Abstract
OBJECTIVE:
Flavored non-cigarette tobacco product (NCTP) use is common among US adult tobacco users. To update the estimates of use patterns of flavored NCTPs, this study assessed current NCTP use among adults by flavor use and flavor categories from 2010–2019.
METHODS:
We analyzed data from the 2010–2019 Tobacco Use Supplement to the Current Population Survey to estimate the weighted proportion of adult NCTP users by flavor use across survey waves. Flavor use was defined as past 30-day use of any menthol/mint or fruit/other flavors. We used the 2018–2019 data to examine the differences in demographic characteristics and tobacco use patterns among users of menthol/mint or fruit/other flavors compared to exclusive users of tobacco flavor, by product type.
RESULTS:
Compared to 2014–2015, electronic nicotine delivery system (ENDS) users were more likely (79.0% vs. 66.6%, p<0.001) to report flavor use in 2018–2019, whereas cigar (26.9% vs. 31.2%, p=0.030) and pipe (56.3% vs. 65.5%, p=0.015) smokers were less likely to report flavor use in 2018–2019. In 2018–2019, the most prevalent flavor categories were exclusive use of tobacco flavor among cigar (73.1%) and smokeless tobacco (48.3%) users, and use of fruit/other flavors among ENDS (64.9%) and pipe (48.4%) users. Flavored users were more likely to be young adults aged 18–24 years (cigars, ENDS, smokeless tobacco) and Non-Hispanic Black or Hispanic persons (cigars, ENDS, pipes) compared to tobacco-flavored users.
CONCLUSIONS:
Flavored product use increased among adult ENDS users but decreased among cigar and pipe smokers. These findings could inform tobacco regulatory efforts concerning flavored NCTPs.
Keywords: Non-Cigarette Tobacco Products, Electronic Nicotine Delivery Systems, Cigars, Pipes, Smokeless Tobacco, Flavored Tobacco Use
INTRODUCTION
In September 2009, the United States (US) Food and Drug Administration (FDA), authorized by the Family Smoking Prevention and Tobacco Control Act of 2009, prohibited the inclusion of characterizing flavors other than tobacco and menthol in cigarettes.1 In May 2016, the FDA finalized a rule extending its tobacco regulatory authority to all other tobacco products.2 While research has shown that the availability of flavors in noncombusted tobacco products such as electronic nicotine delivery system (ENDS) may help some adult users to reduce cigarette consumption or switch to less harmful products,3–5 sweet-tasting flavors such as fruit or candy are particularly enticing to ENDS users of youth and young adults.6–10 Due to increases in youth initiation of flavored ENDS, particularly with cartridge-based ENDS products, the FDA exercised its enforcement to halt the sale of all flavored cartridge-based ENDS other than tobacco or menthol flavors in January 2020.11 The FDA guidance on flavored ENDS was intended to balance the benefits of keeping some flavors available for adults who use or smoke combusted tobacco while discouraging tobacco use among youth and underage adults. Meanwhile, research has indicated that restricting or prohibiting the sales of non-cigarette tobacco products (NCTPs) with characterizing flavors could have substantial public health benefits by reducing both individual-level and population-level harms.7,12–14 Accordingly, in May 2022, FDA published a notice of proposed rulemaking that would prohibit characterizing flavors (other than tobacco) in cigars and their components and parts.15
An enhanced understanding of flavored NCTP use patterns will continue to inform FDA decision-making regarding regulatory actions addressing the diversity of tobacco product use. A study using the 2013–2014 National Adult Tobacco Survey (NATS) found widespread use of flavored NCTPs among US adult tobacco users, and that fruit and sweet flavored product use was particularly common among young adults aged 18–24 years.16 Additionally, studies using waves 1 (2013–2014) and 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study assessed youth and adult use of flavored tobacco products, including combusted cigarettes and NCTPs. These studies, covering tobacco use through 2015, reported the following key findings: flavored tobacco use was higher in young adult tobacco users aged 18–24 years compared to those aged ≥25 years; 86% of young adult tobacco users reported their first product was flavored compared to 54% of adults aged ≥25 years; and menthol/mint, fruit, and candy/sweet were the most prevalent flavors during past 30-day use among flavored tobacco users across all age groups.8,17
To update the estimates of use patterns of NCTPs with more recent data, as well as to provide benchmark estimates for future monitoring and regulatory activities, this analysis assesses current use of NCTPs by flavor use and flavor categories among US adults, by product type, using three pooled survey waves – 2010–2011, 2014–2015, and 2018–2019 – from the nationally representative data for US adults from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS). The main study objectives are to 1) assess the proportion of current NCTP use among adults by flavor use across survey waves for each NCTP type; 2) describe product-specific use of NCTPs by flavor categories; and 3) evaluate the differences in demographic characteristics and tobacco use patterns among any users of menthol/mint flavor or fruit/other flavors compared to exclusive users of tobacco flavor, by product type. This will add to our understanding of the US populations with high usage of flavored NCTPs.
METHODS
Data Source
The TUS-CPS collects nationally representative data on tobacco use among civilian, non-institutionalized adults aged ≥18 years.18 The TUS-CPS employs a multistage and stratified sampling procedure to collect participants’ information on tobacco usage patterns. For this analysis, we used self-reported data from the 2010–2011, 2014–2015, and 2018–2019 TUS-CPS, with associated self-response and replicate weights for the three cycles. The 2010–2011 wave was only used to generate estimates among cigar smokers, as questions on flavors for other NCTPs were not collected in 2010–2011. This study relied on publicly available data from the U.S. Census Bureau and was exempt from human subjects review.
Measures
This analysis assessed use of each of the following NCTPs: cigars (large/regular cigars, cigarillos, and little filtered cigars), ENDS, pipes (combined regular pipe filled with tobacco and waterpipe or hookah pipe filled with tobacco), and smokeless tobacco (snuff, dip, chewing tobacco, and snus). The study sample was restricted to current users of NCTPs, defined as respondents reporting “yes” to ever use of NCTPs and currently using them every day or report past 30-day use if some days at time of interview. Current exclusive users of NCTPs and dual users of NCTPs and cigarettes were included in the sample.
