Waterpipe tobacco brands and flavors sold online in the USA

Abstract

Introduction.

Flavor additives are commonly used in combustible tobacco products to mask harshness and increase appeal. However, research on the availability of flavored waterpipe tobacco (WT) is lacking, yet is important to support implementation of policies.

Methods.

We completed a comprehensive online search in 2020 to identify WT brands and flavors sold online in the USA. We conducted a descriptive content analysis categorizing flavors as explicit (i.e., clear taste/flavor) or concept (i.e., no clear taste/flavor); and coded for 23 flavor descriptors (e.g., fruit, mint/menthol, tobacco). Flavor names were double-coded and discrepancies were resolved by a third coder.

Results.

We identified 66 WT brands with 118 product lines (i.e., sub-brands). We found 2,953 flavors, including 1,871 unique flavors. Brands averaged 45 flavors (range: 1–183). Almost three quarters (73.5%, n=2,171) used explicit flavor names and 26.5% (n=782) used concept flavor names. Concept flavors varied widely, and included names such as 1001 Nights and California Dream. The most common flavor descriptors were fruit (54.1%) and mint/menthol (12.5%). Tobacco was rarely (0.2%) used as a flavor descriptor. Flavor descriptors also included location (10.7%), color (11.1%), candy (6.3%), cool/ice (5.3%), and alcohol (5.5%).

Conclusions.

WT is available in 1,871 unique flavors, likely contributing to product appeal and use. Like other tobacco products, fruit and mint/menthol are common flavors. Given the significant health consequences associated with WT smoking and the role of flavors in product use, regulatory action specifically targeting WT flavors is urgently needed.

Introduction

Waterpipe tobacco (WT) smoking is a centuries-old practice, known across the world by many names, including hookah, narghile, and hubble-bubble (Maziak, Eissenberg, & Ward, 2005). WT smoking involves the passage of air heated by charcoal, through the tobacco then through water or another liquid prior to inhalation. The introduction of flavored WT, a mixture of shredded tobacco with honey or molasses and dried fruit and flavorings, escalated the spread of WT smoking worldwide beginning in the 1990s (Maziak, Ward, Afifi Soweid, & Eissenberg, 2004; Rastam, Ward, Eissenberg, & Maziak, 2004).

WT smoking remains a public health concern, especially among young adults ages 18–24, who, compared to adults over 25, have the highest rates of ever (47.5% vs. 15.5%), past year (25.8% vs. 3.5%), and past 30-day use (9.2% vs. 1.2%) in the USA (Sharma et al., 2020). Those who use WT are exposed to high levels of toxicants, including carcinogenic polycyclic aromatic hydrocarbons, carbon monoxide, heavy metals, and volatile aldehydes (Al Rashidi, Shihadeh, & Saliba, 2008; Daher et al., 2010; Eissenberg & Shihadeh, 2009; Maziak et al., 2009; Shihadeh, 2003; Shihadeh et al., 2015). Exposure to these toxicants results in many of the same health harms as from use of other forms of combustible tobacco (Mamtani et al., 2017; Montazeri, Nyiraneza, El-Katerji, & Little, 2017; Raad et al., 2011; Waziry, Jawad, Ballout, Al Akel, & Akl, 2017). Even infrequent WT smoking is associated with negative health harms, such as lung-related abnormalities and arterial stiffness (Rezk-Hanna et al., 2018; Yano et al., 2015). Moreover, those who use WT are exposed to nicotine, potentially leading to dependence. Growing evidence indicates that WT smoking is prospectively associated with initiation of cigarette smoking, putting young adults at greater risk for cancer (Soneji, Sargent, Tanski, & Primack, 2015; Watkins, Glantz, & Chaffee, 2018).

The availability of WT in the USA is not well understood. WT is not sold in traditional retail outlets that sell other tobacco products, including convenience stores, pharmacies, grocery stores, and warehouse clubs. Therefore, Nielsen scanner data cannot provide brand availability and sales data. Instead, WT is sold in smoke shops, stores that allow WT smoking onsite, such as hookah bars and cafés, and online (King, Merten, & Nicksic, 2021; Tanski et al., 2019). To our knowledge, no study has identified the number of WT brands, product lines or sub-brands, and flavors sold online in the USA, limiting a full understanding of the WT marketplace.

