# data[].attributes.attachment_caption
The Alarming Increase in Vaping Among Youth

# data[].attributes.body
Citation: Thomas, S.P. (2019). The alarming increase in vaping among youth. Issues in Mental Health Nursing, 40(4), 287-288. https://doi.org/10.1080/01612840.2019.1578142

Annotation: This article introduces vaping as an epidemic, especially among adolescents. It also highlights factors that contributed to the increase in e-cigarette use such as marketing, flavors, sleek designs, lax regulations, lack of research and data, and perceptions around e-cigarettes. It also discusses challenges adolescents face while engaging in the behavior such as excessive spending, withdrawal symptoms, developing nicotine addictions, and vaping-related health issues. The intended audience is the general public to inform them about what vaping is, the possible consequences, and ways to educate parents and adolescents about the dangers of vaping. This illuminates my project topic because it gives a solid, informative overview about vaping and its rise to become an epidemic among teens which is my target audience. It also touches on policy challenges and medical perspectives which require more research, but offer new perspectives for me to consider in my project.

# data[].attributes.body
Citation: Cooper, M., Harrell, M.B., Pérez, A., Delk, J., & Perry, C.L. (2016). Flavorings and perceived harm and addictiveness of e-cigarettes among youth. Tobacco regulatory science, 2(3), 278-289. https://doi.org/10.18001/TRS.2.3.7

Annotation: This article assesses perceived harm and addictiveness of e-cigarettes among youth. This study found that those who have never used an e-cigarette are more likely to believe that they are harmful than those who currently use e-cigarettes. Individuals also reported that they believe flavored e-cigarettes are less harmful than non-flavored e-cigarettes. This article is related to the previous article in the bibliography because they both discuss harm and addictiveness perception and they found similar results. It also relates to other research regarding the addictiveness of flavors in e-cigarettes because this article declares the lower perceived harm of flavored e-cigarettes as worrisome since they are indeed harmful and flavors in e-cigarettes is a main reason why adolescents use e-cigarettes. The intended audience for this article is researchers to build upon these findings and further research relating topics such as risk factors for using e-cigarettes among adolescents. This article is beneficial to my topic and project because it found consistent results and shows the difference in attitudes and perceptions about e-cigarettes between users and non-users. It also reinforces the role of flavors on one’s harm and addictiveness perception, as well as use and frequency of use. Lastly, this article also relates to the second article in the bibliography because it mentions the role of marketing and the role of flavors in tobacco/e-cigarette advertisements.

# data[].attributes.attachment_link.readable_text
Tob Regul Sci. Author manuscript; available in PMC 2017 Jul 1.

Published in final edited form as:

Maria Cooper, PhD, Postdoctoral Fellow, Melissa B. Harrell, PhD, Associate Professor, Adriana Pérez, PhD, Associate Professor, Joanne Delk, MS, Research Coordinator, and Cheryl L. Perry, PhD, FAAHB, Professor and Regional Dean

Abstract

Objectives

Given the increasing trend in use of electronic cigarettes ("e-cigarettes") among youth, it is crucial to understand how these products are perceived and how these perceptions are associated with their decision whether or not to use them.

Methods

This is a cross-sectional analysis of data from a rapid response surveillance system of 6th, 8th and 10th grade students' tobacco use behaviors (sample [n] = 3704 from a population of students [N] = 434,601). We used weighted logistic regression models to investigate the relationship between perceptions of harm and addictiveness and e-cigarette use, including the use of flavored and non-flavored e-cigarettes.

Results

Compared to youth who did not use e-cigarettes, ever and current e-cigarette users had higher odds of reporting that e-cigarettes were "not at all harmful" to health and "not at all addictive." Ever and current e-cigarette users had higher odds of reporting that flavored e-cigarettes were "less harmful" than non-flavored e-cigarettes, compared to youth who did not use e-cigarettes.

Conclusions

These findings warrant attention given that nicotine is an addictive substance whose effects on the adolescent brain are potentially negative. Youth e-cigarette users perceived lower harm from flavored e-cigarettes, which is worrisome given emerging research documenting harmful constituents in certain e-cigarette flavorings.

Keywords: adolescents, e-cigarettes, risk perceptions

Given the increasing trend in use of electronic cigarettes ("e-cigarettes") among youth, it is crucial to improve understanding of how these products are perceived by youth and how these perceptions affect their decision to use them or not. Youth e-cigarette ever use and current use has risen significantly between 2011 and 2014 in the United States (US), with the most dramatic increase occurring between 2013 and 2014.1 In 2014, e-cigarettes surpassed conventional cigarettes as the most commonly used tobacco product among youth.1,2 In 2014 in the US, approximately 3.9% of middle school students and 13.4% of high school students used e-cigarettes in the past 30 days.1 In 2014, Texas-specific estimates of current e-cigarette use were even higher at 7.9% for middle school students and 19.1% for high school students.3

To date, a limited number of studies have investigated risk factors associated with the use of e-cigarettes among youth.4-9 Young populations are important to study for various reasons. First, there is emerging evidence that e-cigarette companies are using marketing strategies that appeal to youth. These include sponsorship of youth-oriented events or providing samples at such events; airing of television and radio commercials during events such as the Super Bowl; and marketing of flavors such as grape mint and cherry crush that may be particularly enticing to youth.10 Other marketing strategies used by e-cigarette companies include celebrity spokesmen and social media promotion, both of which may be used to attract young consumers.

Second, nicotine exposure may affect young populations' health particularly negatively, and this population also may tend to underestimate the severity of nicotine's effects. Research has shown that adolescents misjudge the drug's addictiveness; although conventional cigarette smokers in this age group are more likely than nonsmokers to believe they can quit anytime, only a small minority (about 4%) successfully quit each year.11 Other evidence suggests that the brains of younger individuals are more vulnerable to nicotine than older populations. According to one animal study, the plasticity of the developing brain makes it particularly susceptible to certain drugs, like nicotine.12 In fact, nicotine exposure during adolescence may be linked to enhanced vulnerability to nicotine addiction, increased impulsivity and mood disorders.13

Third, public health researchers speculate about other deleterious consequences of early e-cigarette use, including the possibility of a gateway effect leading to later use of conventional and potentially more harmful tobacco products, like cigarettes. To date, there are only limited data that support this idea.14-17 Whereas the "gateway phenomenon" in reference to e-cigarettes and cigarettes is not yet definitively proven, the biological evidence alone serves to caution against the dangers of youth exposure to nicotine, the highly addictive substance that is found in e-cigarettes.18

Given the fact that youth are both experimenting with and regularly using e-cigarettes at rapidly growing rates, it is fundamental to understand common beliefs about their use. Currently, there is a significant gap in our understanding of how youth perceive these products and how such perceptions may affect their decision to use them. To date, only a few published studies exist on the topic.4,6,9,19 For conventional cigarettes, however, there is consensus that perceptions of harmfulness affect smoking behaviors; as perceived harm decreases, conventional smoking behaviors increase.20 The Theory of Planned Behavior lays the foundation for this association, positing that one's perceptions predict changes in behavior.21 One qualitative study of 47 male e-cigarette users between ages of 15-17 found that 30% used e-cigarettes because they believed they were healthier than cigarettes.5 Few studies, however, have explored the perceptions of harm of e-cigarettes in a population-based sample of youth, including users and non-users. One exception are results from the 2012 National Youth Tobacco Survey comparing harm perceptions of e-cigarettes and conventional cigarettes among middle school and high school students (N = 24,658). One in 3 students reported e-cigarettes were less harmful than cigarettes, and boys and white respondents were more likely to hold this perception. In addition, ever e-cigarette use was associated with perceiving e-cigarettes as less harmful. This was consistent regardless of cigarette smoking status.4 However, in a study of Canadian youth and young adults, perceptions of e-cigarette harm did vary by smoking history; among former or never smokers, ever users of e-cigarettes held lower perceptions of harm from e-cigarettes than the never e-cigarette users, whereas the opposite pattern was found among current smokers.22

