Youth and Flavored Tobacco Products

Youth “vaping” of e-cigarettes has been called a national epidemic by the U.S. Surgeon General , and the vast majority of young people’s first experience with vaping involves flavored tobacco products, which range from menthol to candy and dessert flavors. Scientific literature confirms that children and adolescents are strongly inclined towards sweet foods and sweet flavors generally , and their preference for sweet tobacco products is no different . The tobacco industry knows this: industry documents have shown that adolescents and young adults are particularly susceptible to using flavored tobacco products.

Even as combustible cigarette smoking has reached an all-time low of 2.3% in youth, the introduction of e-cigarettes on the scene since 2006 has led to a new wave of nicotine use among young people. The recently released National Institutes of Health (NIH)-supported Monitoring the Future panel study found that vaping reached an all-time high in 2021, nearly tripling levels from 2017. E-cigarette flavors like cotton candy, cupcake, butterscotch, pop rocks, and peanut butter cup played a big role in attracting youth. As demonstrated by the Population Assessment of Tobacco and Health Study (PATH), most youth and young adult new tobacco users first tried a flavored product. Furthermore, flavored more so than plain e-cigarette use is strongly associated with cigarette smoking susceptibility among non-smoking youth.

“We are concerned that the availability of e-cigarettes in flavors is drawing new youth to the realm of nicotine product use, youth who otherwise never would have used any sort of combustible, non-flavored nicotine product,” says Jessica Barrington-Trimis, Associate Professor of Population and Public Health Science at University of Southern California (USC), who has worked on several studies on youth and flavors. “The concern with beginning to vape is, of course, the risk of continued vaping, the risk of development of nicotine dependence, and the risk of transition to other types of nicotine products that may be more harmful to health.”

Youth Gravitate to Flavored Tobacco Products

From menthol to fruity, candy sweet to buttery, flavors enhance the pleasure of using tobacco products. In a recent study, Shannon Watkins and colleagues found that in the Wave 5 PATH Study, three quarters of young adult tobacco users use flavored tobacco and that young adult tobacco users of color use significantly greater flavored tobacco when compared to their White peers. In addition, flavored e-cigarettes, contain compounds that reduce the pH of the product which may increase nicotine’s bioavailability in the body, potentially leading to more addiction and dependence. Taken together these trends suggest that flavored tobacco products have the potential to addict young people and exacerbate health disparities among communities of color.

A comprehensive review found that the vast majority of vaping youth use flavored e-cigarettes. In one study, 80% of youth who started vaping before age 15 currently use flavored e-cigarettes. In the 2014 National Youth Tobacco Survey (NYTS), 63% of adolescents aged 11-17 used flavors (1.58 million youth) and a 2015 Texas study involving nearly 4,000 school-going youth found 98% of current vapers used flavors.

While a federal law banned flavored cigarettes other than menthol in 2009, e-cigarettes, hookah, and certain other tobacco products were not deemed to be tobacco products under federal management until 2016. Epidemiological research suggests that use of flavored e-cigarettes has been on the rise since 2011.

Barrington-Trimis was involved in a large study that followed a group of Los Angeles high school students from 10th through 12th grade (a longitudinal cohort study), using surveys to record information about their tobacco use. The study found that flavors such as fruit and candy were associated with continued vaping over time as well as more puffs per vaping episode compared with flavorless or tobacco and menthol flavors.

Menthol and Health Equity

Mint or menthol flavors have a unique impact on the body: they block pain receptors in the mouth and throat and stimulate receptors that cause a cooling sensation in different parts of the body. In a retrospective cross-sectional study of youth in Los Angeles, a team of researchers found that a “first flavor of menthol” was associated with double the vaping days, indicating potentially greater nicotine dependence. They found that when menthol was the first flavor used in vaping, it was associated with someone continuing to vape (as measured by vaping in the past 30 days). In other words, using menthol the first time someone vapes is more likely to result in a person still vaping, compared to people who first started with non-flavored e-cigarettes, or in that study, even other flavors.