Flavors are added to combustible tobacco products to mask the harshness or throat irritation from smoke and improve the taste (Carpenter, Wayne, Pauly, Koh, & Connolly, 2005; Cummings, Morley, Horan, Steger, & Leavell, 2002). Flavored tobacco may encourage initiation and continued use, especially among adolescents and young adults (Ambrose et al., 2015). Data from the first wave of the Population Assessment of Tobacco and Health (PATH) found that among people who have ever smoked WT, 89% of adolescents (12–17), 89% of young adults (18–24), and 75% of adults 25 years or older initiated use with flavored tobacco (Villanti, Johnson, et al., 2017). Among all age groups, the availability of WT in flavors was the second most endorsed reason for use, behind socialization. The tobacco industry has long known and capitalized on the appeal of flavored tobacco products, especially for youth. Tobacco industry documents revealed that as early as 1972, tobacco companies focused on flavors when developing concepts for new youth-focused cigarettes, “It’s a well-known fact that teenagers like sweet products. Honey might be considered.” (Marketing Innovations Inc. Project Report, 1972).

The WHO Framework Convention on Tobacco Control (FCTC) is the first international treaty developed to address the global epidemic of tobacco. In guidelines for implementation of Articles 9 and 10, it is recommended that flavor prohibitions or restrictions are introduced to reduce product appeal (WHO Framework Convention on Tobacco Control, 2017). The USA Food and Drug Administration (FDA) asserted regulatory authority over WT when the final deeming rule was issued in 2016. This rule extends the authority of the FDA granted in the Family Smoking Prevention and Tobacco Control Act (FSPTCA) passed in 2009. Under the FSPTCA, the FDA has the authority to implement product standards for the protection of public health. The FDA issued a product standard to ban characterizing flavors, excluding menthol and tobacco, in cigarettes, but no product standard exists for non-cigarette tobacco products. In April 2022, the FDA announced two proposed rules: one to prohibit menthol in cigarettes and a second to ban all characterizing flavors, including menthol, in cigar products (USA Department of Health and Human Services, Food and Drug Administaion, Center for Tobacco Products, 2022). However, WT was not included in either proposed rule.

In the absence of a USA federal flavor ban on tobacco products, states and localities have enacted local and statewide prohibitions on the sale of flavored tobacco products (Gammon et al., 2019). Recent research has documented an increase in the use of concept flavors, perhaps in response to increasing local and statewide flavor prohibitions (Gammon et al., 2019). Concept flavors do not include a specific flavor or known taste (e.g., Exotic Pink), which are typically the target of local regulations (Truth Initiative, 2021). The tobacco industry has a long history of modifying product characteristics, labeling, or packaging to avoid restrictions (Truth Initiative, 2021). One study found that seven years after the implementation of a flavor ban in New York City, 70.9% of retailers sold non-cigarette tobacco products with concept flavor names that had not been on the market prior to policy implementation, suggesting that the tobacco industry is deliberately using concept flavors to circumvent local flavor restrictions. However, limited research has examined the extent to which WT products use concept flavor names, nor have studies described the flavors available on the market in the USA To address this gap, we sought to quantify the number of flavored WT products available online and to describe the types and frequencies of those flavors, including the use of concept flavors.

METHODS

Brand Identification.

We conducted a census of all WT tobacco brands sold online in the United States in January-March 2020, based on a similar strategy used for identification of e-cigarette brands (Zhu et al., 2014). First, we searched five third-party websites (hookah-shisha.com, southsmoke.com, hookahcompany.com, thehookah.com, hookahjohn.com) and documented brand names (e.g., Starbuzz), individual product lines or sub-brands (e.g., Starbuzz Bold, Starbuzz Exotic), and flavor names available for sale at that point in time. To confirm no brands were missing, we conducted a Google search for “hookah tobacco” and reviewed the first 10 pages of search results (approximately 100 links) for additional brands (Jackler, VanWinkle, Bumanlag, & Ramamurthi, 2018; Zhu et al., 2014). We also reviewed the adult and youth Wave 4 surveys of the PATH study and included brands reported by participants if they were not already in the sample.

Codebook Development and Content Analysis.