To our knowledge, no studies to date have assessed perceived addictiveness of e-cigarettes and e-cigarette use in youth. In addition, there is limited literature addressing the role of flavors in youth perceptions of harm, and in fact, according to our review, only one assessed whether the presence of flavoring in an e-cigarette influences an individual's belief about its harmfulness. A study of adolescents in the United Kingdom found that e-cigarettes flavored as candy and cherry were perceived as being less harmful than e-cigarettes in general, and those flavored like tobacco were perceived as being more harmful than e-cigarettes in general.23

This study aims to strengthen our understanding of young people's beliefs about e-cigarettes. The specific aim is to evaluate harm perceptions and perceived addictiveness of e-cigarettes among youth, including perceptions of harm specific to flavored e-cigarettes. We also assess whether these relationships differ in magnitude by sex or race/ ethnicity. The hypothesis is that among youth, perceived harm and addictiveness of e-cigarettes is lower among ever and current users of e-cigarettes as compared to non-users. Given the previous literature,4 we hypothesize that this relationship will be greatest among users who are male and white. A second hypothesis is that perceived harm of flavored e-cigarettes is lower than perceived harm of non-flavored e-cigarettes among ever and current users of e-cigarettes as compared to non-users. We also hypothesize that this relationship will be greatest among male and white users.

METHODS

Study Design

The Texas Adolescent Tobacco and Marketing Surveillance system (TATAMS) is a rapid response surveillance system currently being implemented with 6 th, 8 th and 10 th grade students in the 5 counties that surround the 4 largest cities in Texas-Austin, Houston, San Antonio, and Dallas/Ft. Worth. This study is a cross-sectional analysis of baseline data (Wave 1) from TATAMS, collected during the 2014-2015 academic year.

Data from The Texas Education Agency, the Texas Private School Accreditation Commission, and the National Center for Education Statistics were used to generate a sampling frame of 6 th, 8 th and 10 th grade students enrolled in public, private and charter schools in these 5 counties in Texas (Travis, Harris, Bexar, Dallas/Tarrant Counties) in the 2014-2015 academic year. A complex, multistage, probability-design sample of public schools was taken using probability proportional to the grades' enrollment, and later all private and charter schools were invited to participate. The details of this complex procedure are described in Perez et al.24 Overall, 79 schools agreed to participate.

A point person (eg, teacher, school counselor) was identified at each participating grade level and asked to recruit at least 55 students from each participating grade. This contact person was provided a $100 incentive to reimburse them for their time and effort. Some 10 th grade high school classes had students from 9 th grade who were allowed to participate in the study to ease classroom burden. Active parental consent and active student assent were obtained. Students received a $10 incentive upon completion of the survey. The baseline (ie, Wave 1) survey was administered between October 2014 and June 2015 (Sample [n] = 3907 from a population of students [N] = 461,069) using a computerized form on tablets.

Instrument

Survey questions were developed from a catalogue of valid and reliable measures used in state and national tobacco surveillance, including the Population Assessment of Tobacco and Health (PATH) study currently underway by the US Food and Drug Administration (FDA).25-27 A preliminary survey draft was reviewed by a panel of 6 leading experts with extensive experience in tobacco control, measurement, and survey design to establish face validity of the instrument. Additional cognitive interviewing was conducted between April and July 2014 with 27 students, ages 11 to 18, to ensure clear understanding of survey questions and full-color photographs of tobacco and nicotine products. Modifications to the instrument were made based on the expert review and the cognitive interviews.

The final survey instrument includes more than 340 questions specific to demographic factors, tobacco use behaviors (ie, e-cigarettes, cigars and cigarillos, little filtered cigars, smokeless tobacco, hookah, and cigarettes), cognitive and affective factors (eg, perceptions of harm), and self-reported exposure to tobacco marketing (eg, at retail outlets and in magazines and newspapers). Full-color photographs of the products were included to assist participants with their recognition of tobacco and nicotine products, and skip patterns were programmed into the survey to reduce participant burden where applicable.

Outcome Variables

This manuscript focuses on 3 outcome variables. The first outcome was harm perceptions of e-cigarettes. The survey question, in reference to electronic cigarettes, vape pens or e-hookahs, asked: "How harmful are these products to health?" Participants were asked to choose among 4 categories of responses ranging from "not at all harmful" to "extremely harmful." Responses were collapsed into 2 categories: "not at all" harmful and any other response was collapsed to represent the "any perceived harm" category. The "any perceived harm" category served as the reference.

The second outcome was harm perceptions of flavored e-cigarettes. To assess this outcome, students were asked: "Compared to non-flavored electronic cigarettes, vape pens or e-hookahs, how harmful are flavored electronic cigarettes, vape pens or e-hookahs to health?" Response categories were: "less harmful," "about as harmful," and "more harmful." Responses "about as harmful" and "more harmful" were collapsed into "same/higher perceived harm" category versus "less harmful." The "same/higher perceived harm" category served as the reference.

The third outcome of interest was perceived addictiveness of e-cigarettes. Students were asked: "How addictive are electronic cigarettes, vape pens or e-hookah?" Responses included: "not at all addictive," "somewhat addictive," and "very addictive." Responses "somewhat addictive" and "very addictive" were collapsed to represent "any perceived addictiveness" versus "not at all addictive." The "any perceived addictiveness" category served as the reference. All 3 outcomes were collapsed as described above to avoid large standard errors for the regression estimates associated with small cell size in each category.

Exposure

Current and ever e-cigarette use were the exposures of interest, and both were examined as dichotomous variables. To assess current e-cigarette use, respondents were asked: "During the past 30 days, on how many days did you use an electronic cigarette, vape pen or e-hookah?" By including a variety of commonly-used terms, captured through testing our survey instrument and items with cognitive interviewing with youth, we aimed to measure use and perceptions for all electronic nicotine delivery systems (ENDS). Therefore, findings should be applied to all ENDS broadly. Responses greater than zero days were considered past-30 day use. Respondents who reported they had not used e-cigarettes in the past 30 days represented the non-current user group. To assess ever e-cigarette use, respondents were asked: "Have you ever used an electronic cigarette, vape pen, or e-hookah, even one or two puffs?" Youth who responded "yes" were considered ever e-cigarette users and those who responded "no" were considered never e-cigarette users.

Covariates

Other covariates included: sex, grade, race/ethnicity (Hispanic, non-Hispanic white/other, and non-Hispanic black), socioeconomic status, and current use of tobacco products other than e-cigarettes. Socioeconomic status was operationalized asking: "In terms of income, what best describes your family's standard of living in the home where you live most of the time?" and collapsed response categories were: "very well off," "living comfortably," and "just getting by/nearly poor/poor." To assess current use of other tobacco products (cigarettes, little filtered cigars, large cigars or cigarillos, hookah, smokeless tobacco), respondents who indicated they had ever tried any of these products were given separate items that asked: "During the past 30 days, on how many days did you smoke/use cigarettes, little filtered cigars/large cigars or cigarillos/hookah/smokeless tobacco?" For each one of these variables, responses greater than zero days were considered past 30-day use for that tobacco product. These covariates were chosen because they have been found to be associated with risk perceptions of tobacco products and/or e-cigarette use.6,28-31

Statistical Methods

Descriptive statistics were conducted on sex, race/ethnicity, grade, socioeconomic status, e-cigarette user status, other tobacco product use, as well as the 3 outcome variables. All analyses used sampling weights to account for the complex design as well as for the clustering of the students within schools and to generalize to the population of students enrolled in these grades in these 4 Texas cities. Overall, Wave 1 had a sample size (n) of 3907 participants representing (N) 461,069 students in this sampling frame in Texas. Given that there were less than 10% of missing values for any of the variables described before, a complete case analysis32 was conducted on 3704 participants representing 434,601 students in these 4 cities in Texas. A type I error level of 0.05 was considered statistically significant. All data analyses were conducted using Stata 14.1 software package (College Station, TX).