Menthol is a concern because tobacco companies have targeted Black Americans with menthol cigarettes for decades. The industry has disproportionately advertised menthol products in Black communities, using themes of sexuality and sociability, and it worked: more than 77% of Black smokers use menthol versus 23% of white smokers. Black smokers also have higher rates of lung cancer than white smokers. Since most adult smokers start in adolescence, preventing youth from accessing menthol cigarettes or e-cigarettes is a lifelong health equity issue.

Studies have found price promotions for Newport, a popular brand among African Americans, were most common in communities with the highest quartile of Black residents but also areas with higher Asian/Pacific Islander populations. Prices were also lower in neighborhoods with the most youth, Black residents, and low-income households . Removing menthol from the market could prevent thousands of African American deaths annually.

In California, comprehensive restrictions or bans on flavored products in San Francisco and several Alameda County jurisdictions were effective at reducing product availability and advertising in these areas . Availability of flavored tobacco products, including menthol, decreased significantly after comprehensive flavor bans were enacted. In contrast, jurisdictions without a comprehensive flavor ban saw a significant increase in sales and advertising of most flavored tobacco products, including menthol. The study, which compared the two types of bans noted, “comprehensive flavor bans, especially those including menthol, have greater potential to reduce tobacco use and health disparities”. Indeed, across the nation, local restrictions or bans on flavored products were effective at reducing product availability and advertising in these areas, according to a systematic review published in April 2022 . Flavor bans are a proven policy tool available to address the health disparities generated by decades of targeted menthol marketing aimed at African Americans.

It’s Not Just E-Cigarettes

Among adolescents, e-cigarettes are the most commonly used nicotine products, followed closely by “non-tobacco oral nicotine products” such as pouches, lozenges and gummies, according to a 2022 paper involving Barrington-Trimis and her postdoctoral scholar Alyssa Harlow.

“Based on that paper, the FDA issued a warning to one of the companies that has been distributing nicotine gummies telling them not to distribute them because they were illicitly marketed nicotine products,” says Barrington-Trimis. “A comprehensive restriction on the flavors that are available across multiple nicotine products is really going to help to reduce use among youth.”

In response to discussions of flavor bans, there has been much misinformation on social media. For example, the #FlavorsSaveLives trended on Twitter, referring to the idea that flavored e-cigarettes may allow people to transition off of traditional tobacco to a safer product. But e-cigarettes have not been approved as cessation devices, nor has research shown that they are effective in this regard.

“There is not any evidence right now that says that the use of a flavored e-cigarette … is more likely to help people to quit smoking for good,” emphasizes Barrington-Trimis. Even if evidence did exist, there's no research that addresses whether flavored e-cigarettes must be commercially available in stores in order for them to work for adult cigarette smokers as a cessation aid.

On the other hand, there is evidence that the heating, vaporization, and inhalation of flavors can lead to respiratory disease. Diacetyl, acetoin, and 2,3-pentanedione were found in up to 90% of flavored e-cigarettes tested, and these compounds not only damage human bronchial epithelial cells but may also cause respiratory disease.

“There's enough that we know about the ramifications of youth use of flavored e-cigarettes insofar as the risk of continued vaping, the risk of development of nicotine dependence, the risk of transition to other types of products that you don't want youth get into use e-cigarettes, period,” adds Barrington-Trimis, “And if they happen to experiment, we want to reduce the likelihood that they continue to use those products.”

 

Youth and Flavors (one-pager)

 