We conducted a descriptive content analysis to capture the types of flavors used across WT brands, following best practices developed by Riffe, Lacy, and Fico (Riffe, Lacy, & Fico, 2014). The study team developed a codebook that included flavor type (explicit or concept) and flavor descriptors, described below. Three researchers were trained on the codebook and practiced coding fictitious flavors. Codes for each flavor were discussed and the codebook was revised as needed to provide further clarity. After training was completed, all flavors were independently double-coded and a third trained coded resolved any discrepancies.

Flavor Type.

Each flavor name was coded as either an explicit flavor or a concept flavor. An explicit flavor referred to a flavor that could be identified as a specific taste, such as apple, mint, or coffee. A concept flavor was a flavor that could not be easily identified as a specific taste or flavor (e.g., Aloha)(Rogers et al., 2020). If a flavor name included both a concept and explicit flavor component, it was coded as explicit. For example, although Earth Mint includes a concept flavor component (Earth), the explicit flavor component (Mint) prompts the consumer to identify this product as a variation of mint flavor – a known taste. Thus, these types of flavor names were coded as explicit flavors. However, if a flavor name included a general term, such as Candy Crush, rather than a specific type, it was considered a concept flavor.

Flavor Descriptors.

For both types of flavors, we also coded the presence of 23 flavor descriptors: fruit, mint, spice, herb, floral, candy, baked dessert/sweets, coffee/tea/cocoa, other beverage (non-alcoholic), alcohol, cool/ice, tobacco, sexual innuendo, marijuana, mythical, animals, energizing, time of day, time of year, location/place, quality, color, and sensation/emotion. This list of 23 flavor descriptors was developed based on a review of WT flavors from a pilot study that included one hundred flavors. If the flavor could not be coded into any of the 23 flavor descriptors, it was coded as ‘other.’ Flavor names could include a single or multiple descriptors. The results of the content analysis were reviewed by the team, and two flavors were manually recoded under the team’s discretion: ‘eucalyptus’ was recoded as herb instead of mint, and ‘licorice’ and its variants were recoded as candy instead of herb.

Analysis.

The goal of the analysis was to describe the flavors available in WT brands; therefore, we computed frequencies and percentages for all coded data. We report the overall percentage of each of the 23 flavor descriptors and the percentage of brands with each flavor descriptor. For each flavor descriptor, we also report the percentage of flavor names coded as explicit and concept flavors.

RESULTS

The census included 66 WT tobacco brands with 118 product lines. There were 2,953 flavors, including 1,871 unique flavors (Table 1). Brands averaged 45 flavors, but there was a very wide range (1–183).

Table 1.

WT brands, product lines, and flavors

Brand Names (n=66)	Product Line Names	Product Lines (n=118)	Flavors Per Brand (n=2953)
360	Cosmic Series, Classic Series	2	23
Adalya	Original	1	45
Afzal	Original	1	53
Agera	Original	1	15
Al Amir	Original	1	58
Al Fakhamah	Original, Dark	2	16
Al Fakher	Crafted Batch, Golden, Special Edition, Standard Range	4	104
Al Waha	Elite Edition	1	35
Alchemist Blend	Original Blend, Kentucky Fire Cured, Stout, Straight	4	41
Amy Gold	Original	1	10
Argelini	Original Original	1	9
Ayam Zaman	Original	1	7
Azure	Black, Gold	2	94
Baja	Original	1	8
Black Lava	Original	1	33
Bon Bon	Original	1	5
Chaos	Original	1	9
Cloud	Original	1	30
Coco Nara	Original	1	45
Craft Xo	Original	1	4
DeCloud	Original	1	13
Eternal Smoke	Cool, Enjoy, Extreme, Guess What!, Mix, Romance	6	30
Fantasia	Original, Castros, Formula, Hydro, Ice	5	134
Fumari	Original	1	47
Gold Star	Original	1	18
Haze	Original, Cheech and Chong, Jazze Pha	3	90
Hollywood Hookah	Original	1	5
Hookafina	BLAK, Gold	2	96
Hookah-Hookah	Original, Freak	2	57
Hooked-On-Hookah	Original	1	35
Inhale	Original	1	39
Isfahani	Original	1	1
Jewels	Kasbah, Original	2	20
Karizma	Original	1	28
Karma	Original	1	12
Khalil Maamoon	Original	1	26
Lavoo	Dark Leaf, Heritage Reserve Dark Leaf	2	24
Layalina	Original, Golden, Ya Layl	3	154
Malaki	Molasses	1	24
Mazaya	Original	1	96
Moassel Saloum	Original	1	1
MYA	Original	1	6
Nakhla	Original, El Basha, Exotic, Mix, Mizo, Sheherazade, Tropicana	7	89
Nirvana	Eclipse, Othmani, Super Shisha	3	40
Nu	Original	1	30
Over Dozz	Original	1	9
Panorama	Original	1	11
Pharaoh’s	Original	1	27
Pure	Original, FML	2	31
Romman	Black, Golden	2	80
ROR	Original	1	29
Rosetta	Original	1	15
Serbetli	Original	1	19
Shisha Royale	Original	1	19
Shishapresso	Original	1	6
Social Smoke	Original	1	78
Starbuzz	Bold, Exotic, Serpent, Vintage	4	181
Tangiers	Birquq, Burley, F-Line, Noir	4	183
TickTock	Original	1	107
Tonic	Original	1	92
Trifecta	Blonde, Dark	2	66
Ugly	Original	1	38
Voodoo	Original	1	14
XOX	Original	1	12
Zomo	Black, Classic, Splash, Sport, Star, Strong, World	7	122
Zumerret	Black, Blue, Gold, Special Black	4	55

