomitant use of e-cigarettes and other
tobacco products reported by 13.1% of the
study population and 1% not using
e-cigarettes in the past 7 days (Table 1). The
mean number of e-cigarette use times per
day decreased (25.1 at baseline vs. 20.7 at
follow-up; P= 0.02). The mean PSECDI
scores at baseline and follow-up were similar
(8.6 vs. 8.2), indicating a low to medium
level of e-cigaretterelated dependence.
Choices of Flavor Use at E-Cigarette
Initiation and during the Past 30 Days
Figure 1 compares avor uses at e-cigarette
initiation and during the past 30 days before
the follow-up survey. About 60% recalled
using a tobacco avor when they rst started
using e-cigarettes, with menthol or mint,
fruit, or chocolate/candy or other sweet
avor use reported by around 40% each.
The past 30 days avor use indicated
that the dominant avor use shifted to fruit
and chocolate/candy or other sweets in
nearly 60% of the participants, whereas
the use of tobacco, menthol, or mint
dropped to 2628%. Over 75% of study
participants reported having tried at least
10 different avors (interquartile range,
1050), and virtually all (98.2%) used 2
or more avors on a regular basis
(Table 1).
Preferred Flavor Migration: Baseline
versus Follow-Up
At baseline, tobacco was the most preferred
avor (26.6%), followed by fruit (23.8%),
chocolate/candy or other sweets (16.5%),
and menthol or mint (13.6%) (Table 1). At
follow-up, however, chocolate/candy or
other sweets became the most preferred
e-cigarette avor group (29.5%; P,0.0001),
and the preference for tobacco avor
decreased to 11.2% (P,0.0001). Fruit
avor remained one of the top three
preferred avors (23%). There was also a
signicant increase in the preference for
other avors that were not categorized or
self-made (5.2 at baseline vs. 9.1 at follow-
up; P= 0.03).
Figure 2 shows details of avor
preference migration. Across all avor
groups, about 40% of participants
maintained the same preference at baseline
and follow-up. The increase in fruit or
chocolate/candy or other sweets preference
was reected in migration from all baseline
groups. Switching to the tobacco/menthol or
mint avor was uncommon, ranging from
6% to 16%.
Age Patterns in Flavor Preference
Flavor preference was highly varied across
adult age groups (Table 2). Among young
adults (aged 1830 yr), tobacco or menthol
or mint preference was low at both baseline
and follow-up (trend test for the linear
variation of tobacco avor across age
groups, P= 0.04 at baseline and P,0.0001
at follow-up). Young adults had the highest
rates of preference for fruit avor at baseline
(trend test across age groups, P= 0.01) and
maintained a high preference for fruit avor
at follow-up, but chocolate/candy or other
sweets became the top preferred avor in
this group at follow-up (P= 0.04). The
migration to chocolate/candy or other sweet
avors was not limited to young adults. For
example, there was a striking increase in
chocolate/candy or other sweets preference
in the 3145-year-old group, which
showed a greater than twofold increase in
preference for this avor group (13.4% at
baseline vs. 31.7% at follow-up; P,0.0001).
There was also a tendency to show an
increased preference of chocolate/candy or
other sweet avors in the 4660-year-old
groups.
0
10
20
30
40
50
60
70
Tobacco Menthol or
mint
Fruit Clove or
spice
Alcoholic
drink
All other
flavors
Chocolate/candy
or other sweets
At e-cigarette initiation
During the past 30 days
Figure 1. Flavors used at e-cigarette initiation and during the past 30 days. Participants were asked to recall their flavor use at e-cigarette initiation (shownin
gray bar) and during the past 30 days at the follow-up survey (shown in black bar) from a list of flavors, including menthol or mint, tobacco, clove or spice, fruit,
chocolate, candy or other sweets, alcoholic drink, and other flavor. Participants could report multiple flavor uses, not limited to their preferred flavor.
ORIGINAL RESEARCH
576 AnnalsATS Volume 17 Number 5 |May 2020
The preference of tobacco avor
decreased nearly twofold among age groups
who were 60 years old or younger. Although
tobacco groupassociated avor (tobacco
and menthol or mint) was still the top
preferred avor among older adults
(.60 yr), the prevalence was reduced by
nearly 10% from 52.4% to 42.9%.
Changes in Flavor Preference by
E-Cigarette Use Behaviors
We also examined whether avor
preference was related to e-cigarette use
Baseline Follow-up
Chocolate/
candy or other
sweets (N=63)
Fruit (N=89)
Chocolate/
candy or other
sweets (N=113)
6.6%
6.3%
15.9%
All study
subjects
(N=383)
Others (N=96)
Fruit (N=91)
18.7%
Tobacco/
menthol or
mint (N=154)
Tobacco/
menthol or mint
(N=85)
Others (N=75)
40.9%
15.6%
24.0%
44.0%
30.8%
42.9%
19.5%
34.9%
20.0%
36.0%
28.0%
16.0%
Figure 2. Changes in flavor preference over time.