Six separate weighted logistic regression models were used to test the hypothesis that current and ever e-cigarette user status were associated with each of the 3 outcomes each adjusting for the mentioned covariates. Furthermore, sex and race/ethnicity were considered as potential moderators because the perceived risks of e-cigarette use have been shown to vary by sex and race/ethnicity.4,6 That is, in the models examining current e-cigarette use, we included 2-way interaction terms between: (1) current e-cigarette use and sex; and (2) current e-cigarette use and race/ethnicity. Also, in the models examining ever e-cigarette use, we included 2-way interaction terms between: (1) ever e-cigarette use and sex; and (2) ever e-cigarette use and race/ethnicity. When no statistically significant moderation was found, we reported models adjusted for all covariates without the interaction (sex, grade, race/ethnicity, socioeconomic status and cigarette or other tobacco product use). We used the Hosmer-Lemeshow goodness-of-fit test for weighted logistic regression to evaluate model fit.33

RESULTS

Descriptive Statistics

Table 1 provides descriptive statistics. The weighted sample included in this analysis is 49.2% female; 54.6% Hispanic, 28.0% non-Hispanic white/other, 17.4% non-Hispanic black; and 18.5% were from families of lower socioeconomic status. The sample was evenly distributed across 6 th (32.1%), 8 th (34.5%), and 10 th (33.4%) grade levels. An estimated 17.4% of youth reported that e-cigarettes were "not at all" harmful, 27.0% reported that flavored e-cigarettes were "less harmful" than non-flavored e-cigarettes, and 55.5% reported that e-cigarettes were "not at all" addictive. In the past 30 days, 7.1% of youth reported they had used e-cigarettes, and 19.2% reported that they had ever used e-cigarettes. The vast majority of current e-cigarette users (88.4%) reported use of flavored e-cigarettes, which are those that were not tobacco-flavored. In the past 30 days, 6.0% of youth reported using at least one other tobacco product other than an e-cigarette.

Table 1

Socio-Demographic Characteristics

n; N (Weighted %)

Male

1617; 220,682 (50.8%)

Female

2087; 213,919 (49.2%)

Hispanic

1430; 237,314 (54.6%)

Non-Hispanic White/Other

1687; 121,721 (28.0%)

Non-Hispanic Black

487; 75,566 (17.4%)

6th

1061; 139,477 (32.1%)

8th

1255; 149,791 (34.5%)

10th

1388; 145,333 (33.4%)

Very well off

830; 84,079 (19.4%)

Living comfortably

2308; 270,268 (62.2%)

Just getting by/nearly poor/poor

566; 80,254 (18.5%)

Tobacco Use Behaviors n; N (Weighted %)

Non-current E-cigarette User

3466; 403,909 (92.9%)

Current E-cigarette User

238; 30,692 (7.1%)

Never E-cigarette User

3062; 351,030 (80.8%)

Ever E-cigarette User

642; 83,571 (19.2%)

Non-flavored (ie, tobacco flavoring)

25; 3,559 (11.6%)

Flavored (ie, mint, candy, fruit, coffee/alcohol, spice, or other flavoring)

213; 27,133 (88.4%)

No

3537; 408,450 (94.0%)

Yes

167; 26,151 (6.0%)

Perceptions of E-cigarettes n; N (Weighted %)

4 (Extremely harmful)

1502; 180,522 (41.5%)

3

662; 70,310 (16.2%)

2

949; 108,241 (24.9%)

1 (Not at all harmful)

591; 75,528 (17.4%)

More harmful

702; 87,287 (20.1%)

About as harmful

2066; 230,209 (53.0%)

Less harmful

936; 117,106 (27.0%)

Very addictive

652; 76,272 (17.6%)

Somewhat addictive

1081; 117,153 (27.0%)

Not at all addictive

1971; 241,176 (55.5%)

Perceived Harm of E-cigarettes

The F-test statistics, associated degrees of freedom, and associated p-values for the interaction terms for race/ethnicity and current e-cigarette use, sex and current e-cigarette use, race/ethnicity and ever e-cigarette use, and sex and ever e-cigarette use were: F(2,76) = 0.70 (p = .50), F(1,77) = 1.66 (p = .20), F(2,76) = 0.40 (p = .67), and F(1,77) = 0.39 (p = .53), respectively. None of these was statistically significant; therefore, all the models without interactions were used. As Table 2 shows, youth who currently used e-cigarettes had higher odds (OR = 4.77, 95% CI: 3.19 - 7.15) of reporting that e-cigarettes were "not at all" harmful to health compared to non-current e-cigarettes users after adjusting for sex, grade, race/ethnicity, socioeconomic status and cigarette or other tobacco product use. Youth who had ever used e-cigarettes also had higher odds (OR = 3.61, 95% CI: 2.48 - 5.28) of reporting that e-cigarettes were "not at all" harmful to health compared to never users after adjusting for covariates ( Table 3 ). The Hosmer-Lemeshow goodness-of-fit tests indicated good model fit for the adjusted weighted logistic regression models examining current e-cigarette use (χ ² = 1.43, p = .19) and ever e-cigarette use (χ ² = 0.70, p = .71) on perceived harm of e-cigarettes.

Table 2

"Not at all" Harmful

Flavored as "Less Harmful"

"Not at all" Addictive

adjOR
(95% CI)

adjOR
(95% CI)

adjOR
(95% CI)

Non-current e-cigarette use (ref)

1

1

1

Current e-cigarette use

4.77***
(3.19 - 7.15)

2.84***
(1.91 - 4.21)

1.72*
(1.12 - 2.65)

Hispanic

1.54**
(1.13 - 2.09)

1.09
(0.84 - 1.42)

1.63**
(1.22 - 2.84)

8th

1.30
(0.96 - 1.76)

1.76*
(1.11 - 2.78)

0.74
(0.46 - 1.18)

10th

1.94***
(1.37 - 2.76)

2.38***
(1.57 - 3.62)

0.74
(0.49 - 1.12)

Other tobacco use

2.22**
(1.30 - 3.78)

2.48**
(1.45 - 4.23)

1.71*
(1.12 - 2.60)

Table 3

"Not at all" Harmful

Flavored as "Less Harmful"

"Not at all" Addictive

adjOR
(95% CI)

adjOR
(95% CI)

adjOR
(95% CI)

Never e-cigarette use (ref)
1

1

1

Ever e-cigarette use
3.61***
(2.48 - 5.28)

2.88***
(2.42 - 3.42)

1.49**
(1.18 - 1.87)

Hispanic

1.46*
(1.06 - 2.02)

1.05
(0.82 - 1.34)

1.61**
(1.21 - 2.13)

8th

1.11
(0.83 - 1.50)

1.57*
(1.01 - 2.45)

0.71
(0.44 - 1.15)

10th

1.53*
(1.06 - 2.21)

1.96**
(1.30 - 2.96)

0.70
(0.46 - 1.06)

Other tobacco use

2.09**
(1.27 - 3.44)

2.08**
(1.25 - 3.44)

1.69**
(1.15 - 2.47)