For each NCTP including cigars, ENDS, pipes, and smokeless tobacco, flavor use was classified as “flavored” or “tobacco flavor” using the following question: “Some tobacco products come in flavors such as menthol/mint, clove, spice, fruit, chocolate, alcohol, or other flavors. When you smoke/use <NCTP> is it usually flavored?”. Respondents who answered “yes” were classified as flavored product users (e.g., users of non-tobacco flavors); whereas respondents who answered “no” were classified as tobacco-flavored users. Data on flavor categories are only available for 2018–2019 because they were not collected during prior survey waves. In 2018–2019, respondents who answered “yes” were further asked three questions about their NCTP flavor use and respondents could select one or more of the following flavor options: 1) usually menthol/mint flavored; 2) usually flavored like clove, spice, herb, fruit, alcohol, candy, sweets, or chocolate; and 3) usually some other type of flavor. Among ENDS users, respondents were asked whether the product was usually tobacco-flavored. The question on tobacco flavor was only asked for ENDS users because the other NCTPs including cigars, pipes, and smokeless tobacco, are by their nature tobacco-flavored. Due to the nature of flavor questions for ENDS users in 2018–2019, respondents could answer “yes” to both tobacco flavor and menthol/mint flavor or fruit/other flavors. Therefore, for flavor categorization among ENDS users in 2018–2019, we prioritized use of menthol/mint flavor or fruit/other flavors over tobacco flavor, and respondents using either menthol/mint flavor or fruit/other flavors were classified as flavored product users even if they also reported use of tobacco flavor. Furthermore, given the changes in flavor questions for ENDS use from 2014–2015 to 2018–2019, to ensure consistency in trend comparison, we grouped tobacco-flavored ENDS users and non-flavored ENDS users into one category for 2018–2019.
Based on responses to flavor questions, we classified flavor categories for each NCTP into the following: any, exclusive, and non-exclusive use of menthol/mint flavor; any, exclusive, and non-exclusive use of fruit/other flavors; and exclusive use of tobacco flavor. Categories on any use of a flavor are not mutually exclusive, and estimates do not sum up to 100%. Respondents with missing data (e.g., “don’t know”, “refused”, unknown values) on flavor use in 2010–2011 and 2014–2015, or with a combination of missing data or inconsistent responses on flavor use and flavor categories (e.g., answer “yes” to flavor use and “no” to any flavor) in 2018–2019 were excluded from flavor categorization. This comprised a very small proportion of respondents, ranging from 0.7% (n=44) among ENDS users to 1.8% (n=24) among pipe smokers.
To define cigarette smoking status (current, former, and never), current cigarette smokers were defined as respondents who reported smoking cigarettes every day or some days and reported smoking at least 100 cigarettes in their lifetime. Former cigarette smokers were respondents who reported smoking at least 100 cigarettes in their lifetime and did not smoke cigarettes at the time of survey. Never smokers were respondents who reported smoking fewer than 100 cigarettes in their lifetime and did not smoke cigarettes at the time of survey.
We assessed the following demographic characteristics and tobacco use patterns: sex (male and female); race/ethnicity [Non-Hispanic (NH) White, NH Black, Hispanic, and combining NH other or multiple races]; age group (18–24, 25–34, 35–54, and ≥55 years); educational attainment (<high school, high school diploma or GED, some college or associate degree, and ≥bachelor’s degree); metropolitan status (metropolitan and nonmetropolitan); US geographic region (Northeast, Midwest, South, and West); cigarette smoking status (current, former, and never); frequency of NTCP use (every day and some days); and cigar type (restricted to cigar smokers: large/regular cigars, cigarillos, and little filtered cigars).
Analytic Approach
We estimated the weighted proportion of current NCTP use among adults by flavor use across survey waves, by product type. Differences in proportion of flavor use between 2014–2015 and 2018–2019 for each NCTP were examined using Chi-square tests, and linear contrast comparisons were used to assess flavor use trends among cigar smokers from 2010–2019. Data were further restricted to 2018–2019 to characterize the proportion of product-specific use of NCTPs by flavor categories, as these questions were only available for this wave. In addition, we evaluated the differences of demographic characteristics and tobacco use patterns by comparing any use of menthol/mint flavor or fruit/other flavors versus exclusive use of tobacco flavor using Chi-square tests, by product type. Among comparisons of Chi-square tests with statistical significance (p<0.05), pairwise comparisons were used to assess differences between subgroups.
To estimate the prevalence of flavored cigar use, we calculated the weighted prevalence of current adult smokers of flavored cigars by demographic characteristics and tobacco use patterns across 2010–2019. Balanced repeated replication was used with Fay’s adjustment value of 4 to account for the study’s complex design.19 The weighted estimates, percentages, and 95% confidence intervals (CIs) were computed using SAS version 9.4 callable SUDAAN version 11.0.3, and replicate weighting procedures were used to adjust for differential probabilities of selection and response to be representative of the US adult population. Estimates were flagged as unstable if sample size of the denominator was <50 or the relative standard error was >30%.
RESULTS
Current NCTP use among adults by flavor use, 2010–2019
Table 1 presents current NCTP use among adults by flavor use across survey waves 2010–2019, by product type. The total estimated numbers of flavored NCTP users were as follows: cigars (2010–2011, 1.0 million; 2014–2015, 1.2 million; 2018–2019, 0.97 million), ENDS (2014–2015, 3.4 million; 2018–2019, 4.1 million), pipes (2014–2015, 0.95 million; 2018–2019, 0.61 million), and smokeless tobacco (2014–2015, 1.9 million; 2018–2019, 1.7 million). In comparison to 2014–2015, ENDS users were more likely to report using a flavored product in 2018–2019 (79.0% vs. 66.6%, p<0.001); whereas cigar and pipe smokers were less likely to report using a flavored product in 2018–2019 (cigars, 26.9% vs. 31.2%, p=0.030; pipes, 56.3% vs. 65.5%, p=0.015).
Table 1.
Current use of non-cigarette tobacco products (NCTPs)a among adults by flavor use,b by product type, Tobacco Use Supplement to the Current Population Survey, 2010–2019 (% and 95% confidence interval).