Table 2. Changes in preferred avor over time, by age group (N= 383)
Age Group Preferred Flavor Baseline* (n[%]) Follow-Up* (n[%]) Change of Flavor Preference (%)PValue
1830 (n= 71) Tobacco 14 (19.7) 4 (5.6) 214.1% 0.002
Menthol or mint 7 (9.9) 8 (11.3) 1.1% 0.71
Fruit 22 (31.0) 19 (26.8) 24.2% 0.43
Chocolate/candy or other sweets 15 (21.1) 25 (35.2) 14.1% 0.04
3145 (n= 142) Tobacco 33 (23.2) 8 (5.6) 217.6% <0.0001
Menthol or mint 23 (16.2) 15 (10.6) 25.6% 0.04
Fruit 39 (27.5) 36 (25.4) 22.1% 0.65
Chocolate/candy or other sweets 19 (13.4) 45 (31.7) 18.3% <0.0001
4660 (n= 128) Tobacco 42 (32.8) 20 (15.6) 217.2% 0.0002
Menthol or mint 13 (10.2) 12 (9.4) 20.8% 0.84
Fruit 24 (18.8) 27 (21.1) 2.3% 0.58
Chocolate/candy or other sweets 23 (18.0) 34 (26.6) 8.6% 0.06
>61 (n= 42) Tobacco 13 (31.0) 11 (26.2) 24.8% 0.48
Menthol or mint 9 (21.4) 7 (16.7) 24.7% 0.16
Fruit 6 (14.3) 7 (16.7) 2.4% 0.71
Chocolate/candy or other sweets 6 (14.3) 9 (21.4) 7.1% 0.41
Boldface indicates statistical significance (P,0.05).
*Cochran-Armitage trend test two-sided Pvalues to examine if flavor preference varied linearly across age groups at the baseline survey and at the follow-up
survey, respectively:
Tobacco: P=0.04 and P,0.0001.
Menthol or mint: P= 0.46 and P= 0.65.
Fruit: P=0.01 and P= 0.16.
Chocolate/candy or other sweets: P= 0.65 and P= 0.07.
McNemar test two-sided Pvalues to examine changes in flavor preference between the baseline survey and the follow-up survey in each age group.
ORIGINAL RESEARCH
Du, Bascom, Fan, et al.: Long-Term E-Cigarette Flavor Preference Changes 577
behavior (Table 3). Among current
exclusive e-cigarette users, tobacco avor
preference decreased between baseline and
follow-up (26.3% vs. 10.7%; P,0.0001),
whereas chocolate/candy or other sweet
avor preference increased signicantly
(16.9% vs. 31.2%; P,0.0001). The preference
for other avors remained stable. Among
poly-users, there was a 10% decrease in the
preference of tobacco groupassociated avors
(tobacco and menthol or mint) but a slight
increase in other avors, with a smaller sample
size limiting statistical power.
Possible Adverse Health Effects after
E-Cigarette Flavor Use
Twenty-six (6.9%) study participants recalled
ever having had a bad reactionto e-cigarette
avor use, including coughing/breathing
problems/asthma (n= 11), mouth/throat
irritation (n=9), allergic reactions (n=3),
headache or body ache (n=2), nausea/
heartburn (n= 2), and heart problem (n=1).
When asked What avor were you using at
that time?,participants identied tobacco or
menthol (n= 6), cinnamon (n=5), fruit
(n= 5), beverage (n=2),other/notsure(n=3),
and high propylene glycol or vegetable glycerin
(n= 5). In addition, 23.7% and 31.8% reported
having ever used any e-cigarette liquid that
contained either 1) popcorn avor/diacetyl
or 2) cinnamon avor/cinnamaldehyde or
2-methoxicinnamaldehyde, respectively
(Table 1). Participants who had ever used
these avors (total n=154)weremorelikely
than nonusers to report having had a bad
reaction (13.0% vs. 2.7%; P,0.0001).
Anticipated Reactions to Possible
FDA E-Cigarette Flavor
Regulatory Scenarios
Regarding potential FDA regulations, 156
(42.5%) participants believed that the
FDA should regulate e-cigarettes. If their
preferred avor or all the nontobacco
avors were banned, very few
participants anticipated that they would
stop using e-cigarettes or would use
e-cigarettes less, but about 50% reported
they would nd a way to buy my preferred
avoror add avoring agents myself
(Table 4). A total of 36 (9.7%) reported that
I would return to smoking traditional
tobacco cigarettesif all nontobacco avors
were banned.
Discussion
Our longitudinal study of e-cigarette avor
use patterns conducted over 3.7 years
demonstrates a striking increase in the
preference for sweet avors and a decrease
in the preference for tobacco avor in all
demographic groups. The majority of the
study participants had tried multiple
avors, and only about 40% still preferred
the same avor group that they had used
4 years earlier. Age-specic analysis
showed that younger adults (aged 1830
and 3145 yr) continued to prefer fruit
and chocolate/candy or other sweets,
whereas over 40% of the older adults (aged
>61 yr) still preferred traditional tobacco-
related (tobacco and menthol or mint)
avors. The craving and preference for sweet
tastes among adolescents and young adults
have previously been reported (25);
however, our study also showed a preference
migration toward chocolate/candy or other
sweet avors in the older age group
(4660 yr) as well.