Perceived Harm of Flavored E-cigarettes Compared to Non-flavored E-cigarettes

The F-test statistics, associated degrees of freedom, and associated p-values for the interaction terms for race/ethnicity and current e-cigarette use, sex and current e-cigarette use, race/ethnicity and ever e-cigarette use, and sex and ever e-cigarette use were: F(2,76) = 0.99 (p = .38), F(1,77) = 0.12 (p = .74), F(2,76) = 1.72 (p = .19), and F(1,77) = 0.05 (p = .82), respectively. None of these was statistically significant; therefore, all the models without interactions were used. As seen in Table 2 , youth who currently used e-cigarettes had higher odds (OR = 2.84, 95% CI: 1.91 - 4.21) of reporting flavored e-cigarettes as "less harmful" than non-flavored e-cigarettes compared to non-current users after adjusting for covariates. Youth who had ever used e-cigarettes also had higher odds (OR = 2.88, 95% CI: 2.42 - 3.42) of reporting that e-cigarettes were "less harmful" than non-flavored products compared to never users after adjusting for covariates ( Table 3 ). The Hosmer-Lemeshow goodness-of-fit tests indicated good model fit for the adjusted weighted logistic regression models examining current e-cigarette use (χ ² = 0.93, p = .51) and ever e-cigarette use (χ ² = 0.64, p = .76) on perceived harm of flavored e-cigarettes.

Perceived Addictiveness of E-cigarettes

The F-test statistics, associated degrees of freedom, and associated p-values for the interaction terms for race/ethnicity and current e-cigarette use, sex and current e-cigarette use, race/ethnicity and ever e-cigarette use, and sex and ever e-cigarette use were: F(2,76) = 2.13 (p = .13), F(1,77) = 0.00 (p = .98), F(2,76) = 0.18 (p = .84), and F(1,77) = 0.78 (p = .38), respectively. Again, none of these interactions was statistically significant. As Table 2 shows, youth who currently used e-cigarettes had higher odds (OR = 1.72; 95% CI: 1.12 - 2.65) of reporting that e-cigarettes were "not at all" addictive compared to non-current users after adjusting for sex, grade, race/ethnicity, socioeconomic status, and cigarette or other tobacco product use. Similarly, youth who had ever used e-cigarettes also had higher odds (OR = 1.49; 95% CI: 1.18 - 1.87) of reporting that e-cigarettes were "not at all" addictive compared to never users after adjusting for covariates ( Table 3 ). The Hosmer-Lemeshow goodness-of-fit tests indicated good model fit for the adjusted logistic regression models examining current use (χ ² = 0.24, p = .99) and ever use (χ ² = 0.29, p = .97) on perceived addictiveness of e-cigarettes.

DISCUSSION

This study contributes to the limited evidence that low perceptions of harm and addictiveness for e-cigarettes among youth are associated with e-cigarette ever use (including experimentation) and current use. By examining both measures, we have a deeper understanding of the stages of tobacco use in this young age group that may be in an experimentation or more regular stage of use. To our knowledge, this is the first study to explore the association between perceived harm of flavored e-cigarettes and current and ever e-cigarette use. Contrary to expectations, neither race/ethnicity nor sex was detected as moderators, meaning that current and ever e-cigarette use was consistent across sex and race/ethnicity strata.

Current findings are generally consistent with emerging research exploring risk perceptions and e-cigarette consumption among youth.4,6,9 For example, our findings are consistent with those of Ambrose et al4 who found that ever use of e-cigarettes was significantly associated with perceiving e-cigarettes as less harmful than cigarettes among middle and high school students nationwide. Amrock et al6 also investigated the comparative harm of e-cigarettes to cigarettes, and found that both ever users and current users of e-cigarettes reported that e-cigarettes were less harmful than cigarettes. Chaffee et al9 examined perceived risks and benefits of e-cigarettes in a sample of high school boys and found that increasing perceived risk was associated with lower prevalence of ever use of e-cigarettes. Our study extends these findings further, as it is specific to the absolute harm and addictiveness associated with e-cigarettes - not compared to other product use, like cigarettes. It is important to understand youth perceptions of absolute harm from e-cigarettes rather than the relative harm compared to cigarettes to gain an understanding of how middle school and high school students perceive the potential dangers of e-cigarettes separately from cigarettes, for which the hazards are well-documented and better understood by youth.34 This information may become increasingly relevant, as the prevalence of cigarette smoking continues to decline and e-cigarette use rises in youth.2

We found that the vast majority of current e-cigarette users used flavored products, which is consistent with previous research documenting that appealing flavors were a top-cited reason for youth experimentation with e-cigarettes.8 Furthermore, this is the first study to assess the relationship between the role of flavorings in youth's perceptions about the harmfulness of e-cigarettes and e-cigarette use, finding that youth who were current and ever e-cigarette users had higher odds of reporting flavored e-cigarettes as less harmful than non e-cigarette users. This finding extends previous research which found that fruit flavorings in hookah contributed to youth's perceptions of fewer health risks.35 It is possible that the less e-cigarettes resemble conventional cigarettes in taste, the less harmful they are thought to be, though the reasons behind these perceptions for e-cigarettes should be explored in future studies among youth.

To our knowledge, no other studies have investigated the association between perceived addictiveness of e-cigarettes and current and ever use of e-cigarettes in a youth population. Not only was the association between perceived addictiveness and e-cigarette use statistically significant, it is particularly noteworthy to mention that over half of youth (55.5%) reported that e-cigarettes were "not at all" addictive in this study. This finding is generally consistent with Anand et al's survey of public high school students in North Carolina, 60% of whom reported that e-cigarettes were safe or had minimal hazards.7 It is important to note, however, that neither the current manuscript nor the Anand et al study queried youth on specific nicotine concentration levels used in e-cigarettes; thus, it remains unknown how differing nicotine levels may influence youth risk perceptions.

Researchers have not yet reached a consensus regarding the short-term or long-term health consequences of e-cigarettes for youth. Although many have concluded that e-cigarettes are likely less harmful than conventional cigarettes,36 there is, however, evidence suggesting they are not harmless.37 For example, although the level of nicotine delivered to users via an e-cigarette is variable and the threshold for addiction to nicotine associated with e-cigarette use in youth is unknown, nicotine itself is still considered a highly addictive substance. In a neuroimaging study, exposure to intravenous nicotine increased neuronal activity in brain regions also shown to produce reinforcing and dependence properties associated with cocaine, amphetamine and opiates.38 In addition, other studies of e-cigarette aerosols have revealed that some contain potentially harmful toxicants.39,40 Finally, there is emerging literature that has suggested that some flavorings in e-cigarettes present more potential for harm. Farselinos et al41 tested sweet-flavored e-cigarette liquids for the presence of diacetyl and acetyl propionyl, both constituents associated with respiratory disease when inhaled. They found that between 40% and 50% of the samples tested exposed users to levels higher than the recommended safety limits for either substance.

Although we cannot determine causation because this is a cross-sectional study, the lower perceptions of risk among youth may contribute to a decision to use an e-cigarette. Alternatively, previous use of an e-cigarette may contribute to the formulation of favorable perceptions of these products. Future research should explore the association of perceptions of harm and addictiveness as contributors to a decision to use an e-cigarette in longitudinal studies. The study population was limited to students in 6 th, 8 th and 10 th grades within 4 cities in Texas. Therefore, findings may not be generalizable outside of this population including other regions of the US and other countries where e-cigarette regulations and advertising are variable. Additional research also should examine whether and how exposure to e-cigarette advertising influences perceptions of harm and addictiveness specific to e-cigarette use, including use of flavored e-cigarettes, among youth. In a content analysis of 365 YouTube videos featuring e-cigarettes, 85% of which were sponsored by e-cigarette companies, 301 videos (or 82%) presented some sort of positive health claim.42 YouTube has an expansive reach, especially to adolescent audiences. In fact, 54% of all US teens use the website.43 Whereas our current study does not measure media and advertising exposure and e-cigarette use, one previous study has found that most US adolescents learn about e-cigarettes through television advertisements;7 in contrast, a study conducted among Korean youth found the most common contact route on e-cigarettes was the internet.44 This calls into question the content of e-cigarette advertising via various media as it may influence perceptions of harm and addictiveness in this vulnerable population, including perceptions about flavored e-cigarette products.

