Abstract and Introduction
Objectives: To examine the impact of US restrictions implemented in February 2020 prohibiting flavors other than menthol and tobacco in cartridge-based e-cigarettes.
Methods: We analyzed 5 cross-sectional waves of the International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Surveys, conducted online with youths aged 16 to 19 years in the United States, Canada, and England, for differences in usual e-cigarette flavor, device, and brand reported by past-30-day vapers (n = 9512) before (2017, 2018, 2019), during (February 2020), and after (August 2020) implementation of US flavor restrictions.
Results: In August 2020, 78.7% of vapers in the United States reported using a flavor prohibited in cartridges or pods, versus 86.3% in Canada (adjusted odds ratio [AOR] = 1.73; 95% CI = 1.25, 1.40) and 79.8% in England (AOR = 1.10; 95% CI = 0.78, 1.55). Disposable e-cigarettes (exempt from flavor restrictions) increased to a greater extent among vapers in the United States (13.2% to 36.8%) versus Canada (7.7% to 14.2%; AOR = 2.01; 95% CI = 1.33, 3.04) and England (10.8% to 16.4%; AOR = 2.33; 95% CI = 1.52, 3.57). Puff Bar (disposable) emerged as the most popular brand in the United States.
Conclusions: Usual flavors used by youth vapers in the United States were unchanged after 2020 restrictions on cartridge-based e-cigarettes. Youths used brands and devices exempt from the restrictions.
Flavors are a primary reason for tobacco initiation and continued use, particularly among youths and young adults.[1,2] Flavors can increase the appeal of tobacco products through perceptions of improved taste and by decreasing the "harshness" of smoke inhalation.[1,3–5]
Flavors also play an important role in e-cigarette use.[1,6,7] E-cigarettes come in an array of flavors, ranging from tobacco and menthol to exotic flavors numbering in the thousands.[6,8,9] Fruit is the most popular flavor among younger vapers, followed by mint or menthol, and candy or dessert flavors.[10–12] Fruit flavors are also popular among adult smokers who vape, although to a lesser extent than youths, with greater use of tobacco flavors as the age of adult vapers increases.[13–15] The use of fruit and other nontraditional flavors has been associated with greater appeal and longer-term use of e-cigarettes among young people and greater satisfaction among adult smokers who vape.[14,16,17]
An increasing number of jurisdictions are implementing restrictions on e-cigarette flavors, with the goal of reducing the appeal of vaping among young people. In February 2020, the US Food and Drug Administration implemented federal restrictions on the sale of flavors other than tobacco and menthol in cartridge- or pod-based products; the flavor restrictions do not apply to other types of e-cigarettes, such as e-liquids for refillable tank devices or disposable e-cigarettes. Cartridge-based products, such as JUUL, consist of a reusable device that is used with prefilled e-liquid cartridges or "pods." The popularity of JUUL and other cartridge or pod brands among young people in the United States and Canada is well-documented.[19,20] In England, however, cartridge or pod e-cigarettes remain less prevalent than refillable tank devices among both youth and adult vapers.[21–24] Disposable e-cigarettes were the least-popular device type in the United States, Canada, and England before 2020.[21,22,25]
In this study, we examined trends in the use of flavored e-cigarettes among past-30-day vapers in the United States, Canada, and England. We examined whether the use of products with flavors other than tobacco or menthol decreased to a greater extent in the United States following implementation of the federal restrictions, compared with Canada and England, where there was no national policy change implemented for these products. We hypothesized that there would be only modest changes in the flavor profile of e-cigarettes among youth vapers in the United States, along with an increase in the use of product types and brands that were exempt from the flavor restrictions, including disposable e-cigarettes. These hypotheses were based on the partial nature of flavor restrictions that apply to only a subset of products, which have previously been shown to have limited impact.
Am J Public Health. 2022;112(7):1014-1024. © 2022 American Public Health Association