The majority of the study participants
had tried 10 or more avors since they
started using e-cigarettes, and one-fourth of
the cohort had tried 50 or more avors.
Although we did not ask whether they had
tried new avors within the previous 7 or 30
days, most people regularly used two or
more avors. As new avors continue to be
added in the marketplace, the changing
preference patterns may reect the current
marketing strategies of the e-cigarette
manufacturers to promote sweet avors for
the general population (not just limited to
adolescents or young adults) or may reect
a users own experience that using non
tobacco-related avors may constitute a
avor that they can happily use and make
them less likely to return to cigarette
smoking (9). In addition, in our study, there
was a signicant increase in the preference
for chocolate/candy or other sweet avors
between baseline and follow-up among
exclusive e-cigarette users, but no signicant
change in avor use was found in poly-users,
implying that exclusive e-cigarette users
may use certain avors to maintain their
e-cigarette use behaviors (13, 19, 20).
Although e-cigarettes contain much
lower concentrations of the known harmful
toxicants than combustible tobacco
products, they are not harmless, and
although the current multistate outbreak of
Table 3. Changes in preferred avor use, by e-cigarette use behaviors at follow-up
Preferred Flavor Current Exclusive E-Cigarette Users
(n=308)
Current Poly-Users
(n=47)
Baseline
(n[%])
Follow-Up
(n[%])
PValue* Baseline
(n[%])
Follow-Up
(n[%])
PValue* PValue
Tobacco 81 (26.3) 33 (10.7) <0.0001 12 (25.5) 7 (14.9) 0.10 0.40
Menthol or mint 34 (11.0) 30 (9.7) 0.41 13 (27.7) 8 (17.0) 0.06 0.13
Fruit 77 (25.0) 74 (24.0) 0.74 7 (14.9) 8 (17.0) 0.74 0.29
Chocolate/candy or other sweets 52 (16.9) 96 (31.2) <0.0001 7 (14.9) 9 (19.2) 0.53 0.09
Beverage 25 (8.1) 22 (7.1) 0.60 2 (4.3) 3 (6.4) 0.65 0.85
Clove or spice 14 (4.6) 19 (6.2) 0.32 2 (4.3) 4 (8.5) 0.41 0.54
Alcoholic drink 10 (3.3) 8 (2.6) 0.62 0 (0) 4 (8.5) NA 0.04
Other 15 (4.9) 26 (8.4) 0.06 4 (8.5) 4 (8.5) 1.00 0.99
Definition of abbreviation: NA = Not applicable.
Boldface indicates statistical significance (P,0.05).
*McNemar test Pvalues to examine changes in the preferred flavor between the baseline survey and the follow-up survey in current exclusive e-cigarette
users or in current poly-users.
Chi-square test Pvalues to examine differences in the preferred flavor between current exclusive e-cigarette users and current poly-users atthe follow-up survey.
ORIGINAL RESEARCH
578 AnnalsATS Volume 17 Number 5 |May 2020
vaping-related lung injury in the United
States appears to be caused primarily by use
of illicit vaping products containing vitamin E
acetate or tetrahydrocannabinol, it also
indicates the dangers of inhaling unknown
chemicals into the lungs (2628). A recent
comprehensive review summarized ndings
of in vitro studies, animal models, and
population studies to describe adverse
effects of e-cigarette use on the respiratory
system, including the large airways and the
alveolar space (29). E-cigarette use in
general can cause airway and alveolar
inammation and injury, affect immune
function, increase susceptibility to bacterial
or viral infections, and worsen existing
lung diseases such as asthma or chronic
obstructive pulmonary disease, but
respiratory effects of e-cigarette avors are
unclear (29, 30). Most e-cigarette avors,
including popular fruit or sweet avors,
contain chemical constituents that can be
efciently aerosolized for inhalation and
cause oxidative stress, DNA damage,
or pulmonary epithelial toxicity and
inammation (3135). However, few
population studies have examined chronic
effects of avor use, especially in the long
term, on exclusive e-cigarette users. About
7% of our study participants reported acute
adverse reactions, mainly minor respiratory
irritation but also including self-reported
asthma attacks, after using certain avors or
high levels of propylene glycol or vegetable
glycerin in the e-liquids. About 40% of
the study participants had ever used
at least one avor that contained diacetyl
or cinnamon avor/cinnamaldehyde or
2-methoxicinnamaldehyde, and they were also
more likely to report having a bad
reaction.These results suggest avor-
specic adverse health effects and support
enhancing the existing adverse experiences
reporting system to collect detailed
information about e-cigarette avor use (36).
Given the increasing popularity of e-cigarettes,
clinicians may need to include e-cigarette use
or exposure history (similar to smoking
history) in the risk assessment when caring for
patients with respiratory symptoms (37). The
American Thoracic Society also strongly
encourages healthcare professionals and the
general public to be educated about
e-cigaretteassociated respiratory distress (38).