IMPLICATIONS FOR TOBACCO REGUALTION

Our finding that youth e-cigarette users viewed flavored e-cigarettes as less harmful than non-flavored e-cigarettes is especially concerning and provides scientific rationale for the FDA to regulate characterizing flavors in these products as they are associated with lower harm perceptions. Future health communication campaigns, such as the FDA's "The Real Cost," which does not explicitly address e-cigarettes at present,45 should focus on dispelling commonly held misperceptions by youth that e-cigarettes are not harmful and not addictive. This is particularly important given our current finding that 55.5% believed they were not at all addictive and other findings that some e-cigarette aerosol contains toxins such as carbonyl compounds, volatile organic compounds, and nitrosamines, albeit at lower levels than traditional cigarettes.46 Nicotine concentrations typically range from 6 to 24 mg/ml in e-cigarettes,47 making them potentially addictive products. Future campaigns also should address misperceptions that flavored e-cigarettes are less harmful than non-flavored e-cigarettes.

The current study confirms limited research to date that perceived harm and addictiveness of e-cigarettes are related to e-cigarette use in youth. Our study uses a measure of absolute harm which adds a new dimension to previous research, highlighting the perceptions of harm of e-cigarettes alone (rather than compared to cigarettes, which are known to be extremely harmful). In addition, it is the first US study to note that youth e-cigarette users had higher odds of reporting flavored e-cigarettes as less harmful than non-flavored e-cigarettes. Finally, more than half of the youth reported that e-cigarettes are "not at all" addictive, a finding that warrants attention given that nicotine is present in many, though not all, e-cigarettes. Findings should inform future regulatory action on e-cigarettes and communication campaigns for young people, now that the FDA has the authority to act on these products.

Acknowledgments

Research reported in this publication was supported by grant number [1 P50 CA180906] from the National Cancer Institute and the FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

Footnotes

Human Subjects Statement
The University of Texas Health Science Center's Institutional Review Board approved this study (reference number HSC-SPH-13-0377). For participating schools, district and principal approval, and where appropriate, school Institutional Review Board approval, were obtained.
Conflict of Interest Statement
The authors affirm no conflicts of interest.

Contributor Information

Maria Cooper, The University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Austin Campus, Austin, TX.

Melissa B. Harrell, The University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Austin Campus, Austin, TX.

Adriana Pérez, The University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Austin Campus, Austin, TX.

Joanne Delk, The University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Austin Campus, Austin, TX.

Cheryl L. Perry, The University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Austin Campus, Austin, TX.

References

14. Wills TA, Knight R, Sargent JD, et al. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control. 2016 pii: tobaccocontrol-2015-052705. [Epub ahead of print] [[ PMC free article] [ PubMed] Google Scholar]

21. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211. [ Google Scholar]

24. Pérez A, Jackson C, Delk J, et al. Design, Sampling Weights, Reweighting for Unit Nonresponse, and Monitoring of the Texas Adolescent Tobacco and Marketing Surveillance (TATAMS) Study; Joint Statistical Meetings Session 541: Weighting and Design effects, JSM2015 program book; August 12/2015; Seattle, WA. 2015. [Accessed June 1, 2016]. p. 222. Available at: [ http://www.amstat.org/sections/srms/proceedings/allyears.html. Google Scholar]

27. Substance Abuse and Mental Health Services Administration (SAMHSA) Rockville, MD: SAMHSA; 2011. National Survey on Drug Use and Health. [ Google Scholar]

28. Liu JT, Hsieh CR. Risk perception and smoking behavior: empirical evidence from Taiwan. J Risk Uncertain. 1995;11(2):139-157. [ Google Scholar]

34. Slovic P. What does it mean to know a cumulative risk? Adolescents' perceptions of short-term and longterm consequences of smoking. J Behav Dec Making. 2000;13:259-266. [ Google Scholar]

# data[].attributes.attachment_link.title
Flavorings and Perceived Harm and Addictiveness of E-cigarettes among Youth

# data[].attributes.attachment_link.description
Given the increasing trend in use of electronic cigarettes ("e-cigarettes") among youth, it is crucial to understand how these products are perceived and how these perceptions are associated with their decision whether or not to use them.This ...

# data[].attributes.attachment_caption
Harm and Addiction Perceptions of the JUUL E-Cigarette Among Adolescents 

# data[].attributes.body
Citation: Russell, C., Katsampouris, E., & Mckeganey N. (2020). Harm and addiction perceptions of the JUUL e-cigarette among adolescents. Nicotine & Tobacco Research, 22(5), 713-721. https://doi.org/10.1093/ntr/ntz183

Annotation: This article assesses perceptions of the harm and addictiveness of JUULs and frequency of use among adolescents aged 13-17. This study found that most individuals believe using a JUUL will put them at some, very minimal risk, and a smaller portion of the sample believed they could use a JUUL without ever being harmed or becoming addicted. They also found that they believed JUULs/e-cigarettes are less harmful and addictive than traditional tobacco cigarettes which is consistent with other studies. The intended audience is other researchers because the authors express that there is a gap in research about adolescents’ perceptions of harm and addictiveness for e-cigarettes. This illuminates my topic because it shows that many adolescents are unaware of the harms of e-cigarettes which can lead to continued use, nicotine addiction, and poor health outcomes related to smoking. I am interested in educating adolescents who may be unaware and susceptible to engaging in this behavior.

# data[].attributes.attachment_link.title
Harm and Addiction Perceptions of the JUUL E-Cigarette Among Adolescents

# data[].attributes.attachment_link.description
AbstractIntroduction. This study assessed adolescents’ harm and addiction perceptions of the highest-selling brand—JUUL—of the most commonly used tobacco produc

# data[].attributes.attachment_caption
E-Cigarette Marketing Exposure Is Associated With E-Cigarette Use Among US Youth

# data[].attributes.body
Citation: Mantey, D.S., Cooper, M.R., Clendennen, S.L., Pasch, K.E., & Perry, C.L. (2016). E-cigarette marketing exposure is associated with e-cigarette use among US youth. Journal of Adolescent Health 58(6), 686-690. https://doi.org/10.1016/j.jadohealth.2016.03.003

Annotation: This article assesses the association between exposure and susceptibility to e-cigarette marketing and e-cigarette use among youths. This study found that increased exposure to marketing is significantly associated with likelihood of e-cigarette use among adolescents. These findings are consistent with other research about promotion of traditional tobacco products and increased use. The intended audience is other researchers, scholars, and students because this article mentions the need for additional research and longitudinal studies on these relationships. This article is relevant to my topic because it focuses on the fact that e-cigarette companies’ advertisements have an impact on adolescents’ attitudes, beliefs, and likelihood of using e-cigarettes. This article also focuses on adolescents which is my population of interest.