MEDIA CONTACT
Wendee Nicole Holtcamp, wendeenicole@gmail.com 

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Sources

1. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/pdfs/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018-h.pdf   
2. Goldenson NI, Leventhal AM, Simpson KA, Barrington-Trimis JL. A Review of the Use and Appeal of Flavored Electronic Cigarettes. Curr Addict Rep. 2019 Jun;6(2):98-113. doi: 10.1007/s40429-019-00244-4. Epub 2019 May 17. PMID: 31453046; PMCID: PMC6709993.
3. Rose SW, Johnson AL, Glasser AM, Villanti AC, Ambrose BK, Conway K, Cummings KM, Stanton CA, Delnevo C, Wackowski OA, Edwards KC, Feirman SP, Bansal-Travers M, Bernat J, Holder-Hayes E, Green V, Silveira ML, Zhou Y, Abudayyeh H, Hyland A. Flavour types used by youth and adult tobacco users in wave 2 of the Population Assessment of Tobacco and Health (PATH) Study 2014-2015. Tob Control. 2020 Jul;29(4):432-446. doi: 10.1136/tobaccocontrol-2018-054852. Epub 2019 Sep 21. PMID: 31542778; PMCID: PMC7462091.
4. Patrick, M. E., Schulenberg, J. E., Miech, R. A., Johnston, L. D., O’Malley, P. M., & Bachman, J. G. (2022). Monitoring the Future Panel Study annual report: National data on substance use among adults ages 19 to 60, 1976-2021. Monitoring the Future Monograph Series. University of Michigan Institute for Social Research: Ann Arbor, MI. doi:10.7826/ISRUM.06.585140.002.07.0001.2022
5. Villanti AC, Johnson AL, Glasser AM, Rose SW, Ambrose BK, Conway KP, Cummings KM, Stanton CA, Edwards KC, Delnevo CD, Wackowski OA, Feirman SP, Bansal-Travers M, Bernat JK, Holder-Hayes E, Green VR, Silveira ML, Hyland A. Association of Flavored Tobacco Use With Tobacco Initiation and Subsequent Use Among US Youth and Adults, 2013-2015. JAMA Netw Open. 2019 Oct 2;2(10):e1913804. doi: 10.1001/jamanetworkopen.2019.13804. PMID: 31642927; PMCID: PMC6820032.
6. Chen JC, Das B, Mead EL, Borzekowski DLG. Flavored E-cigarette Use and Cigarette Smoking Susceptibility among Youth. Tob Regul Sci. 2017 Jan;3(1):68-80. doi: 10.18001/TRS.3.1.7. PMID: 30713989; PMCID: PMC6355139.
7. Shannon Lea Watkins, Felicia Pieper, Benjamin W. Chaffee, Valerie B. Yerger, Pamela M. Ling, Wendy Max, Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study, Journal of Adolescent Health,Volume 71, Issue 2, 2022, Pages 226-232, https://doi.org/10.1016/j.jadohealth.2022.02.013.
8. St Helen G, Dempsey DA, Havel CM, Jacob P 3rd, Benowitz NL. Impact of e-liquid flavors on nicotine intake and pharmacology of e-cigarettes. Drug Alcohol Depend. 2017 Sep 1;178:391-398. doi: 10.1016/j.drugalcdep.2017.05.042. Epub 2017 Jun 30. PMID: 28704768; PMCID: PMC5565733. 
9. Goldenson NI, Leventhal AM, Simpson KA, Barrington-Trimis JL. A Review of the Use and Appeal of Flavored Electronic Cigarettes. Curr Addict Rep. 2019 Jun;6(2):98-113. doi: 10.1007/s40429-019-00244-4. Epub 2019 May 17. PMID: 31453046; PMCID: PMC6709993.
10. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2016. Chapter 2, Patterns of E-Cigarette Use Among U.S. Youth and Young Adults. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538687/  
11. Leventhal AM, Goldenson NI, Cho J, Kirkpatrick MG, McConnell RS, Stone MD, Pang RD, Audrain-McGovern J, Barrington-Trimis JL. Flavored E-cigarette Use and Progression of Vaping in Adolescents. Pediatrics. 2019 Nov;144(5):e20190789. doi: 10.1542/peds.2019-0789. PMID: 31659004; PMCID: PMC6856781.
12. Ahijevych K, Garrett BE. Menthol pharmacology and its potential impact on cigarette smoking behavior. Nicotine Tob Res. 2004 Feb;6 Suppl 1:S17-28. doi: 10.1080/14622200310001649469. PMID: 14982706.