Attention to long-term e-cigarette users is
warranted because of the potential
cumulative toxicities over a longer lifetime
of use. In addition, further prospective
studies with larger sample sizes are needed
to evaluate the unforeseen health effects of
e-cigarette avors. Our data indicating
the concurrent use of multiple avors
suggest a complex pattern of avor use
and motivate a need for toxicity testing
to assess poly-exposure. In vitro high-
throughput methods that look for pathway
perturbations may be needed as a toxicity
assessment approach.
Our results regarding anticipated
reactions to FDA e-cigarette avor
regulation suggest complexities such that
the benets and risks of avor ban need to
be carefully evaluated (19). Restrictions on
all nontobacco e-cigarette avors (or all
e-cigarettes) could help prevent nonusers
(especially adolescents or youth) from
initiating e-cigarette use, and over 40% of
our study participants believed in the
necessity of implementing regulations.
However, a majority anticipated that they
would personally attempt to circumvent
potential FDA regulations of e-cigarettes by
obtaining e-cigarette avors from various
illicit sources (e.g., Internet orders from
foreign countries) or even self-making
avors. This maintenance of access to
avors despite regulation suggests an
element of e-cigaretterelated dependence
that requires further evaluation. The
use of avoring agents purchased from
unregulated sources could lead to additional
unanticipated toxicities. It is also concerning
that some established e-cigarette users
believed that they would return to cigarette
smoking if nontobacco e-cigarette avors
were banned. Thus, for adult e-cigarette
users who use certain avors to facilitate
smoking cessation or reduction, banning all
nontobacco avors could precipitate relapse
to smoking.
Although our study provides important
results to understand migration in avor use
patterns, major limitations need to be
discussed when interpreting our results. Our
study participants were long-term adult
e-cigarette users who volunteered to
participate in the online surveys. The study
crude retention rate was 39.8%, and we
Table 4. Anticipated reactions to possible U.S. Food and Drug Administration e-cigarette avor regulatory scenarios
Anticipated Reactions If Your Preferred Flavor Were
Banned (n[%])
If All Nontobacco Flavorings Were
Banned (n[%])
I would miss my old avor. 15 (4.0) 6 (1.6)
I would be angry. 53 (14.2) 81 (21.8)
I would try to stop using e-cigs. 4 (1.1) 5 (1.3)
I would return to smoking traditional tobacco
cigarettes.
19 (5.1) 36 (9.7)
I dont really know what I would do. 24 (6.4) 10 (2.3)
I would use e-cigs less than I do now. 1 (0.3) 2 (0.5)
I would nd a way to buy my preferred avor. 76 (20.4) 71 (19.2)
I would continue to use e-cigs about the same as I do
now.
29 (7.8) 22 (5.9)
I might try tobacco cigarettes or smokeless tobacco
that comes in my preferred avor.
0 (0) 0 (0)
I would not consider using avored e-cig liquids other
than my preferred avor.
9 (2.4) 3 (0.8)
I would switch to another avor. 26 (7.0) 13 (3.5)
I would be able to stop using e-cigs. 1 (0.3) 1 (0.3)
I might switch to cigars that are avored. 0 (0) 0 (0)
I would add avoring agents myself. 114 (30.6) 122 (32.8)
I would use e-cigs more than I do now. 1 (0.3) 0 (0)
ORIGINAL RESEARCH
Du, Bascom, Fan, et al.: Long-Term E-Cigarette Flavor Preference Changes 579
further excluded participants with key
missing data. Our study population is
therefore not representative of general
e-cigarette users, and our results may be
biased to reect the avor use experience
specic to a subset of long-term stable users.
Meanwhile, e-cigaretterelated adverse
respiratory effects could be underestimated
if many former or occasional users (who
could not tolerate the adverse reactions
of e-cigarette use) did not participate in
our surveys. Another important limitation
for survey research that relies on self-
reported data is information bias:
E-cigarette users may have changed avor
preference multiple times between the two
surveys, or they may not have accurately
recalled or known all the avors they used,
especially the avor used at e-cigarette
initiation. We also did not have sufcient
data to evaluate if device characteristics
would affect avor use. Despite these
limitations, our study included a large
number of established exclusive e-cigarette
users so that we could examine the avor
use history and distinguish the independent
health effects due to e-cigarette use. Our
results are consistent with previous research
indicating the popularity of nontobacco-
related avors among e-cigarette users (13,
14). We also provide new evidence to better
understand avor use behaviors in older
adults and possible health risks in long-term
e-cigarette users.
In conclusion, our study indicates
rapidly shifting avor use patterns in all
demographic groups of long-term
e-cigarette users. The evidence for regular
use of multiple avors and trial use of
many avors, coupled with evidence of
variable adverse respiratory effects from
certain e-cigarette avors, motivates
future research to understand the health
risks associated with these changing
avor use patterns. The present study
can inform clinicians, researchers, and the
FDA to address the concern that many
long-term users state an intention to seek
illicit avor sources in the event of a avor
ban, which may cause unforeseen
health problems. n
Author disclosures are available with the text
of this article at www.atsjournals.org.
