Many researchers are focusing on the role played by e-cigarette flavourings in encouraging young non-smokers to use these products.
Earlier this year, the Nordic Welfare Council produced a report intended to inform public health efforts by governments in the Nordic Region (Iceland, Sweden, Denmark, Norway, Faroe Islands, Finland, Aland, and Greenland).
Their report – The significance of flavour additives in the use of moist snuff and e-cigarettes – with a focus on young people and the Nordic region – provides a readable summary of the evidence as well as a summary of e-cigarette and oral tobacco (snus) use in those countries.
Their conclusions are pasted below, with links to the research on which they based their findings. Because this report is already 11 months old, further studies are also identified at the end of this blog post.
CONCLUSIONS OF THE NORDIC WELFARE COUNCIL:
- “Flavour additives are a leading cause of young people trying tobacco products or e-cigarettes.”
- “New users have a preference for the particularly sweet flavours, such as those of sweets, fruit, chewing gum, soft drinks, etc.”
- “Young people also have a perception that e-cigarettes with the flavour of fruit, for example, are less harmful to health than e-cigarettes with the flavour of tobacco.”
- ” If the product also contains nicotine, this may lead to dependence and potentially interest in trying other, more harmful tobacco products.”
- “Restrictions and regulations on flavour additives in e-cigarettes and e-liquids will therefore most likely have an impact on the use of these products by young people.”
ARTICLES REVIEWED BY THE NORDIC WELFARE COUNCIL:
Berg, 2016: Preferred flavors and reasons for ecigarette use and discontinued use among never, current, and former smokers.
Never, current, and former smokers had distinct reasons for e-cigarette use and discontinued use and differed in flavor preferences.
Never, current, and former smokers (n=1,567; age 18-34)
Bold, 2016: Reasons for Trying E-cigarettes and Risk of Continued Use
Several reasons for first trying e-cigarettes predicted continued e-cigarette use, including good flavors, does not smell bad, can hide from adults, low cost, friends use, can use anywhere, to quit smoking regular cigarettes, and because they are healthier than cigarettes.
Longitudinal surveys. Middle and high school students (n=340)
Chaffee, 2017: Perceived Flavored Smokeless Tobacco Ease-of-use and Youth Susceptibility.
Smokeless tobacco susceptibility was greatest among tobacco never-users who perceived flavored ST as easier to use.
2013-2014 Population Assessment of Tobacco and Health study (PATH) Tobacco never-users (n=7,718; age 12-17)
Cooper, 2016: Flavorings and Perceived Harm and Addictiveness of E-cigarettes among Youth.
Ever and current e-cigarette users had higher odds of reporting that flavored ecigarettes were “less harmful” than nonflavored e-cigarettes, compared to youth who did not use e-cigarettes.
Data from a rapid response surveillance system. Students (sample [n]=3,704 from a population of students [N]=434,601; grade 6, 8, and 10)
Corey, 2015: Flavored Tobacco Product Use Among Middle and High School Students–United States, 2014.
The popularity of flavors across the range of tobacco products e.g. e-cigarettes and hookah suggest that flavoring might have broad appeal to young tobacco users.
2014 National Youth Tobacco Survey (NYTS). Middle and high school students (n=22,007).
Couch, 2017: ST product characteristics and relationships with perceptions and behaviors among rural adolescent males: a qualitative study.
Participants associated flavored smokeless tobacco with appealing non-tobacco products, such as chewing gum and alcohol. Availability of different varieties and flavors stimulated interest and curiosity in sampling or switching between smokeless tobacco products.
Interview. Adolescent males and smokeless tobacco users (n=23)
Dai, 2016: Flavored Electronic Cigarette Use and Smoking Among Youth.
Use of flavored e-cigarettes was associated with higher odds of intention to initiate cigarette use, lower odds of intention to quit tobacco use, and a lower prevalence of perception of tobacco’s danger.
2014 National Youth Tobacco Survey (NYTS). Middle and high school students (n=21,491).
Dai, 2018: Single, Dual, and Poly Use of Flavored Tobacco Products Among Youths.
Use of flavored tobacco products is prevalent among youths. E-cigarettes were the leading flavored product and often concurrently used with other flavored tobacco products.
2014 National Youth Tobacco Survey (NYTS). (n=21,926)
Evans-Polce, 2018: Reasons for Vaping Among U.S. 12th Graders.
Three distinct classes of vapers were identified: adolescents who were Vaping for Taste + Entertainment, Vaping to Experiment, and Vaping to Replace Cigarettes.
2015 and 2016 Monitoring the Future study. Students, 12th graders.
Harrell, 2017: Flavored Tobacco Product Use among Youth and Young Adults: What if Flavors Didn’t Exist?
Most of the youth and young adult tobacco users reported using flavored tobacco. Three-fourths of flavored product users said they would no longer use the product if it was not flavored. This was highest for e-cigarettes and hookah and lowest for cigarettes.
Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS). Youth (n=2,483) and Marketing and Promotions across Colleges in Texas (MPACT). Young adults (n=4,326)
Hoffmann, 2016: Flavour preferences in youth versus adults: a review.
Tobacco products in flavours preferred by young people may impact tobacco use and initiation, while flavours preferred by adults may impact product switching or dual use.
Review study. (n=59 studies)
Kong, 2015: Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults.
The top reasons for experimentation with e-cigarettes were curiosity, appealing flavors, and peer influences.
Focus group and survey. Students (n=1,302; age 12- 22)
Kowitt, 2017: Perceptions and Experiences with Flavored NonMenthol Tobacco Products: A Systematic Review of Qualitative Studies.