# data[].attributes.body
Citation: Schneller, L.M., Bansal-Travers, M., Goniewicz, M.L., McIntosh, S., Ossip, D., & O’Connor, R.J. (2019). Use of flavored e-cigarettes and the type of e-cigarette devices used among adults and youth in the US- results from wave 3 of the population assessment of tobacco and health study (2015-2016). International Journal of Environmental Research and Public Health, 16(16), 2991. https://doi.org/10.3390/ijerph16162991

Annotation: This article assesses frequency of use of flavored e-cigarettes, e-liquid flavor preferences, type of e-cigarette, and smoking status among youth and adults. This study found that youth vapers are more likely than adult vapers to use fruit or sweet flavored e-cigarettes, and that adult vapers are more likely to use tobacco or menthol flavored e-cigarettes. It also concluded related behaviors like individuals who were former smokers were more likely to use non-tobacco flavored e-cigarettes, and that vapers who use two or more different flavors are more likely to have made an attempt to quit. Flavors are also found to promote continued use and positive reinforcement among young adults. The intended audience of this article is other researchers, scholars, or students because this article’s findings can be built upon and referenced through other studies. This work illuminates my topic because it focuses on e-cigarette behaviors and preferences among young adults, which is my population of interest, and because it helps me understand the role of flavors in young adults’ e-cigarette-related decisions.

# data[].attributes.attachment_link.readable_text
Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA

Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA

Author to whom correspondence should be addressed.

1. Introduction

The United States (U.S.) Food and Drug Administration (FDA) was given the authority to regulate all tobacco products, including electronic cigarettes (e-cigarettes), following the passing of the Deeming rule in August 2016 [ 1]. Per these regulations, the FDA now has the authority to regulate the presence of 'characterizing flavors' in e-cigarettes, as was done with cigarettes through the Family Smoking Prevention and Control Act of 2009 [ 1]. The wide variety of flavored e-cigarettes is enticing to both new consumers and established cigarette smokers [ 2, 3, 4, 5, 6]. In 2018, 4.9% of U.S. middle schoolers and 20.8% of U.S. high schoolers used an e-cigarette in the past 30-days [ 7], while 2.8% of U.S. adults were current e-cigarette users in 2017 [ 8]. Former FDA Commissioner Gottlieb characterized e-cigarette use among the youth population as an epidemic [ 9]. Consumers must be 18 years or older to purchase e-cigarette products in most states, but underage sales are occurring in retailers and online [ 9]. As a result, the FDA is investigating policies that would allow e-cigarettes to be available and attractive for adults trying to transition from cigarette smoking, but less accessible and appealing to youth and young adult nonsmokers [ 9].

The sensory effect of e-cigarette use (vaping) is created by a combination of taste, smell, and airway stimulation [ 10, 11]. Many e-cigarette characteristics, including type of device, electrical power source, nicotine content, and e-liquid flavors, influence the sensory effects of e-cigarettes [ 11, 12, 13, 14, 15, 16, 17]. The addition of flavorings is shown to reduce the harshness of the nicotine taste in many tobacco products, which allows for increased inhalation, increased nicotine delivery, and increased appeal [ 18, 19, 20, 21, 22, 23]. Established cigarette smokers looking to quit may use e-cigarettes as a cessation tool in part because of appealing flavors [ 5]. However, the FDA has expressed concern that certain flavored e-cigarettes (e.g., JUUL brand) are appealing to youth who may be unaware of the products' addictiveness and otherwise may have never tried a nicotine product [ 24]. According to data from 2013 to 2014, 81% of current youth e-cigarette users in the U.S. reported that a main reason for use was the availability of flavors [ 2]. Sweeter flavors like fruit and candy are preferred among young adults 18-30 years of age, while flavors like tobacco or clove/spice are not as appealing [ 11, 25, 26, 27].

Previous studies have looked at why consumers use flavored e-cigarettes [ 2, 5], the health perceptions of flavored e-cigarettes [ 28], the effect of flavored e-cigarettes on youth and young adult tobacco use [ 3], flavored e-cigarette use among youth versus adults [ 29, 30, 31], and common flavors and number of flavors used by consumers [ 32]. However, newer data from the Population Assessment of Tobacco and Health (PATH) Study allows researchers to assess the use of different flavors, such as tobacco flavor, in combination with other flavors, as questionnaires were updated to keep up with the changing e-cigarette marketplace. Policy change would likely only affect the youth (12-17 years) population, and a better understanding of the flavor preferences among the youth and adult populations could be informative in the banning of characterizing flavors. Although a certain flavor(s) (e.g., tobacco versus a sweeter flavor, or the ability to 'mix and match' flavors) could be attractive to an adult smoker trying to quit, it may also be enticing to a teen who has never used an e-cigarette or even a nicotine product. This analysis aimed to assess the use of flavored e-cigarettes and the association of the number of flavors reported with the type of e-cigarette product used, vaping frequency, and smoking status, among nationally-representative samples of adults and youth in the U.S. from Wave 3 (W3) of the PATH Study.

2. Materials and Methods

2.1. Study Design and Population

The PATH Study is a nationally representative, longitudinal cohort study of tobacco use and its health effects developed by the National Institutes of Health (NIH) and the FDA [ 33]. Its sample population aims to represent all of the noninstitutionalized U.S. population, 12 years of age or older. The PATH Study W3 Youth (12-17 years old) and Adult (18+ years old) public-use data files were analyzed. Data were collected between October 19, 2015 and October 23, 2016. W3 included measures that allowed participants to identify use of specific flavor categories for each product used, including e-cigarettes. There were 28,148 total adult cases and 11,814 total youth cases. Information about the PATH Study design and methods can be found elsewhere [ 34].

This study reports W3 cross-sectional estimates from 415 youth (12-17 years) participants and 2123 adult (18 years and older) participants who reported use of an e-cigarette, not exclusive to the use of other electronic nicotine delivery systems (ENDS) or other tobacco products, in the past 30-days. Analyses were done to identify the most prevalent e-liquid flavor categories used individually or in combination with other flavor categories, and the association of the number of flavor categories reported with the type of e-cigarette product used, vaping frequency and smoking status taking into account participant demographics (see Table 1).

2.2. Nicotine Use Behavior

Participants were asked "In the past 30 days, were/was any of the e-cigarettes/e-cigarette cartridges/e-liquid you used flavored to taste like tobacco, menthol or mint, clove or spice, fruit, chocolate, an alcoholic drink, a nonalcoholic drink, candy, dessert or other sweets, or some other flavor? Choose all that apply." The response options provided flavor categories including tobacco, menthol/mint, clove/spice, fruit, chocolate, an alcoholic drink, a non-alcoholic drink, candy/desserts/other sweets, or some other flavor. Tobacco flavor was of interest because any ban on characterizing flavors probably would not include tobacco flavor. In addition, the number of flavors was of interest because the wide range of flavors that can be 'mixed and matched' are appealing to consumers of all ages.

Participants were also categorized based on the type of e-cigarette product they reported using (e.g., open/refillable versus closed/not refillable). Participants were asked, "Can you refill your e-cigarette with 'e-liquid'?" Furthermore, participants were categorized on vaping frequency (e.g., daily versus non-daily). They were asked, "On how many of the past 30 days did you use an e-cigarette?" If they reported 30 days, then they were considered daily vapers, and if they reported less than 30, then they were considered non-daily vapers.

Cigarette smoking status (e.g., Never, Former, Someday, and Every day) was assessed. Derived variables for smoking status were provided for the adult population. Among the youth population, only an "Ever Smoker" variable, as well as a "Current smoker" variable, was provided. Therefore, if the participant was not marked as an ever smoker, then they were considered a never smoker. If participants were marked as an ever smoker but not marked as a current smoker, then they were considered a former smoker. Someday and every day smoking status was determined if they were marked as a current smoker, and by the following question, "In the past 30 days, on how many days did you smoke cigarettes?" Participants who reported 30 days were considered every day smokers, and participants who reported less than 30 days were considered someday smokers. Finally, participants who currently smoked were asked "In the past 12 months have you tried to quit smoking completely?" as well as "Do you plan to quit smoking for good?"