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Du, Bascom, Fan, et al.: Long-Term E-Cigarette Flavor Preference Changes 581
... Our findings indicate that AEs are relatively common among e-cigarette users. In line with previous studies, mouth and throat dryness and irritation, cough, and headache were the most frequently reported AEs, particularly in our current daily e-cigarette user sample [15,[22][23][24][25][35][36][37]. The rate of AEs varies across studies with different study designs between 7-58% [15,22,24,35,36,[38][39][40]. ...
... In line with previous studies, mouth and throat dryness and irritation, cough, and headache were the most frequently reported AEs, particularly in our current daily e-cigarette user sample [15,[22][23][24][25][35][36][37]. The rate of AEs varies across studies with different study designs between 7-58% [15,22,24,35,36,[38][39][40]. In a meta-analysis by Liu et al. (2018), reported AE rates were found to be higher in web-based surveys than in clinical trials [36], although some more recent online questionnaire-based studies showed remarkably lower rates [15,35]. ...
... The rate of AEs varies across studies with different study designs between 7-58% [15,22,24,35,36,[38][39][40]. In a meta-analysis by Liu et al. (2018), reported AE rates were found to be higher in web-based surveys than in clinical trials [36], although some more recent online questionnaire-based studies showed remarkably lower rates [15,35]. According to these, the proportion of reporting any AE and some specific AEs explored in our quantitative study with an in-person interviewing method is consistent with the higher range of AE rates. ...
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Purpose The purpose of this study was to assess product appeal, likelihoods of use, and intended use of a disposable electronic nicotine delivery system (ENDS) product (BIDI® Stick), that is available in a variety of flavors, among adults and young adults in the United States with different tobacco use histories. Methods Product appeal, likelihood to try, likelihood to regularly use, and intended use of eleven flavor varieties of BIDI® Stick products was assessed among adult and young adult current, former, and never tobacco users. Participants were screened and recruited from an online panel of individuals in the United States. A total of N = 2,820 participants were enrolled in the study, including n = 1,484 current, n = 568 former, and n = 768 never tobacco users. Participants rated product appeal and reported how likely they would be to try and regularly use the product. Current cigarette smokers reported their intended use of eleven flavor varieties of BIDI® Stick. Results Current tobacco users found BIDI® Stick products to be more appealing than tobacco non-users. Tobacco non-users, including former and never tobacco users, reported significantly lower likelihood to try (p < 0.001) and likelihood to regularly use (p < 0.001) any BIDI® Stick product, regardless of whether the product was tobacco flavored, menthol flavored, or non-tobacco flavored. Young adult (ages 21–24 years) tobacco non-users did not report statistically different likelihood to try BIDI® Stick, regardless of flavor, when compared to older adult (age ≥ 25 years) tobacco non-users (p = 0.148). Most current cigarette users intending to quit smoking reported they intend to use BIDI® Stick to reduce or quit cigarette smoking. Conclusions This research helps address gaps in knowledge regarding perceptions and potential use of a disposable ENDS product that is available in a variety of flavors. Results demonstrate that tobacco non-users, including young adult tobacco non-users, are unlikely to use any BIDI® Stick product, regardless of flavor. Current tobacco users reported significantly higher likelihood to try and likelihood to regularly use BIDI® Stick than tobacco non-users and reported higher likelihood to try non-tobacco flavored BIDI® Stick products. Current cigarette users reported they intend to use BIDI® Stick to reduce or quit smoking. Availability of BIDI® Stick, and specifically non-tobacco/non-menthol flavored BIDI® Stick products, may benefit current cigarette users without posing a substantial risk of initiation by tobacco non-users, including young adults.
... Even though the FDA is interested in research that shows benefits of reducing nicotine content in tobacco products, there are no clear guidelines on the relative amounts of other components in e-liquids, including flavors. More recently, an online survey study found that flavorassociated adverse reactions, such as respiratory irritations, were reported by 6.9% participants 30 . ...
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Introduction: Cigarette smoking poses many health risks and can cause chronic obstructive pulmonary disease (COPD), cardiovascular disease, cancer of the lung and other organs. Smokers can substantially reduce their risks of these diseases by quitting, but nicotine addiction makes this difficult. Alternatives, such as electronic cigarettes (e-cigarettes), may provide a similar dose of nicotine, but expose users to fewer toxic chemicals than traditional cigarettes and may still be harmful especially for dual users, therefore, we sought to develop bioassays that can assess the potential toxicity and inflammatory response induced by e-cigarette liquids (e-liquids) with and without flavors. Methods: E-liquids with varying nicotine content and flavors were aerosolized through growth media and exposed to human bronchial epithelial cell line (BEAS-2B) and human monocyte-macrophage cell line (THP-1) in vitro. Cytotoxicity in response to e-cigarette aerosols was measured by MTT assay in BEAS-2B cells and inflammatory response was measured by TNF-α, IL-6, IL-8, and MCP-1 released from THP-1 cells. In addition, the oxidative stress marker, REDD1, and impact on phagocytosis, was assessed following exposure of BEAS-2B and THP-1 derived macrophages, respectively. Cigarette smoke extract was used as a positive control with known cytotoxicity and impairment of inflammatory response. Results: E-cigarette aerosols induced moderate cellular toxicity in bronchial epithelial cells. Our data also show that low nicotine levels are less damaging to the bronchial epithelial cells, and flavors in e-liquids influence the combined inflammatory response markers, phagocytosis, and REDD1 when examined in vitro. Conclusions: Our in vitro bioassays can be utilized to effectively measure flavor and nicotine-induced effects of e-cigarettes on combined inflammatory response and cytotoxicity in human macrophages and human bronchial epithelial cells, respectively.