Note. Original means either a single product line under the brand or the brand name was used as one of the product lines.

Flavor Type.

Of the identified flavors, 73.5% (n=2,171) were coded as explicit and 26.5% (n=782) as concept flavors. Most brands (89.3%) included explicit and concept flavor products, however, almost all brands (89.8%) had more explicit flavors than concept flavors. Examples of concept flavors (with brands) included WTF (Chaos), After Sex (Tonic), Purple Haze (Fantasia), Pandora’s Box (Social Smoke), Jack the Ripper (Starbuzz), and Dark Soul (Inhale).

Flavor Descriptors.

In addition to categorizing each flavor name as an explicit or concept flavors, flavors were coded into 23 flavor descriptors or an ‘other’ category. Table 2 describes the prevalence of each flavor descriptor in the full sample and by flavor type (explicit vs. concept). Below we review the 10 most prevalent flavor descriptors and a few others of interest.

Table 2.

Frequencies of flavor descriptors

Rank	Flavor Descriptors	Frequency (N=2,953)	Percent of Total	Percent of Explicit	Percent of Concept	Examples
1	Fruit	1598	54.1	71.9	4.9	Apple, Forbidden Fruit
2	Mint/menthol	368	12.5	17.0	0	Chocolate Mint, Mint Knockout
3	Color	328	11.1	10.0	14.2	White Grape, Gold
4	Location/place	317	10.7	6.0	23.8	Bahrain Apple, Paradise
5	Other	198	6.7	0.5	23.9	Da Vinci, Zero Gravity
6	Candy	180	6.1	7.0	3.5	White Gummy Bear, Candy Crush
7	Alcohol	161	5.5	6.5	2.6	Margarita, Cocktail
8	Cool/Ice	157	5.3	5.5	4.7	Cool Lemon, Green Ice
9	Sensation/emotion	136	4.6	3.5	7.8	Berry Bliss, Euphoria
10	Spice (non-mint)	119	4.0	5.2	0.8	Cinnamon, Love Spice
11	Coffee/tea/cocoa	103	3.5	4.5	0.5	Cappuccino, Boston Tea Party
11	Other beverage	103	3.5	4.1	1.7	Cola, Aussie Juice
13	Mythical	82	2.8	0.5	9.1	Dragon’s Breath, Nectar of the Gods
14	Baked dessert/sweets	79	2.7	3.5	0.4	Blueberry Muffin, American Cake
15	Quality	75	2.5	1.9	4.3	Fancy Grape, 24 Karat
16	Sexual innuendo	73	2.5	0.7	7.4	Virgin Strawberry, Code 69
17	Floral	55	1.9	1.9	1.8	Marigold, Cactus Blast
18	Time of day	50	1.7	0.6	4.9	Pineapple Sunrise, Miami Nights
19	Energizing	49	1.7	0.6	4.6	Cinnamon Blast, Shock Energy Drink
20	Time of year	44	1.5	0.9	3.2	Christmas Mix, Sweet Summer Sun
21	Animals	37	1.3	0.3	3.8	Amber Eagle, Flamingo
22	Herb	9	0.3	0.4	0	Lavender Mint, Jasmine
23	Tobacco	6	0.2	0.1	0.4	Sweet Cigar, Shisha on the Beach
23	Marijuana	6	0.2	0.1	0.5	Mary Jane, Purple Haze

Fruit.