13. James D Sargent, MD, Mike Stoolmiller, PhD, Hongying Dai, PhD, Jessica L Barrington-Trimis, PhD, Rob McConnell, MD, Janet Audrain-McGovern, PhD, Adam M Leventhal, PhD, First E-Cigarette Flavor and Device Type Used: Associations With Vaping Persistence, Frequency, and Dependence in Young Adults, Nicotine & Tobacco Research, Volume 24, Issue 3, March 2022, Pages 380–387, https://doi.org/10.1093/ntr/ntab172  
14. Richardson A, Ganz O, Pearson J, et al How the industry is marketing menthol cigarettes: the audience, the message and the medium Tobacco Control 2015;24:594-600.
15. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2015. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software. https://www.lung.org/quit-smoking/smoking-facts/impact-of-tobacco-use/tobacco-use-racial-and-ethnic 
16. https://www.cdc.gov/tobacco/basic_information/menthol/public-health-problem.html 
17. Smiley SL, Cho J, Blackman KCA, Cruz TB, Pentz MA, Samet JM, Baezconde-Garbanati L. Retail Marketing of Menthol Cigarettes in Los Angeles, California: a Challenge to Health Equity. Prev Chronic Dis. 2021 Feb 11;18:E11. doi: 10.5888/pcd18.200144. PMID: 33571082; PMCID: PMC7879965.
18. Mendez D, Le TTT. Tob Control 2022; 31:569–571
19. Holmes LM, Lempert LK, Ling PM. Flavored Tobacco Sales Restrictions Reduce Tobacco Product Availability and Retailer Advertising. Int J Environ Res Public Health. 2022 Mar 15;19(6):3455. doi: 10.3390/ijerph19063455. PMID: 35329145; PMCID: PMC8953832.
20. Todd Rogers, PhD, Elizabeth M Brown, MPH, Leah Siegel-Reamer, MPH, Basmah Rahman, MPH, Ashley L Feld, MPH, Minal Patel, PhD, Donna Vallone, PhD, Barbara A Schillo, PhD, A Comprehensive Qualitative Review of Studies Evaluating the Impact of Local US Laws Restricting the Sale of Flavored and Menthol Tobacco Products, Nicotine & Tobacco Research, Volume 24, Issue 4, April 2022, Pages 433–443, 
21. Alyssa F. Harlow, Erin A. Vogel, Alayna P. Tackett, Junhan Cho, Dae-Hee Han, Melissa Wong, Myles G. Cockburn, Steve Y. Sussman, Jennifer B. Unger, Adam M. Leventhal, Jessica L. Barrington-Trimis; Adolescent Use of Flavored Non-Tobacco Oral Nicotine Products. Pediatrics August 2022; 150 (3): e2022056586. 10.1542/peds.2022-056586
22. Kirkpatrick MG, Dormanesh A, Rivera V, Majmundar A, Soto DW, Chen-Sankey JC, Cruz TB, Unger JB, Allem JP. #FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans. Nicotine Tob Res. 2021 Aug 4;23(8):1431-1435. doi: 10.1093/ntr/ntaa276. PMID: 33394024; PMCID: PMC8517966.
23. Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, Stewart JH, Christiani DC. 2016. Flavoring chemicals in e-cigarettes: diacetyl, 2,3-pentanedione, and acetoin in a sample of 51 products, including fruit-, candy-, and cocktail-flavored e-cigarettes. Environ Health Perspect 124:733–739; http://dx.doi.org/10.1289/ehp.1510185  
24. Park, HR., Vallarino, J., O’Sullivan, M. et al. Electronic cigarette smoke reduces ribosomal protein gene expression to impair protein synthesis in primary human airway epithelial cells. Sci Rep 11, 17517 (2021). https://doi.org/10.1038/s41598-021-97013-z 
25. Wold LE, Tarran R, Crotty Alexander LE, Hamburg NM, Kheradmand F, St Helen G, Wu JC; American Heart Association Council on Basic Cardiovascular Sciences; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; and Stroke Council. Cardiopulmonary Consequences of Vaping in Adolescents: A Scientific Statement From the American Heart Association. Circ Res. 2022 Jul 22;131(3):e70-e82. doi: 10.1161/RES.0000000000000544. Epub 2022 Jun 21. PMID: 35726609.