... [62][63][64][65] This is supported by surveys of adult e-cigarette users, which show that over time, flavor preferences have changed, migrating from traditional tobacco flavors (tobacco and menthol/mint) toward sweets and candy flavors. 66 One survey found that between 2011 and 2016, tobacco as an initial flavor decreased from 46% to 24% of e-cigarette users, while fruit as a first flavor increased from 17.8% to 33.5%, followed closely by dessert/pastry and candy/chocolate/sweets flavors. 67 This change may be the result of an increased availability of flavors or a real change in flavor preference. ...
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While rates of smoking combustible cigarettes in the United States have trended down in recent years, use of electronic cigarettes (e-cigarettes) has dramatically increased, especially among adolescents. The vast majority of e-cigarette users consume “flavored” products that contain a variety of chemosensory-rich additives, and recent literature suggests that these additives have led to the current “teen vaping epidemic.” This review, covering research from both human and rodent models, provides a comprehensive overview of the sensory implications of e-cigarette additives and what is currently known about their impact on nicotine use. In doing so, we specifically address the oronasal sensory contributions of e-cigarette additives. Finally, we summarize the existing gaps in the field and highlight future directions needed to better understand the powerful influence of these additives on nicotine use.
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The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public—including most smokers—now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay’s authors, encourage the health community, media, and policymakers to more carefully weigh vaping’s potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation. (Am J Public Health. Published online ahead of print August 19, 2021: e1–e12. https://doi.org/10.2105/AJPH.2021.306416 )
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Regulations limiting the sale of flavored e-cigarette products are controversial for their potential to interfere with e-cigarette use as a cessation aid in addition to curbing youth use. Limited research suggests that flavor might enhance the addictive potential of e-cigarettes; however, the acute effects of flavored aerosols on brain function among humans have not been assessed. The present study aimed to isolate and compare the neural substrates of flavored and unflavored e-cigarette aerosols on brain function among nine female daily smokers. Participants inhaled aerosolized e-liquid with 36 mg/mL of nicotine with and without a strawberry-vanilla flavor while undergoing functional magnetic resonance imaging. We used general linear modeling to compare whole-brain mean neural activation and seed-to-voxel task-based functional connectivity between the flavored and unflavored inhalation runs. Contrary to our hypothesis, the flavored aerosol was associated with weaker activation than the unflavored aerosol in the brain stem and bilateral parietal-temporal-occipital region of the cortex. Instead, the flavor engaged taste-related brain regions while suppressing activation of the neural circuits typically engaged during smoking and nicotine administration. Alternatively, functional connectivity between subcortical dopaminergic brain seeds and cortical brain regions involved in motivation and reward salience were stronger during the flavored compared to unflavored aerosol run. The findings suggest that fruity and dessert-flavored e-cigarettes may dampen the reward experience of aerosol inhalation for smokers who initiate e-cigarette use by inhibiting activation of dopaminergic brain circuits. These preliminary findings may have implications for understanding how regulations on flavored e-cigarettes might impact their use as cessation aids. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Importance Flavors in tobacco products may appeal to young and inexperienced users. Objective 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. Design, Setting, and Participants 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. Main Outcomes and Measures Prevalence of tobacco product use at wave 2. Results 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. Conclusions and Relevance 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.
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CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical partners are investigating a multistate outbreak of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. In late August, CDC released recommendations for health care providers regarding e-cigarette, or vaping, product use associated lung injury (EVALI) based on limited data from the first reported cases (1,2). This report summarizes national surveillance data describing clinical features of more recently reported cases and interim recommendations based on these data for U.S. health care providers caring for patients with suspected or known EVALI. It provides interim guidance for 1) initial clinical evaluation; 2) suggested criteria for hospital admission and treatment; 3) patient follow-up; 4) special considerations for groups at high risk; and 5) clinical and public health recommendations. Health care providers evaluating patients suspected to have EVALI should ask about the use of e-cigarette, or vaping, products in a nonjudgmental and thorough manner. Patients suspected to have EVALI should have a chest radiograph (CXR), and hospital admission is recommended for patients who have decreased blood oxygen (O2) saturation (<95%) on room air or who are in respiratory distress. Health care providers should consider empiric use of a combination of antibiotics, antivirals, or steroids based upon clinical context. Evidence-based tobacco product cessation strategies, including behavioral counseling, are recommended to help patients discontinue use of e-cigarette, or vaping, products. To reduce the risk of recurrence, patients who have been treated for EVALI should not use e-cigarette, or vaping, products. CDC recommends that persons should not use e-cigarette, or vaping, products that contain tetrahydrocannabinol (THC). At present, CDC recommends persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products.