2.3. Statistical Analysis

Prevalence of top flavor combinations, as well as flavors used alone, was assessed among youth and adult past 30-day e-cigarettes users. Analyses were conducted using W3 replicate weights and balanced repeated replication methods with Fay's adjustment of 0.3 in Stata 14 software (2011, StataCorp LLC, College Station, TX, USA). Descriptive statistics and logistic regressions were used to look at the association of the type of ENDS flavor category used and the number of ENDS flavor categories used among past 30-day youth and adult e-cigarette users with demographic and nicotine use behaviors. In addition, the association of past combustible cigarette quit attempts and intentions with the type of ENDS flavor category used and the number of ENDS flavor categories used among past 30-day adult e-cigarette users was assessed. Weighted percentages, adjusted odds ratios (AOR) and 95% confidence intervals (95%CI) are reported. Models were adjusted for gender, race/ethnicity, and type of e-cigarette device used (open versus closed). Models assessing the association of quit attempts and quit intentions were adjusted for covariates listed above, as well as time to first nicotine product of the day.

3. Results

3.1. Demographic Characteristics of Past 30-Day Adult and Youth E-Cigarette Users

The adult and youth vaping populations did not differ in gender or race/ethnicity. However, significant differences between the adult and youth populations were seen in the number of flavor categories reported (p < 0.0001), type of e-cigarette device (p < 0.0001), vaping frequency (p = 0.0002), and smoking status (p < 0.0001; see Table 1). Among youth who reported using an e-cigarette on at least one day in the past 30 days, 53.9% were male, 78.5% were Non-Hispanic White, 85.9% used an open, refillable e-cigarette, 93.2% were non-daily vapers, and 38.3% were never cigarette smokers (see Table 1). Among adult past 30-day e-cigarette users, 55.2% were male, 79.7% were non-Hispanic White, 76.7% reported using an open, refillable e-cigarette device, 97.1% were non-daily vapers, and 30.7% were former cigarette smokers (see Table 1).

3.2. Flavor Category Preferences of Past 30-Day Adult and Youth E-Cigarette Users

Among the 226 youth participants (51.6%) who reported using only one flavor category, the top three flavor categories reported included fruit (52.8%), candy/desserts/other sweets (24.4%), and menthol/mint (10.8%; see Table 2). Nearly half (45.5%) of youth participants reported two or more flavor categories. Fruit flavor was in nine out of the top 10 flavor combinations while candy/desserts/other sweets appeared in seven out of the top 10 flavor combinations. Clove/spice was the least popular individually reported flavor category (0.8%) and did not appear in any of the top 10 flavor combinations (see Table 2).

There were 1809 adult participants (66.6%) who reported using only one flavor category. The top three flavor categories included fruit (30.8%), tobacco (24.5%), and candy/desserts/other sweets (18.2%; see Table 2). There were 944 adult participants (32.1%) who reported two or more flavor categories. Similar to the youth population, fruit flavor was the most common flavor category to be reported alone and with another flavor(s), while clove/spice was the least popular individually reported flavor category and did not appear in any of the top 10 flavor combinations. In addition, the alcoholic drink flavor category did not appear in the top 10 flavor combinations (see Table 2).

3.3. Association of Demographic and Nicotine Use Behavior Characteristics with Type of Flavor Category among Past 30-Day Adult and Youth E-Cigarette Users

Adjusting for gender, race/ethnicity, dual use of cigarettes, and device type, youth had 21 times greater odds (96%CI: 5.92, 75.12) of using a non-tobacco flavor in their e-cigarette. Furthermore, after the adjustment for the demographic and nicotine use behavior characteristics, consumers who identified as an Other Race/Ethnicity were more likely to use a non-tobacco flavor vaping product (AOR: 2.08, 95%CI: 1.33, 3.24). When examining the types of devices, consumers who use an open device that can be refilled were more likely to report a non-tobacco flavor category or some combination of flavor categories versus tobacco alone, compared to a closed, non-refillable device (AOR: 5.42, 95%CI: 4.07, 7.22), after adjustment for age, gender, and race/ethnicity. Consumers who were past 30-day vapers and a current smoker were less likely to report a non-tobacco flavor category or some flavor combination versus a tobacco flavor alone in comparison to exclusive vapers (AOR: 0.67, 95%CI: 0.48, 0.93), after adjustment (see Table 3). In addition, after the adjustment for age group, gender, race/ethnicity, and ENDS device, current vapers who were never smokers were more likely to report a non-tobacco flavor category or some flavor combination versus a tobacco flavor alone in comparison to current smokers (AOR: 40.1, 95%CI: 2.76, 581.5). However, there were few never smokers who reported using tobacco flavor alone, making this point estimate unstable.

3.4. Association of Demographic and Nicotine Use Behavior Characteristics with the Number of Flavor Categories Among Past 30-Day Adult and Youth E-Cigarette Users

The youth population was more likely to report using two or more flavors compared to the adult population (AOR: 2.03, 95%CI: 1.55, 2.65). In contrast, past 30-day vapers who were Non-Hispanic Black were less likely to report two or more flavors compared to those identifying as Non-Hispanic White (AOR: 0.67 95%CI: 0.48, 0.92). Finally, those who used an open, refillable device were more likely to report two or more flavors compared to those using a closed, non-refillable device (AOR: 3.29, 95%CI: 2.39, 4.53; see Figure 1).

3.5. Association of Demographic Characteristics and Ever Smoking Status with the Type of Flavor Category Among Past 30-Day Adult E-Cigarette Users

The association of demographic characteristics and ever smoking status with type of flavor category was assessed for the adult population only, due to sample size for the youth population. Adult past 30-day adult e-cigarette users who were older than 18 to 24 years of age were less likely to report using a non-tobacco flavor category or some flavor combination versus tobacco alone (25-34 years: AOR: 0.37, 95%CI: 0.19, 0.71; 35-54 years: AOR: 0.13, 95%CI: 0.08, 0.23; 55 years and older: AOR: 0.08, 95%CI: 0.05, 0.14), after adjustment, relative to the 18-24 group. In contrast, after adjustment, females (AOR: 1.75, 95%CI: 1.29, 2.36) and Non-Hispanic Blacks (AOR: 2.65, 95%CI: 1.37, 5.12) were more likely to report using a non-tobacco flavor category or some flavor combination versus tobacco alone. Similar to the above analysis, consumers who reported using an open, refillable ENDS device were more likely to report using a non-tobacco flavor category or some flavor combination versus tobacco alone (AOR: 5.31, 95%CI: 3.84, 7.34), after adjustment. Finally, among the past 30-day adult e-cigarette users who were ever smokers, those who were former smokers were about one and a half times more likely (95%CI: 1.00, 2.12) to report using a non-tobacco flavor category or some flavor combination versus tobacco alone compared to current smokers, after adjustment, though this association was of borderline significance (see Table 4).

3.6. Association of Type of Flavor Category and Number of Flavor Categories with Past Cigarette Smoking Quit Attempts and Cigarette Smoking Quit Intentions Among Adult Past 30-Day Vapers and Current Smokers

For adults who were past 30-day users of e-cigarettes and current smokers (dual users), there was no association between type of ENDS flavor category or flavor combination versus tobacco flavor alone and a cigarette quit attempt in the past 12 months (AOR: 1.41, 95%CI: 0.97, 2.05). Conversely, dual users who reported using two or more flavors were more likely to have made a cigarette quit attempt in the past 12 months compared to those who reported using only one ENDS flavor (AOR: 1.49, 95%CI: 1.09, 2.06). Finally, there was no association between type of flavor category (AOR: 1.36, 95%CI: 0.83, 2.22) or number of flavor categories reported (AOR: 1.07, 95%CI: 0.72, 1.60) and cigarette smoking quit intentions among adult past 30-day dual users.

