Q&A: Restrictions may reduce use of flavored e-cigarette use by adolescents, young adults

Key takeaways:

• Most adolescents and young adults said they would discontinue e-cigarettes if tobacco was the only option.
• Approaching patients in a nonjudgmental way and providing early cessation access may reduce use.

About 70% of adolescents and young adults would discontinue their e-cigarette use under a hypothetical tobacco-only federal product standard, a recent study in the Journal of Studies on Alcohol and Drugs found.

In recent years, the FDA has enforced several bans and penalties on e-cigarettes and e-cigarette manufactures. One study, however, found that only 4.9% of e-cigarette users said they quit entirely in response to policies, while most switched to other smoking methods.

“It is logical to expect that establishing a product standard that only allows tobacco- and menthol-flavored e-liquid may affect consumer preferences,” Natasha K. Sidhu, MS, a psychology fellow in the department of psychiatry at Yale School of Medicine, and colleagues wrote. “However, evidence addressing this possibility is limited. How different flavor restrictions (eg, removal of all flavors except tobacco or tobacco and menthol) may affect use intention by flavor preference has not yet been examined among [adolescents and young adult (AYA)] populations.”

To evaluate discontinuation trends under hypothetical restriction scenarios, Sidhu and colleagues conducted a survey among 1,411 e-cigarette users aged 14 to 21 years.

Overall, 38.8% of respondents reported they would discontinue e-cigarette use if tobacco and menthol-flavored e-liquids were the only options available, and 70.8% said they would discontinue e-cigarette use under a tobacco-only product standard. AYAs who preferred fruit ice (adjusted OR [aOR] = 11.96; 95% CI, 4.23-33.79) or cool mint (aOR = 12.30; 95% CI, 4.23-35.74) flavors reported higher odds of discontinuation compared with methanol users.

Sidhu and colleagues also pointed out that aORs of AYAs discontinuing vaping if preferred flavors were unavailable ranged from 6.66 to 29.31 compared with those keeping their preferred flavor under the product standards,.

“This indicates that the effect size of e-liquid flavor preference on intentions to discontinue e-cigarette use is very large,” they wrote.

The researchers concluded that a tobacco-only product standard “may increase intent to discontinue vaping for all groups other than tobacco flavor users, with the largest effects observed for those using fruit and nonmenthol cooling flavors.”

Healio spoke with Sidhu to learn more about the current status of banned flavored e-cigarettes, the clinical implications of the findings and more.

Healio: What drove you to conduct this analysis?

Sidhu: The restriction of the availability for certain e-cigarette e-liquid flavors has been considered by various regulatory agencies. Our team was interested in surveying youth and young adults to understand their thoughts on what choices they might make should regulatory policies only allow menthol and/or tobacco flavors in e-cigarette e-liquid products.

Healio: With there having been FDA bans on many flavored e-cigarettes, which ones are currently available?

Sidhu: The restriction of the sale of flavored cartridge-based e-cigarettes other than tobacco and menthol flavors was issued in February 2020. To date, only a handful of tobacco and menthol flavors have received FDA premarket tobacco product application authorization.

Healio: What are the clinical implications of the study?

Sidhu: AYAs who preferred vaping fruit/sweet flavor were most sensitive to either restricted scenario, compared with other flavor preferences. This suggests that a restriction of certain flavors may be helpful to reduce AYA use of e-cigarettes. It is unknown if the current self-reported intentions extend to actual behavior in the natural environment, future research should examine this in areas/states that have enacted a flavor restriction policy.

However, an important consideration not addressed in this study is how this may impact adult smokers who are interested in using e-cigarettes as an alternative to quit smoking. Cigarette smoking remains the leading cause of preventable death in the United States. Although preventing use of e-cigarettes among young people is a critical goal for public health, we cannot ignore the potential impact of e-cigarette regulation on adults who smoke and have switched to using e-cigarettes. Many adults prefer using non-tobacco flavors to switch from combustible cigarettes to e-cigarettes. Flavor restriction policies should consider the best ways to protect public health but also to support adults in choosing potentially less harmful alternatives to quit smoking.

It is important to note that our study was cross-sectional and cannot prove causation.

Healio: Is there anything else you’d like to add?

Sidhu: Primary care physicians can directly assess or inquire about tobacco and e-cigarette use. Asking young people about their behaviors in a non-judgmental way and providing early access to cessation services at point of care may be beneficial to reducing e-cigarette use among young people.

References:

• Li D, et al. Tob Control. 2022;doi:10.1136/tobaccocontrol-2022-057492.
• Sidhu N, et al. J Stud Alcohol Drugs. 2023;doi:10.15288/jsad.21-00466.