| 2010–2011c | 2014–2015 | 2018–2019 | P-valued | P-valuee | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| N | Weighted N | Weighted % (95% CI) | N | Weighted N | Weighted % (95% CI) | N | Weighted N | Weighted % (95% CI) | |||
| Large/Regular Cigars/Cigarillos/Little Filtered Cigars | |||||||||||
| Overall Sample | 2,529 | 3,729,046 | 2,390 | 3,962,486 | 1,854 | 3,595,086 | 0.594 | 0.030 | |||
| Flavoredf | 681 | 1,047,513 | 28.1 (25.9, 30.4) | 673 | 1,235,304 | 31.2 (28.9, 33.5) | 468 | 966,354 | 26.9 (24.1, 29.9) | ||
| Tobacco flavorg | 1,848 | 2,681,533 | 71.9 (69.6, 74.1) | 1,717 | 2,727,183 | 68.8 (66.5, 71.1) | 1,386 | 2,628,732 | 73.1 (70.1, 75.9) | ||
| Electronic Nicotine Delivery System (ENDS) | |||||||||||
| Overall Sample | — | — | 3,431 | 5,079,489 | 2,532 | 5,211,246 | — | <0.001 | |||
| Flavoredf | — | — | — | 2,194 | 3,381,307 | 66.6 (64.5, 68.6) | 1,924 | 4,117,405 | 79.0 (77.0, 80.9) | ||
| Tobacco flavorg | — | — | — | 1,237 | 1,698,182 | 33.4 (31.4, 35.5) | 608 | 1,093,841 | 21.0 (19.1, 23.0) | ||
| Regular Pipe/Hookah/Waterpipe | |||||||||||
| Overall Sample | — | — | 818 | 1,452,998 | 504 | 1,085,867 | — | 0.015 | |||
| Flavoredf | — | — | — | 494 | 951,725 | 65.5 (61.1, 69.6) | 260 | 610,841 | 56.3 (50.1, 62.2) | ||
| Tobacco flavorg | — | — | — | 324 | 501,273 | 34.5 (30.4, 38.9) | 244 | 475,026 | 43.7 (37.8, 49.9) | ||
| Smokeless Tobacco | |||||||||||
| Overall Sample | — | — | 2,704 | 3,659,330 | 2,135 | 3,266,707 | — | 0.892 | |||
| Flavoredf | — | — | — | 1,292 | 1,884,809 | 51.5 (49.3, 53.7) | 1,045 | 1,690,042 | 51.7 (49.0, 54.4) | ||
| Tobacco flavorg | — | — | — | 1,412 | 1,774,521 | 48.5 (46.3, 50.7) | 1,090 | 1,576,665 | 48.3 (45.6, 51.0) | ||
Defined as ever NCTP users and currently use them “every day” or report past 30-day use if “some days”
Respondents with missing data (“don’t know”, “refused”, unknown values) on flavor use in 2010–2015, or with a combination of missing data or inconsistent responses on flavor use and flavor categories (e.g., answer “yes” to flavor use and “no” to any flavor) in 2018–2019 are excluded from flavor categorization: large/regular cigars/cigarillos/little filtered cigars (2010–2011, n=31; 2014–2015, n=26; 2018–2019, n=30); ENDS (2014–2015, n=10; 2018–2019, n=34); regular pipe/hookah/waterpipe (2014–2015, n=5; 2018–2019, n=19); smokeless tobacco (2014–2015, n=20; 2018–2019, n=50)
Wave 2010–2011 only contains flavor use data for large/regular cigars/cigarillos/little filtered cigars but not the other NCTPs
Linear contrast comparison assesses the trend across survey waves 2010–2011, 2014–2015, and 2018–2019
Wald F Chi-square tests compare the differences between survey waves 2014–2015 and 2018–2019; bolded p-values indicate statistical significance of p-values <0.05
Any use of menthol/mint flavor, or any use of fruit/other flavors that include clove, spice, herb, fruit, alcohol, candy, sweets, chocolate, or other flavor
Exclusive use of tobacco flavor
Current NCTP use among adults by flavor categories, 2018–2019
By flavor categories, the majority of cigar smokers exclusively used tobacco flavor (73.1%, 95% CI: 70.1, 75.9), followed by any use of fruit/other flavors (24.7%, 95% CI: 21.9, 27.7), and any use of menthol/mint flavor (5.5%, 95% CI: 4.3, 7.0) (Table 2). Among ENDS users, any use of fruit/other flavors accounted for a significant proportion (64.9%, 95% CI: 62.5, 67.3) [exclusive use of fruit/other flavors: 45.9%, 95% CI: 43.2, 48.7], whereas any use of menthol/mint flavor and exclusive use of tobacco flavor only represented 26.3% (95% CI: 24.0, 28.7) and 21.0% (95% CI: 19.1, 23.0), respectively. We found that 48.4% (95% CI: 42.3, 54.6) and 26.3% (95% CI: 21.0, 32.4) of pipe smokers reported any use of fruit/other and menthol/mint flavors, respectively. Among smokeless tobacco users, exclusive use of tobacco flavor was the most common flavor category (48.3%, 95% CI: 45.6, 51.0), followed by any use of menthol/mint (42.0%, 95% CI: 39.4, 44.6) and fruit/other flavors (20.3%, 95% CI: 18.0, 22.7).
Table 2.
Current use of non-cigarette tobacco products (NCTPs)a among adults by flavor categories, by product type, Tobacco Use Supplement to the Current Population Survey, 2018–2019 (% and 95% confidence interval).
| Large/Regular Cigars/Cigarillos/Little Filtered Cigars |
Electronic Nicotine Delivery System (ENDS) |
Regular Pipe/Hookah/Waterpipe |
Smokeless Tobacco |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N | Weighted N | Weighted % (95% CI) | N | Weighted N | Weighted % (95% CI) | N | Weighted N | Weighted % (95% CI) | N | Weighted N | Weighted % (95% CI) | |
| Overall Sample c | 1,854 | 3,595,086 | 2,532 | 5,211,246 | 504 | 1,085,867 | 2,135 | 3,266,707 | ||||
| Flavoredd | 468 | 966,354 | 26.9 (24.1, 29.9) | 1,924 | 4,117,405 | 79.0 (77.0,80.9) | 260 | 610,841 | 56.3 (50.1, 62.2) | 1,045 | 1,690,042 | 51.7 (49.0, 54.4) |
| Any use of menthol/mint flavor | 86 | 197,458 | 5.5 (4.3, 7.0) | 583 | 1,369,505 | 26.3 (24.0, 28.7) | 107 | 285,576 | 26.3 (21.0, 32.4) | 841 | 1,371,259 | 42.0 (39.4, 44.6) |
| Exclusive use of menthol/mint flavor | 38 | 79,535 | 2.2 (1.5, 3.3) | 216 | 500,275 | 9.6 (8.2, 11.2) | 41 | 85,047 | 7.8 (5.5, 11.0) | 608 | 1,015,750 | 31.1 (28.5, 33.8) |