4. Discussion

Findings from the PATH Study W3, a nationally representative, longitudinal cohort study in the U.S., indicate that past 30-day youth vapers are substantially more likely than adults to be using a non-tobacco flavor vape. In addition, youth are significantly more likely to use more than one flavor, and to use combinations that do not involve tobacco. Fruit flavor was commonly used, alone and in combination with other flavor categories, among both youth and adult populations. However, the preference for tobacco flavor was more common among the adult population. Finally, an open, refillable system appears to be associated with the use of a greater variety of flavors. Previously, Schneller, et al. [ 32] identified that fruit flavor was the most common flavor category reported alone and in combination among past 30-day youth vapers followed by candy/other sweets using the PATH Study Wave 2 (W2; 2014-2015). The analyses presented in this paper using the next wave of PATH data (2015-2016) showed similar results, but with slightly fewer youth reporting fruit alone (55% in W2 and 53% in W3) and slightly more reporting candy/other sweets alone (21% in W2 and 24% in W3). However, differences were seen in the individual flavor preference among adults: at W2, menthol/mint was the most common flavor reported alone followed by fruit, while at W3, most adults reported fruit followed by tobacco flavor, and menthol/mint was the fourth most common flavor reported alone. This difference may partially be due to the change in the PATH Study questionnaire. At W2, tobacco flavor was not listed as a choice, but was added at W3 along with non-alcoholic beverage. Many similar flavor combinations appeared among the youth and adult populations with slight differences in prevalence, but this could also be a result of the additional flavor options at W3.

A similar study was conducted by Sonjei et al. [ 35] using PATH W2 data. Sonjei et al. [ 35] also identified that fruit and candy flavored e-cigarettes were most common among youth and young adults, while tobacco flavored e-cigarettes were most common among older adult e-cigarette users. In addition, never smokers were less likely to use a tobacco flavored e-cigarette. Finally, Sonjei et al. [ 35] found that youth and young adults were more likely to report using two or more flavors. However, one difference to note between the study by Sonjei et al. [ 35], the study by Schneller, et al. [ 32], and this current study is that Sonjei et al. [ 35] assessed three age groups, adolescents, young adults, and older adults, while the other two studies only assessed two, youth and adults.

Although the PATH study has strong external validity, internal validity, and retention rates, there are some limitations to note. First, although PATH has a large overall sample size, our statistical power to assess associations among past 30-day youth and adult e-cigarette users was limited. Second, the flavor category data are reported based on a "check all that apply" list. Therefore, we cannot distinguish if multiple flavor categories are used together or individually. Third, the flavor list provided to participants is of flavor categories, which does not allow us to look at the use of multiple individual flavors that might fall under the same category. Fourth, we cannot identify the chemical additives used to create the flavors listed, as various chemical additives could be used to create a single flavor profile and may differ between brands. Finally, we did not assess the presence of nicotine in the e-cigarettes, which should be done in the future. Nicotine levels could provide public health implications as some adult smokers use e-cigarettes as a cessation tool [ 5], while many youth are misinformed and unaware of the nicotine concentration of e-cigarettes [ 36].

5. Conclusions

These findings build upon previous research [ 11, 25, 26, 27], and reinforce the FDA concerns about the role of flavors in youth vaping appeal, as many youth are unaware of the addictiveness of e-cigarettes [ 36]. The addition of flavorings to a variety of tobacco products have been shown to reduce the harshness of the nicotine taste and promotes continued use [ 18, 19, 20, 21, 22, 23]. Previous research has shown that sweet flavors such as fruit or dessert are more satisfying and act as a positive reinforcer among the young adult population (18-30 years) [ 26]. With a multitude of flavors and flavor combinations available on the market, consumers of all ages have many options that enable them to tailor their choices to their individual preferences and thus may encourage initial and continued use. Although most past 30-day e-cigarette users reported using only one flavor category, non-tobacco flavors are far more common among youth than adults. Results from this study identified differences in flavor preferences among adult versus youth vapers that may imply roles for flavors in both the initiation of youth vaping and in adult vaping, including for smoking cessation.

Author Contributions

Conceptualization, M.L.G., S.M., D.O., and R.J.O.; methodology, M.B.T.; formal analysis, L.M.S.; writing-original draft preparation, L.M.S.; writing-review and editing, M.B.T., M.L.G., S.M., D.O, and R.J.O.; supervision, R.J.O.; project administration, L.M.S.; funding acquisition, R.J.O and M.L.G.

Funding

Research reported in this paper was supported by the National Cancer Institute of the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) Center for Tobacco Products under Award Number U54CA228110. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.

Conflicts of Interest

M.L.G. received a research grant from Pfizer and served as a member of the advisory board to Johnson & Johnson, manufacturers of smoking cessation medications. M.B.T. and L.M.S. receive funding from the Population Assessment of Tobacco and Health contract mechanism (HHSN271201100027C to Westat), outside of the submitted work. The remaining authors have declared that no competing interests exist.

References

1. US Food and Drug Administration, H.H.S. Deeming Tobacco Products to Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. Final Rule. Available online: https://www.fda.gov/media/97875/download (accessed on 20 August 2019).

2. Villanti, A.C.; Johnson, A.L.; Ambrose, B.K.; Cummings, K.M.; Stanton, C.A.; Rose, S.W.; Feirman, S.P.; Tworek, C.; Glasser, A.M.; Pearson, J.L.; et al. Flavored tobacco product use in youth and adults: Findings from the first wave of the PATH Study (2013-2014). Am. J. Prev. Med. 2017. [Google Scholar] [CrossRef] [PubMed]

3. US Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on Advancing New Policies Aimed at Preventing Youth Access to, and Appeal of, Flavored Tobacco Products, Including E-Cigarettes and Cigars; US Food and Drug Administration: Silver Spring, MD, USA, 2019.

4. US Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on New Enforcement Actions and a Youth Tobacco Prevention Plan to Stop Youth Use of, and Access to, JUUL and Other E-Cigarettes; US Food and Drug Administration: Silver Spring, MD, USA, 2018.

5. Westat. PATH Study Public Use Files User Guide; ICPSR: Rockville, MD, USA, 2017; Volume 36498. [Google Scholar]

Schneller LM, Bansal-Travers M, Goniewicz ML, McIntosh S, Ossip D, O'Connor RJ. Use of Flavored E-Cigarettes and the Type of E-Cigarette Devices Used among Adults and Youth in the US-Results from Wave 3 of the Population Assessment of Tobacco and Health Study (2015-2016). International Journal of Environmental Research and Public Health. 2019; 16(16):2991. https://doi.org/10.3390/ijerph16162991

Chicago/Turabian Style

Schneller, Liane M., Maansi Bansal-Travers, Maciej L. Goniewicz, Scott McIntosh, Deborah Ossip, and Richard J. O'Connor. 2019. "Use of Flavored E-Cigarettes and the Type of E-Cigarette Devices Used among Adults and Youth in the US-Results from Wave 3 of the Population Assessment of Tobacco and Health Study (2015-2016)" International Journal of Environmental Research and Public Health 16, no. 16: 2991. https://doi.org/10.3390/ijerph16162991

# data[].attributes.attachment_link.title
Use of Flavored E-Cigarettes and the Type of E-Cigarette Devices Used among Adults and Youth in the US-Results from Wave 3 of the Population Assessment of Tobacco and Health Study (2015-2016)

# data[].attributes.attachment_link.description
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.