Fruit was the most common descriptor overall (n = 1,598; 54.1%) and almost all brands (93.9%) included at least one fruit flavor (Table 3). Just about three quarters (71.9%) of explicit flavors included a fruit descriptor, while only 4.9% of concept flavors included a fruit descriptor. A fruit flavor was only coded as a concept flavor when the flavor name included a generic term, such as Forbidden Fruit, rather than a specific fruit flavor, such as banana. Apple was the most used fruit flavor, appearing in 9.8% of the flavors coded as fruit. Lemon (8.1%), grape (7.5%), orange (6.2%), peach (5.9%), blueberry (5.7%), and strawberry (5.6%) were also common fruit flavors.

Table 3.

Percent of Brands (N=66) with One or More Flavors with Each Flavor Descriptor

Flavor Descriptor	N (Percent)
Fruit	62 (93.9)
Mint/menthol	56 (84.8)
Color	55 (83.3)
Location/place	51 (77.3)
Other	44 (66.7)
Candy	42 (63.6)
Alcohol	39 (59.1)
Cool/Ice	39 (59.1)
Sensation/emotion	37 (56.1)
Spice (other than mint)	44 (66.7)
Coffee/tea/cocoa	37 (56.1)
Other beverage (non-alcoholic)	36 (54.5)
Mythical	33 (50.0)
Baked dessert/sweets	30 (45.5)
Quality	32 (48.5)
Sexual innuendo	26 (39.4)
Floral	28 (42.4)
Time of day	27 (40.9)
Energizing	25 (37.9)
Time of year	13 (19.7)
Animals	20 (30.3)
Herb	8 (12.1)
Tobacco	6 (9.1)
Marijuana	4 (6.1)

Mint/Menthol and Cool/Ice.

Mint/menthol was the second most common flavor descriptor (n=368; 12.5%) and was used by 84.8% of all brands. No concept flavor was coded as mint/menthol because mint/menthol is an explicit flavor. Menthol was only used in six (1.2%) flavor names. In addition to mint/menthol, 157 (5.3%) of flavor names were coded as cool/ice and 59.1% of brands used this descriptor. Ice, cool, artic, breeze, and freeze/frozen were common terms used in this category. Together, 496 (16.7%) of the flavor names were coded as either mint/menthol or cool/ice.

Color and Location.

Eleven percent of flavors included a color descriptor (e.g., White Grape and Gold), including 10% of those coded as explicit flavors and 0.4% of those coded as concept flavors. Most brands (83.3%) included at least one flavor name with a color descriptor. Overall, 10.7% of flavors were coded as containing location descriptors (e.g., Bahrain Apple and Paradise), including 6.0% of those coded as explicit flavors and 23.8% of those coded as concept flavors. Over three-fourths of brands (77.3%) had at least one flavor that included a location descriptor.

Candy and Baked Goods/Sweets.

Candy descriptors were used in 180 (6.1%) of flavor names, including in 7.0% of those coded as explicit flavor and 3.5% of those coded as concept flavors. Gum was the most commonly used candy descriptor in 67 (25.9%) flavor names. Seventy-nine (2.7%) flavors were coded as baked goods or sweets, including 3.5% of those coded as explicit flavors and 0.4% of those coded as concept flavors. About two thirds of brands (63.3%) included at least one flavor with a candy descriptor and almost half (45.5%) had at least one flavor with a baked goods/sweets descriptor.

Beverage.

Beverages were used as flavor descriptors in 362 (12.2%) flavor names. These included 161 (5.5%) coded as alcohol (6.5% of explicit flavors; 2.6% of concept flavors), 103 (3.5%) coded as coffee, tea, or cocoa (4.5% of explicit flavors; 0.5% of concept flavors), and 103 (3.5%) coded as other non-alcoholic beverages (4.1% of explicit flavors; 1.7% of concept flavors). Coffee, tea, or cocoa descriptors were used by 56.1% of brands, alcohol descriptors were used by 59.1% of brands, and other (non-alcoholic) beverages were used by 54.5% of brands.