| Non-exclusive use of menthol/mint flavor | 48 | 117,923 | 3.3 (2.3, 4.7) | 367 | 869,230 | 16.7 (14.8, 18.8) | 66 | 200,530 | 18.5 (13.7, 24.4) | 233 | 355,510 | 10.9 (9.2, 12.8) |
| Any use of fruit/other flavors | 430 | 886,819 | 24.7 (21.9, 27.7) | 1,602 | 3,384,521 | 64.9 (62.5, 67.3) | 219 | 525,794 | 48.4 (42.3, 54.6) | 431 | 662,328 | 20.3 (18.0, 22.7) |
| Exclusive use of fruit/other flavors | 377 | 755,573 | 21.0 (18.4, 23.9) | 1,155 | 2,393,571 | 45.9 (43.2, 48.7) | 146 | 311,945 | 28.7 (23.4, 34.7) | 200 | 309,936 | 9.5 (8.0, 11.2) |
| Non-exclusive use of fruit/other flavors | 53 | 131,246 | 3.7 (2.6, 5.1) | 447 | 990,950 | 19.0 (17.1, 21.1) | 73 | 213,849 | 19.7 (14.9, 25.6) | 231 | 352,392 | 10.8 (9.1, 12.7) |
| Tobacco flavore | 1,386 | 2,628,732 | 73.1 (70.1, 75.9) | 608 | 1,093,841 | 21.0 (19.1, 23.0) | 244 | 475,026 | 43.7 (37.8, 49.9) | 1,090 | 1,576,665 | 48.3 (45.6, 51.0) |
Defined as ever NCTP users and currently use them “every day” or report past 30-day use if “some days”
Respondents with a combination of missing data (“don’t know”, “refused”, unknown values) or inconsistent responses on flavor use and flavor categories (e.g., answer “yes” to flavor use and “no” to any flavor) are excluded from flavor categorization: large/regular cigars/cigarillos/little filtered cigars (n=30); ENDS (n=34); regular pipe/hookah/waterpipe (n=19); smokeless tobacco (n=50)
Any use of menthol/mint flavor, or any use of fruit/other flavors that include clove, spice, herb, fruit, alcohol, candy, sweets, chocolate, or other flavor
Exclusive use of tobacco flavor
Any use of menthol/mint flavor or fruit/other flavors versus exclusive use of tobacco flavor by user characteristics, 2018–2019
In 2018–2019, cigar and pipe smokers who reported using menthol/mint (cigars, 34.9% vs. 11.0%, p<0.001; pipes, 33.7% vs. 15.1%, p=0.006; Table 3) or fruit/other flavors (cigars, 26.1% vs. 11.0%, p<0.001; pipes, 34.0% vs. 15.1%, p<0.001; Table 4) were more likely to be female compared to tobacco-flavored users. Cigar, ENDS, and pipe users who reported using menthol/mint flavors, as compared to tobacco flavor, were more likely to be either NH Black (cigars, 45.0% vs. 17.5%, p<0.001) or Hispanic persons (ENDS, 13.0% vs. 6.7%, p<0.041; pipes, 30.0% vs. 12.4%, p<0.001). Similarly, a greater proportion of cigar and pipe smokers who used fruit/other flavors rather than tobacco flavor were identified as NH Black (cigars, 29.0% vs. 17.5%, p<0.001; pipes, 24.4% vs. 14.0%, p=0.004) or Hispanic persons (pipes, 24.9% vs. 12.4%, p=0.004). Among users of cigars, ENDS, and smokeless tobacco, those who used menthol/mint (ENDS, 39.1% vs. 11.1%, p<0.001; smokeless tobacco, 17.6% vs. 10.3%, p<0.001; Table 3) or fruit/other flavors (cigars, 20.5% vs. 10.0%, p<0.001; ENDS, 30.9% vs. 11.1%, p<0.001; Table 4) were more likely to be young adults aged 18–24 years compared to tobacco-flavored users. Moreover, cigar smokers who reported using menthol/mint (27.8% vs. 9.2%, p<0.001) and fruit/other flavors (15.0% vs. 9.2%, p<0.001) were more likely to have an educational attainment of less than high school. ENDS and pipe users who reported using menthol/mint (ENDS, 29.0% vs. 10.0%, p<0.001; pipes, 63.4% vs. 41.5%, p=0.005) and fruit/other flavors (ENDS, 26.1% vs. 10.0%, p<0.001; pipes, 58.5% vs. 41.5%, p=0.006) were more likely to be never cigarette smokers compared to tobacco-flavored users. In contrast, cigar and smokeless tobacco users who used menthol/mint (cigars, 57.5% vs. 27.1%, p=0.002) or fruit/other flavors (cigars, 43.4% vs. 27.1 %, p<0.001; smokeless tobacco, 21.9% vs. 16.3%, p=0.022) were more likely to be current cigarette smokers compared to tobacco-flavored users.
Table 3.
Demographic characteristics and tobacco use patterns comparing any use of menthol/mint flavored versus tobacco-flavored current adult users of non-cigarette tobacco products (NCTPs),a by product type, Tobacco Use Supplement to the Current Population Survey, 2018–2019 (% and 95% confidence interval).
| Large/Regular Cigars/Cigarillos/Little Filtered Cigars |
Electronic Nicotine Delivery System |
Regular Pipe/Hookah/Waterpipe |
Smokeless Tobacco |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Menthol/mint flavor | Tobacco flavor | P-valueb | Menthol/mint flavor | Tobacco flavor | P-valueb | Menthol/mint flavor | Tobacco flavor | P-valueb | Menthol/mint flavor | Tobacco flavor | P-valueb | |
| N | 86 | 1,386 | 583 | 608 | 107 | 244 | 841 | 1,090 | ||||
| Weighted N | 197,458 | 2,628,732 | 1,369,505 | 1,093,841 | 285,576 | 475,026 | 1,371,259 | 1,576,665 | ||||
| Characteristics (weighted %, 95% CI) | ||||||||||||
| Sex | <0. 001 | 0.134 | 0.006 | 0.142 | ||||||||
| Male | 65.1 (52.4, 75.9)c | 89.0 (86.9, 90.9)c | 56.8 (51.8, 61.6) | 61.8 (57.3, 66.2) | 66.3 (54.2, 76.6)c | 84.9 (77.3, 90.3)c | 97.2 (95.6, 98.2) | 95.6 (93.8, 96.9) | ||||
| Female | 34.9 (24.1, 47.6)c | 11.0 (9.1, 13.1)c | 43.2 (38.4, 48.2) | 38.2 (33.8, 42.7) | 33.7 (23.4, 45.8)c | 15.1 (9.7, 22.7)c | 2.8 (1.8, 4.4) | 4.4 (3.1, 6.2) | ||||
| Race/ethnicity | <0.001 | 0.041 | <0.001 | 0.037 | ||||||||