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The United States (U.S.) Food and Drug Administration has expressed concern about flavored e-cigarettes (e.g., JUUL brand) because they are appealing to youth who may be unaware that the product is addictive. The Population Assessment of Tobacco and Health Study Wave 3 provided data on flavor categories, type of e-cigarette product, and smoking status among past 30-day youth and adult e-cigarette users in the US. Most past 30-day youth and adult users reported using only one flavor category, with fruit (53% youth, 31% adult) being the most commonly reported category. Adults were far more likely to report using tobacco flavor alone, compared to any other individual flavor category or flavor category combinations (OR: 21.08, 95%CI: 5.92, 75.12). Whereas, youth were more likely to report using multiple flavor categories (OR: 2.03, 95%CI: 1.55, 2.65), with the most reported pairing being fruit and candy (36%). The variety of flavors on the market appeals to consumers of all ages. Although most past 30-day e-cigarette users reported only one flavor category, non-tobacco flavors were far more common among youth. Differences in flavor preferences among adult versus youth vapers may have implications for the role of flavors in both the initiation of youth vaping and adult vaping for smoking cessation.
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Purpose of Review E-cigarettes are available in a variety of flavors not found in traditional tobacco products (i.e., “nontraditional flavors”), which is a commonly cited reason for e-cigarette use. This review examines the prevalence of nontraditional-flavored e-cigarette use, mechanisms through which flavorings enhance product appeal, use of nontraditional-flavored e-cigarettes for smoking cessation, and differences in these findings between youth and adults. Recent Findings Nontraditional-flavored e-cigarettes are used at e-cigarette initiation by the majority of youth. These flavors enhance the appeal of e-cigarettes by creating sensory perceptions of sweetness and coolness and masking the aversive taste of nicotine. Use of nontraditional-flavored e-cigarettes is higher among youth and young adults (vs. older adults) and among nonsmokers (vs. combustible cigarette smokers). Summary Nontraditional-flavored e-cigarettes are popular among youth, but may be less common among older adults and combustible cigarette smokers. Further research is needed to determine whether use of e-cigarettes in nontraditional flavors affects smoking cessation.
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Objectives: The use of flavored electronic cigarettes (e-cigarettes) is common among e-cigarette users, but little is known about the potential harms of flavorings, the extent to which the concurrent use of multiple flavor types occurs, and the correlates of flavor type use. The objective of this study was to assess the types of e-cigarette flavors used by adolescent (aged 12-17), young adult (aged 18-24), and older adult (aged ≥25) e-cigarette users. Methods: We assessed the prevalence of flavored e-cigarette use within the past month by flavor types and concurrent use of multiple flavor types among past-month e-cigarette users sampled during Wave 2 (2014-2015) of the Population Assessment for Tobacco and Health Study among 414 adolescents, 961 young adults, and 1711 older adults. We used weighted logistic regression models for the use of fruit-, candy-, mint/menthol-, tobacco-, or other-flavored e-cigarettes and concurrent use of multiple flavor types. Covariates included demographic characteristics, e-cigarette use frequency, cigarette smoking status, current use of other tobacco products, and reasons for e-cigarette use. Results: The leading e-cigarette flavor types among adolescents were fruit, candy, and other flavors; among young adults were fruit, candy, and mint/menthol; and among older adults were tobacco or other flavors, fruit, and mint/menthol. Compared with older adults, adolescents and young adults were more likely to use fruit-flavored e-cigarettes (adjusted odds ratio [aOR] = 3.35; 95% confidence interval [CI], 2.56-4.38; and aOR = 2.31; 95% CI, 1.77-3.01, respectively) and candy-flavored e-cigarettes (aOR = 3.81; 95% CI, 2.74-5.28; and aOR = 2.95; 95% CI, 2.29-3.80, respectively) and concurrently use multiple flavor types (aOR = 4.58; 95% CI, 3.39-6.17; and aOR = 2.28; 95% CI, 1.78-2.91, respectively). Conclusions: Regulation of sweet e-cigarette flavors (eg, fruit and candy) may help reduce the use of e-cigarettes among young persons without substantially burdening adult e-cigarette users.
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Electronic cigarettes (e-cigarettes) are alternative, non-combustible tobacco products that generate an inhalable aerosol containing nicotine, flavors, propylene glycol, and vegetable glycerin. Vaping is now a multibillion dollar industry that appeals to current smokers, former smokers, and young people who have never smoked. E-cigarettes reached the market without either extensive preclinical toxicology testing or long term safety trials that would be required of conventional therapeutics or medical devices. Their effectiveness as a smoking cessation intervention, their impact at a population level, and whether they are less harmful than combustible tobacco products are highly controversial. Here, we review the evidence on the effects of e-cigarettes on respiratory health. Studies show measurable adverse biologic effects on organ and cellular health in humans, in animals, and in vitro. The effects of e-cigarettes have similarities to and important differences from those of cigarettes. Decades of chronic smoking are needed for development of lung diseases such as lung cancer or chronic obstructive pulmonary disease, so the population effects of e-cigarette use may not be apparent until the middle of this century. We conclude that current knowledge of these effects is insufficient to determine whether the respiratory health effects of e-cigarette are less than those of combustible tobacco products.