Positive perceptions of flavored tobacco products and flavors led to experimentation and/or initiation of flavored tobacco products.
Review study. (n=20 studies)
Miech, 2017: What are kids vaping? Results from a national survey of US adolescents.
Among students who had ever used a vaporiser, 65-66% last used ‘just flavouring’ in 12th, in 10th and in 8th grade, more than all other responses combined. Nicotine use came in a distant second, at about 20% in 12th and 10th grade and 13% in 8th grade.
Survey. Students (n=44,892; grade 8, 10, and 12)
ModestoLowe, 2017: E-cigs . . . Are They Cool? Talking to Teens About E-Cigarettes.
Electronic cigarettes have gained wide acceptance among adolescents, especially those with sweet flavors such as bubble gum and cheesecake. This article outlines the basics of e-cigarettes and potential health hazards.
Morean, 2018: Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults.
Compared to adults, a larger proportion of adolescents preferred fruit, alcohol, and “other”-flavored e-liquids, whereas adults disproportionately preferred tobacco, menthol, mint, coffee, and spiceflavored e-liquids.
School-based survey. Adolescents (n=396), and MTurk survey. Adults (n=590). 25
Patrick, 2016: Self-reported reasons for vaping among 8th, 10th, and 12th graders in the US: Nationally-representative results.
Overall, results suggest that decisions to vape are based on curiosity, taste, and pleasure, rather than for reasons such as quitting regular cigarettes or substituting for regular cigarette smoking.
2015 Monitoring the Future study. Students (n=4,066; grade 8, 10, and 12)
Pepper, 2016: Adolescents’ interest in trying flavoured e-cigarettes.
Adolescents were more likely to report interest in trying an e-cigarette offered by a friend if it were flavoured like menthol, candy or fruit compared with tobacco. Adolescents believed that fruitflavoured e-cigarettes were less harmful to health than tobacco-flavoured e-cigarettes. Perceived harm mediated the relationship between some flavours and interest in trying e-cigarettes.
Phone survey. Adolescents (n=1,125; ages 13-17)
Schiffman, 2015: The Impact of Flavor Descriptors on Nonsmoking Teens’ and Adult Smokers’ Interest in Electronic Cigarettes.
The e-cigarette flavors tested appealed more to adult smokers than to nonsmoking teens, but interest in flavors was low for both groups. Online survey. Non-smoking teens and adult smokers (n=648; age 13-80)
Shang, 2018: The impact of flavour, device type and warning messages on youth preferences for electronic nicotine delivery systems: evidence from an online discrete choice experiment. Fruit/sweets/beverage flavours significantly increase the probability of choosing ENDS among youth and flavour has the most pronounced impact among three attributes.
Tsai, 2016: Reasons for Electronic Cigarette Use Among Middle and High School Students – National Youth Tobacco Survey, United States, 2016.
Among students who reported ever using e-cigarettes, the most commonly selected reasons for use were use by “friend or family member”, availability of “flavors such as mint, candy, fruit, or chocolate”; and the belief that “they are less harmful than other forms of tobacco such as cigarettes”. Availability of flavors as a reason for use was more commonly selected by high school users than by middle school users.
2016 National Youth Tobacco Survey (NYTS). Student U.S. middle school (grades 6-8) and high school (grades 9-12).
Villanti, 2017: Flavored Tobacco Product Use in Youth and Adults: Findings From the First Wave of the PATH Study (2013-2014).
Flavor was a primary reason for using a given tobacco product, particularly among youth. Eighty-one percent of youth and 86% of young adult ever tobacco users reported that their first product was flavored versus 54% of adults aged ≥25 years.
2013-2014 Population Assessment of Tobacco and Health study (PATH) Adults and youth (n=45,971; age >12)
Zare, 2018: A systematic review of consumer preference for ecigarette attributes: Flavor, nicotine strength, and type.
Consumers preferred flavored e-cigarettes, and preference varied with age groups and smoking status. Several flavors were associated with decreased harm perception while tobacco flavor was associated with increased harm perception.
Review study. (n=66 studies)
STUDIES PUBLISHED SUBSEQUENT TO THE NORDIC COUNCIL REVIEW
Chen-Sankey, 2019: Perceived ease of flavored e-cigarette use and e-cigarette use progression among youth never tobacco users,
Perceiving flavored e-cigarettes as easier to use than unflavored e-cigarettes may lead to e-cigarette use progression among youth never tobacco users.
Path Study 2013-2014 and 2014-2015 (n=6,983).
Goldenson 2019: A Review of the Use and Appeal of Flavored Electronic Cigarettes
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.
Meernick, 2019: Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated systematic review
Non-menthol flavours in e-cigarettes decrease harm perceptions (five studies) and increase willingness to try and initiation of e-cigarettes (six studies). Among adults, e-cigarette flavours increase product appeal (seven studies) and are a primary reason many adults use the product (five studies). The role of flavoured e-cigarettes on smoking cessation remains unclear (six studies).
Review Study (n=51 studies)
Schneller 2019: Use of Flavored E-Cigarettes and the Type of E-Cigarette Devices Used among Adults and Youth in the US—Results fromWave 3 of the Population Assessment of Tobacco and Health Study (2015–2016)
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%).
Path Study (n=28,148 adults, 11,814 youth)
Soneji, 2019: Use of Flavored E-Cigarettes Among Adolescents, Young Adults, and Older Adults: Findings From the Population Assessment for Tobacco and Health Study
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.
Path Study 2014-2015 (n=3086)