| Non-Hispanic White | 32.6 (22.4, 44.7)c | 68.5 (64.8, 71.9)c | 73.0 (68.3, 77.1)c | 80.9 (76.3, 84.8)c | 31.4 (22.4, 42.0)c | 62.7 (54.1, 70.5)c | 92.4 (89.4, 94.6)c | 87.6 (84.7, 90.0)c | ||||
| Non-Hispanic Black | 45.0 (31.8, 58.9)c | 17.5 (14.7, 20.8)c | 6.6 (4.6, 9.4) | 5.6 (3.4, 9.2) | 26.2 (17.1, 38.0) | 14.0 (8.5, 22.2) | 1.3 (0.7, 2.4)c,d | 4.1 (2.6, 6.3)c | ||||
| Hispanic | 14.8 (7.3, 27.6)d | 10.7 (8.5, 13.4) | 13.0 (9.9, 16.9)c | 6.7 (4.6, 9.5)c | 30.0 (19.2, 43.6)c | 12.4 (7.8, 19.2)c | 2.6 (1.5, 4.5) | 3.0 (1.9, 4.8) | ||||
| Non-Hispanic Othere | 7.7 (2.9, 19.0)d | 3.3 (2.3, 4.7) | 7.4 (5.3, 10.3) | 6.8 (4.5, 10.1) | 12.4 (6.7, 21.9)d | 10.9 (6.4, 18.1) | 3.6 (2.0, 6.3) | 5.3 (3.7, 7.6) | ||||
| Age group (year) | 0.096 | <0.001 | <0.001 | <0.001 | ||||||||
| 18–24 | 23.7 (13.2, 38.8) | 10.0 (7.6, 13.1) | 39.1 (34.0, 44.5)c | 11.1 (8.1, 15.1)c | 31.2 (19.2, 46.4) | 20.7 (14.0, 29.6) | 17.6 (14.0, 21.9)c | 10.3 (7.1, 14.5)c | ||||
| 25–34 | 26.6 (16.0, 41.0) | 19.8 (17.5, 22.3) | 27.0 (22.6, 31.9)c | 19.1 (15.6, 23.2)c | 47.4 (35.0, 60.3)c | 19.7 (14.5, 26.3)c | 29.9 (26.1, 34.0)c | 13.8 (11.4, 16.5)c | ||||
| 35–54 | 25.7 (16.1, 38.4) | 34.1 (30.9, 37.5) | 21.3 (17.7, 25.3)c | 36.4 (31.8, 41.2)c | 17.3 (10.2, 27.8) | 21.0 (15.2, 28.4) | 35.7 (32.2, 39.3)c | 44.6 (40.6, 48.7)c | ||||
| ≥55 | 24.0 (14.9, 36.2) | 36.1 (33.2, 39.1) | 12.6 (10.1, 15.7)c | 33.4 (29.5, 37.5)c | 4.0 (2.0, 7.9)c,d | 38.5 (31.8, 45.7)c | 16.8 (14.2, 19.8)c | 31.4 (28.3, 34.7)c | ||||
| Educational attainment | <0.001 | 0.108 | 0.923 | 0.778 | ||||||||
| <High school | 27.8 (17.3, 41.4)c | 9.2 (7.3, 11.6)c | 6.9 (4.5, 10.5) | 11.4 (8.5, 15.1) | 10.8 (4.8, 22.6)d | 10.7 (6.5, 17.3) | 8.9 (6.3, 12.3) | 10.9 (8.6, 13.6) | ||||
| High school diploma or GED | 31.4 (20.7, 44.5) | 25.0 (22.5, 27.6) | 33.7 (28.8, 38.9) | 33.4 (28.9, 38.2) | 22.2 (12.5, 36.3) | 25.8 (19.4, 33.3) | 38.8 (34.3,43.6) 37.6 (33.4, 42.0) | |||||
| Some college/associate degree | 34.1 (22.7, 47.5) | 30.6 (27.8, 33.6) | 41.0 (36.3, 45.7) | 35.4 (31.1, 40.0) | 29.5 (20.4, 40.6) | 25.6 (19.6, 32.7) | 32.5 (28.4, 36.8) | 31.6 (27.9, 35.6) | ||||
| ≥Bachelor’s degree | 6.8 (2.7, 16.1)c,d | 35.2 (32.4, 38.2)c | 18.5 (14.9, 22.7) | 19.8 (16.1, 24.1) | 37.5 (26.4, 50.1) | 37.9 (30.4, 46.1) | 19.8 (16.7, 23.4) | 19.9 (16.5, 23.8) | ||||
| Metropolitan status | 0.187 | 0.038 | 0.007 | 0.402 | ||||||||
| Metropolitan | 81.9 (71.8,89.0) | 87.7 (85.2, 89.8) | 89.5 (86.4,91.9)c | 85.0 (81.2, 88.1)c | 93.9 (86.6, 97.3)c | 83.1 (75.9, 88.4)c | 65.2 (59.5, 70.5) | 62.4 (57.5, 67.1) | ||||
| Nonmetropolitan | 18.1 (11.0, 28.2) | 12.3 (10.2, 14.8) | 10.5 (8.1, 13.6)c | 15.0 (11.9, 18.8)c | 6.1 (2.7, 13.4)c,d | 16.9 (11.6, 24.1)c | 34.8 (29.5, 40.5) | 37.6 (32.9, 42.5) | ||||
| Geographic region | 0.209 | 0.131 | 0.155 | <0.001 | ||||||||
| Northeast | 13.0 (6.2, 25.2)d | 18.8 (16.4, 21.4) | 14.7 (11.4, 18.8) | 20.5 (16.3, 25.4) | 29.9 (19.6, 42.7) | 20.2 (14.2, 28.0) | 11.1 (8.4, 14.6)c | 7.5 (5.8, 9.6)c | ||||
| Midwest | 24.8 (15.3,37.5) | 23.8 (21.1, 26.8) | 25.3 (21.2, 29.9) | 21.3 (17.5, 25.6) | 18.2 (10.7, 29.4) | 16.6 (11.3, 23.8) | 33.3 (29.5, 37.3)c | 20.3 (16.8, 24.2)c | ||||
| South | 52.6 (38.4, 66.4) | 41.1 (37.6, 44.6) | 33.4 (28.8, 38.2) | 36.4 (31.8, 41.2) | 37.6 (26.4, 50.3) | 36.9 (30.2, 44.1) | 40.8 (36.6, 45.2)c | 52.2 (48.0, 56.3)c | ||||
| West | 9.6 (4.2, 20.6)d | 16.3 (14.1, 18.8) | 26.6 (22.1, 31.5) | 21.8 (18.0, 26.2) | 14.3 (8.2, 23.8) | 26.2 (19.7, 34.0) | 14.7 (11.9, 18.0)c | 20.1 (16.6, 24.0)c | ||||
| Frequency of use | 0.024 | 0.156 | <0.001 | 0.006 | ||||||||
| Every day | 34.2(22.4, 48.5)c | 18.3 (16.2, 20.7)c | 48.3 (43.3, 53.3) | 43.2 (38.7, 47.9) | 3.6 (1.4, 8.8)c,d | 21.8 (16.5, 28.3)c | 60.7 (56.1, 65.1)c | 68.9 (64.8, 72.7)c | ||||
| Some daysf | 65.8 (51.5, 77.6)c | 81.7 (79.3, 83.8)c | 51.7 (46.7, 56.7) | 56.8 (52.1, 61.3) | 96.4 (91.2, 98.6)c | 78.2 (71.7, 83.5)c | 39.3 (34.9, 43.9)c | 31.1 (27.3, 35.2)c | ||||
| Cigarette smoking status | 0.002 | <0.001 | 0.005 | 0.279 | ||||||||
| Never | 26.7 (15.9, 41.3)c | 47.0 (43.7, 50.2)c | 29.0 (23.9, 34.6)c | 10.0 (7.2, 13.6)c | 63.4 (52.2, 73.2)c | 41.5 (33.8, 49.6)c | 50.3 (45.8, 54.8) | 55.1 (51.3, 58.8) | ||||
| Current | 57.5 (43.3, 70.5)c | 27.1 (24.2, 30.2)c | 35.9 (30.9, 41.3)c | 50.3 (45.5, 55.1)c | 25.3 (16.5, 36.7)c | 38.4 (31.4, 45.9)c | 19.1 (15.9, 22.7) | 16.3 (13.4, 19.6) | ||||
| Former | 15.8 (8.7, 27.1)c | 26.0 (23.5, 28.6)c | 35.1 (30.7, 39.8) | 39.8 (35.3, 44.3) | 11.4 (5.8, 21.1)d | 20.1 (14.3, 27.5) | 30.6 (27.1, 34.3) | 28.7 (25.3, 32.2) | ||||
Defined as ever NCTP users and currently use them “every day” or report past 30-day use if “some days”
Wald F Chi-square tests compare any use of menthol/mint flavor versus exclusive use of tobacco flavor; bolded p-values indicate statistical significance of p-values <0.05
Pairwise comparisons assess differences of the variable subgroups; marked subgroups indicate statistical significance of p-values <0.05
Unstable estimates with relative standard error of >30% are flagged
Non-Hispanic American Indian and Alaskan Native, Asian, Hawaiian or Pacific Islander, and persons of multiple races are combined into one category due to sample size and analytic concerns
“Some days” users are only included if report past 30-day use
Table 4.