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Prevalence of e-cigarette use among US adolescents substantially increased from 2017 to 2018.¹ Whether prevalence also increased among young adults (18-24 years)—a population with high vaping rates² and vulnerability to nicotine dependence and other health consequences of nicotine exposure³—is unknown.
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Background: The prevalence of electronic cigarette use has grown over the past decade, with some users reportedly initiating e-cigarette use primarily due to flavors. This study examined the role of flavors in initiation among adult e-cigarette users, as well as the association of flavors with satisfaction and perceived addiction to vaping. Methods: The analysis sample consisted of 1492 current e-cigarette users aged 18 or older, drawn from an online quantitative survey conducted in 2016. Multivariable logistic regression and general linear models were used. Results: Most current e-cigarette users (62.9%) typically used flavors other than tobacco (including fruit, mint/menthol, sweet, candy, coffee and other), 24.2% typically used tobacco flavors, and 12.9% typically used non-flavored e-cigarettes. Flavor was a common reason for vaping initiation, selected by 29.5% of the sample. Flavor, particularly fruit flavor, was more likely to motivate young adults 18-24 to initiate vaping compared adults 35-44. Those who used flavors, particularly mint/menthol and flavors other than tobacco flavor, had higher odds of reporting high satisfaction with vaping and had higher odds of perceived addiction to vaping than respondents who did not use flavored e-cigarettes. Conclusions: Users of flavored e-cigarettes reported greater satisfaction and self-perceived addiction than users of non-flavored e-cigarettes. The appeal of flavors, particularly among young adults, has implications for regulatory policy regarding the marketing and promotion of flavored products. These findings may provide direction for the Food and Drug Administration's plans to restrict flavors other than menthol, mint, and tobacco.
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Introduction: Little is known about the effects of long-term e-cigarette use, particularly the risks of relapse to cigarette smoking or increased dependence. Methods: In a 2012-2014 baseline online e-cigarette survey, 1,863 respondents consented to participate in future research. A follow-up online survey was conducted in 2017-2018 to assess changes in e-cigarette use behaviors and e-cigarette-related dependence. For both surveys, exclusive e-cigarette use was defined as only using e-cigarettes in the past 7 days, and poly use was defined as using both e-cigarettes and other tobacco or nicotine products in the past 7 days. The Penn State Electronic Cigarette Dependence Index (PSECDI) score was calculated for each study subject and was used to evaluate e-cigarette dependence. Paired t-tests or Pearson correlation coefficients were used to examine changes in e-cigarette use behaviors or PSECDI scores between baseline and follow-up. Baseline and follow-up survey data were analyzed in January 2019. Results: A total of 494 subjects provided complete data on both surveys. At baseline, 402 subjects (81.4%) were exclusive e-cigarette users, and 71 subjects (14.4%) were poly users. Among baseline exclusive e-cigarette users, the majority (88.3%) continued using e-cigarettes exclusively, but 37 users (9.2%) became poly users and 1 returned to cigarette smoking at follow-up. Among baseline poly users, 60.6% became exclusive e-cigarette users at follow-up. The mean PSECDI score remained similar over time (8.4 at baseline vs 8.3 at follow-up). Conclusions: Findings suggest that the risk of relapse to cigarette smoking is low, and e-cigarette-related dependence remains stable in long-term e-cigarette users.
Article
Objectives: Little evidence is available on the association of e-cigarettes with health indices. We investigated the association of e-cigarette use with diagnosed respiratory disorder among adults in data from the Behavioral Risk Factor Surveillance Survey (BRFSS). Methods: The 2016 Hawaii BRFSS, a cross-sectional random-dial telephone survey, had 8087 participants; mean age was 55 years. Items asked about e-cigarette use, cigarette smoking, and being diagnosed by a health professional with (a) asthma or (b) chronic obstructive pulmonary disease. Multivariable analyses tested associations of e-cigarette use with the respiratory variables controlling for smoking and for demographic, physical, and psychosocial variables. Results: Controlling for the covariates and smoking there was a significant association of e-cigarette use with chronic pulmonary disorder in the total sample (AOR = 2.58, CI 1.36-4.89, p < 0.01) and a significant association with asthma among nonsmokers (AOR = 1.33, CI 1.00-1.77, p < 0.05). The associations were stronger among nonsmokers than among smokers. Results were similar for analyses based on relative risk and absolute risk. There was also a greater likelihood of respiratory disorder for smokers, females, and persons with overweight, financial stress, and secondhand smoke exposure. Conclusions: This is the first study to show a significant independent association of e-cigarette use with chronic respiratory disorder. Several aspects of the data are inconsistent with the possibility that e-cigarettes were being used for smoking cessation by persons with existing respiratory disorder. Theoretical mechanisms that might link e-cigarettes use and respiratory symptoms are discussed.