Demographic characteristics and tobacco use patterns comparing any use of fruit/other flavored versus tobacco-flavored current adult users of non-cigarette tobacco products (NCTPs),a by product type, Tobacco Use Supplement to the Current Population Survey, 2018–2019 (% and 95% confidence interval).
| Large/Regular Cigars/Cigarillos/Little Filtered Cigars |
Electronic Nicotine Delivery System |
Regular Pipe/Hookah/Waterpipe |
Smokeless Tobacco |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Fruit/other flavors | Tobacco flavor | P-valueb | Fruit/other flavors | Tobacco flavor | P-valueb | Fruit/other flavors | Tobacco flavor | P-valueb | Fruit/other flavors | Tobacco flavor | P-valueb | |
| N | 430 | 1,386 | 1,602 | 608 | 219 | 244 | 431 | 1,090 | ||||
| Weighted N | 886,819 | 2,628,732 | 3,384,521 | 1,093,841 | 525,794 | 475,026 | 662,328 | 1,576,665 | ||||
| Characteristics (weighted %, 95% CI) | ||||||||||||
| Sex | <0.001 | 0.437 | <0.001 | 0.875 | ||||||||
| Male | 73.9 (68.7, 78.5)c | 89.0 (86.9, 90.9)c | 59.7 (56.8, 62.6) | 61.8 (57.3, 66.2) | 66.0 (58.4, 73.0)c | 84.9 (77.3, 90.3)c | 95.4 (92.7, 97.1) | 95.6 (93.8, 96.9) | ||||
| Female | 26.1 (21.5, 31.3)c | 11.0 (9.1, 13.1)c | 40.3 (37.4, 43.2) | 38.2 (33.8, 42.7) | 34.0 (27.0, 41.6)c | 15.1 (9.7, 22.7)c | 4.6 (2.9, 7.3) | 4.4 (3.1, 6.2) | ||||
| Race/ethnicity | <0.001 | 0.041 | <0.001 | 0.037 | ||||||||
| Non-Hispanic White | 32.6 (22.4, 44.7)c | 68.5 (64.8, 71.9)c | 73.0 (68.3, 77.1)c | 80.9 (76.3, 84.8)c | 31.4 (22.4, 42.0)c | 62.7 (54.1, 70.5)c | 92.4(89.4, 94.6)c | 87.6 (84.7, 90.0)c | ||||
| Non-Hispanic Black | 45.0 (31.8, 58.9)c | 17.5 (14.7, 20.8)c | 6.6 (4.6, 9.4) | 5.6 (3.4, 9.2) | 26.2 (17.1, 38.0) | 14.0 (8.5, 22.2) | 1.3 (0.7, 2.4)c,d | 4.1 (2.6, 6.3)c | ||||
| Hispanic | 14.8 (7.3, 27.6)d | 10.7 (8.5, 13.4) | 13.0 (9.9, 16.9)c | 6.7 (4.6, 9.5)c | 30.0 (19.2, 43.6)c | 12.4 (7.8, 19.2)c | 2.6 (1.5, 4.5) | 3.0 (1.9, 4.8) | ||||
| Non-Hispanic Othere | 7.7 (2.9, 19.0)d | 3.3 (2.3, 4.7) | 7.4 (5.3, 10.3) | 6.8 (4.5, 10.1) | 12.4 (6.7, 21.9)d | 10.9 (6.4, 18.1) | 3.6 (2.0, 6.3) | 5.3 (3.7, 7.6) | ||||
| Age group (year) | 0.096 | <0.001 | <0.001 | <0.001 | ||||||||
| 18–24 | 23.7 (13.2, 38.8) | 10.0 (7.6, 13.1) | 39.1 (34.0, 44.5)c | 11.1 (8.1, 15.1)c | 31.2 (19.2, 46.4) | 20.7 (14.0, 29.6) | 17.6 (14.0, 21.9)c | 10.3 (7.1, 14.5)c | ||||
| 25–34 | 26.6 (16.0, 41.0) | 19.8 (17.5, 22.3) | 27.0 (22.6, 31.9)c | 19.1 (15.6, 23.2)c | 47.4 (35.0, 60.3)c | 19.7 (14.5, 26.3)c | 29.9 (26.1, 34.0)c | 13.8 (11.4, 16.5)c | ||||
| 35–54 | 25.7 (16.1, 38.4) | 34.1 (30.9, 37.5) | 21.3 (17.7, 25.3)c | 36.4 (31.8, 41.2)c | 17.3 (10.2, 27.8) | 21.0 (15.2, 28.4) | 35.7 (32.2, 39.3)c | 44.6 (40.6, 48.7)c | ||||
| ≥55 | 24.0 (14.9, 36.2) | 36.1(33.2, 39.1) | 12.6 (10.1, 15.7)c | 33.4 (29.5, 37.5)c | 4.0 (2.0, 7.9)c,d | 38.5 (31.8, 45.7)c | 16.8 (14.2, 19.8)c | 31.4 (28.3, 34.7)c | ||||
| Educational attainment | <0.001 | 0.108 | 0.923 | 0.778 | ||||||||
| <High school | 27.8 (17.3, 41.4)c | 9.2 (7.3, 11.6)c | 6.9 (4.5, 10.5) | 11.4 (8.5, 15.1) | 10.8 (4.8, 22.6)d | 10.7 (6.5, 17.3) | 8.9 (6.3, 12.3) | 10.9 (8.6, 13.6) | ||||
| High school diploma or GED | 31.4 (20.7, 44.5) | 25.0 (22.5, 27.6) | 33.7 (28.8, 38.9) | 33.4 (28.9, 38.2) | 22.2 (12.5, 36.3) | 25.8 (19.4, 33.3) | 38.8 (34.3, 43.6) | 37.6 (33.4, 42.0) | ||||
| Some college/associate degree | 34.1 (22.7, 47.5) | 30.6 (27.8, 33.6) | 41.0 (36.3, 45.7) | 35.4 (31.1, 40.0) | 29.5 (20.4, 40.6) | 25.6 (19.6, 32.7) | 32.5 (28.4, 36.8) | 31.6 (27.9, 35.6) | ||||
| ≥Bachelor’s degree | 6.8 (2.7, 16.1)c,d | 35.2 (32.4, 38.2)c | 18.5 (14.9, 22.7) | 19.8 (16.1, 24.1) | 37.5 (26.4, 50.1) | 37.9 (30.4, 46.1) | 19.8 (16.7, 23.4) | 19.9 (16.5, 23.8) | ||||
| Metropolitan status | 0.187 | 0.038 | 0.007 | 0.402 | ||||||||
| Metropolitan | 81.9 (71.8, 89.0) | 87.7 (85.2, 89.8) | 89.5 (86.4, 91.9)c | 85.0 (81.2, 88.1)c | 93.9 (86.6, 97.3)c | 83.1 (75.9, 88.4)c | 65.2 (59.5, 70.5) | 62.4 (57.5, 67.1) | ||||
| Nonmetropolitan | 18.1 (11.0, 28.2) | 12.3 (10.2, 14.8) | 10.5 (8.1, 13.6)c | 15.0 (11.9, 18.8)c | 6.1 (2.7, 13.4)c,d | 16.9 (11.6, 24.1)c | 34.8 (29.5, 40.5) | 37.6 (32.9, 42.5) | ||||
| Geographic region | 0.209 | 0.131 | 0.155 | <0.001 | ||||||||
| Northeast | 13.0 (6.2, 25.2)d | 18.8 (16.4, 21.4) | 14.7 (11.4, 18.8) | 20.5 (16.3, 25.4) | 29.9 (19.6, 42.7) | 20.2 (14.2, 28.0) | 11.1 (8.4, 14.6)c | 7.5 (5.8, 9.6)c | ||||
| Midwest | 24.8 (15.3, 37.5) | 23.8 (21.1, 26.8) | 25.3 (21.2, 29.9) | 21.3 (17.5, 25.6) | 18.2 (10.7, 29.4) | 16.6 (11.3, 23.8) | 33.3 (29.5, 37.3)c | 20.3 (16.8, 24.2)c | ||||
| South | 52.6 (38.4, 66.4) | 41.1 (37.6, 44.6) | 33.4 (28.8, 38.2) | 36.4 (31.8, 41.2) | 37.6 (26.4, 50.3) | 36.9 (30.2, 44.1) | 40.8 (36.6, 45.2)c | 52.2 (48.0, 56.3)c | ||||
| West | 9.6 (4.2, 20.6)d | 16.3 (14.1, 18.8) | 26.6 (22.1, 31.5) | 21.8 (18.0, 26.2) | 14.3 (8.2, 23.8) | 26.2 (19.7, 34.0) | 14.7 (11.9, 18.0)c | 20.1 (16.6, 24.0)c | ||||
| Frequency of use | 0.024 | 0.156 | <0.001 | 0.006 | ||||||||
| Every day | 34.2 (22.4,48.5)c | 18.3 (16.2, 20.7)c | 48.3 (43.3, 53.3) | 43.2 (38.7, 47.9) | 3.6 (1.4, 8.8)c,d | 21.8 (16.5, 28.3)c | 60.7 (56.1, 65.1)c | 68.9 (64.8, 72.7)c | ||||
| Some daysf | 65.8 (51.5, 77.6)c | 81.7 (79.3, 83.8)c | 51.7 (46.7, 56.7) | 56.8 (52.1, 61.3) | 96.4 (91.2, 98.6)c | 78.2 (71.7, 83.5)c | 39.3 (34.9, 43.9)c | 31.1 (27.3, 35.2)c | ||||
| Cigarette smoking status | 0.002 | <0.001 | 0.005 | 0.279 | ||||||||
| Never | 26.7 (15.9, 41.3)c | 47.0 (43.7, 50.2)c | 29.0 (23.9, 34.6)c | 10.0 (7.2, 13.6)c | 63.4 (52.2, 73.2)c | 41.5 (33.8, 49.6)c | 50.3 (45.8, 54.8) | 55.1 (51.3, 58.8) | ||||
| Current | 57.5 (43.3, 70.5)c | 27.1 (24.2, 30.2)c | 35.9 (30.9, 41.3)c | 50.3 (45.5, 55.1)c | 25.3 (16.5, 36.7)c | 38.4 (31.4, 45.9)c | 19.1 (15.9, 22.7) | 16.3 (13.4, 19.6) | ||||
| Former | 15.8 (8.7, 27.1)c | 26.0 (23.5, 28.6)c | 35.1 (30.7, 39.8) | 39.8 (35.3, 44.3) | 11.4 (5.8, 21.1)d | 20.1 (14.3, 27.5) | 30.6 (27.1, 34.3) | 28.7 (25.3, 32.2) | ||||
Defined as ever NCTP users and currently use them “every day” or report past 30-day use if “some days”
Wald F Chi-square tests compare any use of fruit/other flavors versus exclusive use of tobacco flavor; bolded p-values indicate statistical significance of p-values <0.05
Pairwise comparisons assess differences of the variable subgroups; marked subgroups indicate statistical significance of p-values <0.05
Unstable estimates with relative standard error of >30% are flagged
Non-Hispanic American Indian and Alaskan Native, Asian, Hawaiian or Pacific Islander, and persons of multiple races are combined into one category due to sample size and analytic concerns
“Some days” users are only included if report past 30-day use
Prevalence of adult flavored cigar smokers by demographic characteristics and tobacco use patterns, 2010–2019
Supplemental Table presents the prevalence of current adult smokers of flavored cigars. Notably, across the three survey waves, among young adults aged 18–24 years (2010–2011, 1.2%; 2014–2015, 1.5%; 2018–2019, 0.7%, p=0.003) and among NH White persons (2010–2011, 0.5%; 2014–2015, 0.5%; 2018–2019, 0.3%, p<0.001), flavored cigar use was the least prevalent in 2018–2019.
DISCUSSION
This study characterizes the trends in use patterns of flavored NCTPs among the US adult population, expanding our current understanding of these products and providing a comprehensive range of estimates to support monitoring of trends of use patterns of flavored NCTPs. Our findings show that the number of flavored ENDS users increased from 3.4 million in 2014–2015 to 4.1 million in 2018–2019, and that ENDS users were more likely to report using a flavored product in 2018–2019 compared to 2014–2015. On the contrary, cigar and pipe smokers were less likely to report using a flavored product in 2018–2019 than 2014–2015.
We found that ENDS were the most commonly used flavored NCTP in 2018–2019 and that ENDS users who were young adults and never cigarette smokers were more likely to report using menthol/mint or fruit/other flavors compared to tobacco flavor. Studies have shown that unlike older adult ENDS users, which may include former or current cigarette smokers who are using ENDS in an effort to quit smoking cigarettes,9 young adult ENDS users often initiate tobacco use through experimentation with flavored ENDS due to their appealing flavors.17,20,21 Youth and young adults who use ENDS appear to be unlikely to initiate combusted cigarettes as smoking prevalence has continued to decline in this group.22–24 However, given the growing popularity and diversification of flavored ENDS among youth and young adults, the research literature has indicated that restricting the availability of flavored ENDS can help to prevent never tobacco users from initiating ENDS use and promote cessation among current ENDS users.16 Our findings can help inform FDA’s ongoing regulatory decision-making on the marketing of flavored ENDS.25–27 It should also be noted that collection of the latest 2018–2019 TUS-CPS data took place approximately seven to seventeen months prior to release of the FDA final guidance on flavored ENDS enforcement priorities.28 Therefore, this study provides a cross-sectional assessment of use patterns of flavored ENDS before the introduction of the FDA enforcement guidance.
In this analysis, cigar (2014–2015, 1.2 million; 2018–2019, 0.97 million) and pipe smokers (2014–2015, 0.95 million; 2018–2019, 0.61 million) were less likely to report flavored product use in 2018–2019 compared to 2014–2015. From 2010–2019, among young adults aged 18–24 years, use of flavored cigars was the least prevalent in 2018–2019. With the limited availability of similar studies of adult data for comparison, an assessment on trends of flavored tobacco use using the National Youth Tobacco Surveys showed that flavor use with cigars, hookahs, and pipes had all decreased in high school students during 2014–2018.29 As authors of the study note, such decreases could be due to the actual decreases in flavored product use or decreases in respondents’ awareness that the products they used were flavored.29 Although research using Nielsen data on US cigar unit sales from 2016–2020 showed that overall cigar sales varied during this time, unit sales of fruit-flavored cigarillos and regular cigars, and alcohol-flavored little filtered cigars decreased over time.30 Flavored product use has decreased among cigar smokers, but the number of flavored adult cigar smokers still represent a considerable number at 966,354 individuals in 2018–2019, and our findings show a disproportionate use of flavored cigars by sex, race/ethnicity, and educational attainment.
Results from this study extend previous research on flavored NCTP use. Consistent with prior studies using nationally representative adult samples, we found that females were more likely than males to report using flavored cigars and hookahs.13,16,31 Our findings also suggest disparities in cigar smoking among African Americans or Black persons. In comparison to tobacco-flavored cigar smokers, cigar smokers who reported using menthol/mint or fruit/other flavors were more likely to be NH Black persons. These findings align with prior research using the NATS that reported use of flavored cigars was higher among racial minorities.16 Similarly, an analysis of adult data from waves 1–5 of the PATH Study found that NH Black cigar smokers were more likely to use flavored products in the past 30 days than their NH White counterparts.32 Additionally, a study of university students revealed that NH Black cigar smokers had greater odds of using flavored cigars than their NH White cigar smoking peers.33 A substantial body of literature based on nationally representative data have indicated that flavored NCTPs, especially ENDS,9,10,16,17,31,34,35 cigars,16,17,32,35 and hookahs,17,31 which are commonly marketed as flavored products,17 were more commonly used in young adults aged 18–24 years than among older adults. We identified that cigar smokers of menthol/mint or fruit/other flavors were more likely to have an educational attainment of less than high school. This finding is supported by the PATH Study showing that adult cigar smokers with a higher educational attainment (e.g., college degree) were less likely to use flavored products.32 Consistent with our findings, studies have demonstrated that flavored ENDS are more commonly used by adults who are never cigarette smokers (versus current or former smokers),9,10,16,34,35 This result may partly be explained by the fact that flavored ENDS users tend to be young adults aged 18–24 years, who also tend to be never cigarette smokers compared to adults of other age groups.36
This analysis is subject to some limitations. First, all information on user characterstics and product use was self-reported by respondents, which may be subject to misreporting or lead to under or overestimation of the true estimates. Second, due to the limited samples of regular pipe smokers reporting any use of menthol/mint flavor (n=20) and hookah or waterpipe smokers reporting exclusive use of tobacco flavor (n=43), we combined regular pipe filled with tobacco and waterpipe or hookah pipe filled with tobacco into a single NCTP category; this limited the study’s ability to produce generalizable estimates by different types of pipe products. Furthermore, since “menthol/mint” flavor was given as a single response option for each NCTP in 2018–2019, it was not possible to distinguish between the use of these two flavors, which may have different appeals to consumers. Additionally, since the TUS-CPS has limited data on ENDS product characteristics (e.g., older generations, nicotine salt), we were unable to assess product characteristic information, such as comparing reusable devices with nicotine salt liquids in disposable pods or cartridges versus older generations. Although data are available on ENDS device type (open versus closed systems) in 2018–2019, such information was not captured during prior waves, and we were unable to make comparison between waves. Lastly, as the TUS-CPS does not specifically capture data on blunt use (cannabis) among cigar smokers, we could not examine how blunt use may have contributed to our findings given the popularity of flavored wrapper cigars. Despite these limitations, this study is a nationally representative analysis of large sample size, which provides estimates on use patterns of flavored NCTPs over a nearly 10-year period.
CONCLUSIONS
ENDS users were more likely to report using a flavored product in 2018–2019 compared to 2014–2015. Consistent with previous studies using nationally representative adult samples, for some NCTPs, users who reported using menthol/mint flavor or fruit/other flavors were more likely to be young adults aged 18–24 years (cigars, ENDS, smokeless tobacco), NH Black or Hispanic persons (cigars, ENDS, pipes), and female (cigars, pipes) compared to exclusive users of tobacco flavor. Our study findings can inform tobacco control and regulatory efforts concerning flavored NCTPs. The study also highlights the US populations with high usage of flavored NCTPs, which suggests there may be a role for targeted tobacco cessation interventions to address health disparities in disproportionately affected communities.
Supplementary Material
Highlights.
Flavored product use has increased among electronic nicotine delivery system users
Flavored product use has decreased among cigar and pipe smokers
Flavored users are more likely to be Non-Hispanic Black or Hispanic persons
Acknowledgement:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Food and Drug Administration, National Institutes of Health, or Department of Health and Human Services.
Funding:
This work was supported by the Center for Tobacco Products, US Food and Drug Administration and the National Cancer Institute, National Institutes of Health.
Footnotes
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Declaration of Interests: All authors have no conflict of interest.
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Data Availability:
Data used are publicly available for download at the TUS-CPS website https://cancercontrol.cancer.gov/brp/tcrb/tus-cps.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data used are publicly available for download at the TUS-CPS website https://cancercontrol.cancer.gov/brp/tcrb/tus-cps.