Sensation/Emotion.

Sensation and emotion descriptors were used in 4.6% of flavor names and over half of brands (56.1%). While only 3.5% of explicit flavors had sensation/emotion descriptors, 7.8% of concept flavors had this descriptor. Examples include Berry Bliss and Euphoria.

Spice.

Spices, other than mint, were used in 4.0% of flavor names, and were more common in explicit (5.2%) than in concept (0.8%) flavors. Two thirds of brands (66.7%) included at least one flavor name with a spice descriptor. Flavor names with a spice descriptor include Cinnamon and Love Spice.

Sexual Innuendo.

Although less common, sexual innuendo was used in 73 (2.5%) flavor names and 39.4% of brands had flavors coded as sexual innuendo. Sexual innuendo descriptors were more common in concept flavors (7.4%) than in explicit flavors (0.7%). The word sex was used explicitly in 14 flavor names. Flavor names also included euphemisms for sex such as Bump ‘n Grind, Afternoon Delight, and Get Lei’d.

Tobacco.

Tobacco was very rarely used as a descriptor in flavor names (n=6, 0.2%) and only 9.1% of brands included tobacco as a flavor descriptor. Flavor names included Sweet Cigar and Holy Shisha.

DISCUSSION

Our comprehensive online review resulted in 66 WT brands, including 118 product lines. To our knowledge, this study is the first to identify the number of WT brands, product lines, and flavors sold online in the USA. All tobacco manufacturers are required to register with the FDA and file a list of all tobacco products being manufactured, prepared, compounded, or processed by that company (USA Department of Health and Human Services, Food and Drug Administaion, Center for Tobacco Products, 2023). However, at the time of the study, the FDA registration list was not public. Therefore, this study is a critical step in understanding the landscape of available WT products sold online in the USA.

It is well understood that flavors influence perceptions of and experiences with tobacco products, leading to increased product appeal (Huang et al., 2017). A recent systematic review found that flavored tobacco products were perceived as having better taste, being less harmful, and were more appealing, especially for youth and young adults (Huang et al., 2017). In fact, the availability of WT in flavors plays an important role in use among youth and young adults (Huang et al., 2017). Our study found that WT sold online in the USA is available in over 1,800 unique flavors. Like other tobacco products, fruit and mint/menthol were the most commonly used descriptors. Fruit is a common flavor descriptor in many non-cigarette tobacco products and is often reported as the most utilized flavor across many products. For example, data from PATH Wave 3 show that among adults who smoke WT, fruit was the most commonly reported flavor (Schneller et al., 2020).

If the proposed product standards to eliminate menthol in cigarettes and all characterizing flavors in cigar products in the USA are finalized, this would leave WT as the only combustible product with characterizing flavors available on the USA market. This is concerning given that some people who smoke cigarettes or cigars may seek out WT as a substitution product since it will still be available in a wide variety of flavors. Several studies have demonstrated the potential for substitution after a flavor ban (Chaiton et al., 2020; Courtemanche, Palmer, & Pesko, 2017; Rossheim et al., 2020). For example, data from the National Youth Tobacco Survey found that in the four years following the ban of all flavors other than menthol for cigarettes, there was a 17% decrease in the current cigarette smoking prevalence among youth, but a 14% increase in cigar, smokeless tobacco, and pipe use (Courtemanche et al., 2017). These data suggest that flavor bans in one type of tobacco product may result in substitution of a different tobacco product that is still available in flavors. Given the impending product standards for cigarettes and cigars, and the available flavors in WT products, the FDA should consider implementation of product standards eliminating all flavors in WT so that no combustible products are available in flavors.

Just over a quarter of the flavors identified were concept flavors (26.5%) and most brands (89.3%) sold both concept and explicit flavors. Concept flavors have come under scrutiny for potentially being used by the tobacco industry to circumvent state and local policies prohibiting the sale of flavored tobacco (Gammon et al., 2019; Rogers et al., 2021; Viola, Giovenco, Miller Lo, & Delnevo, 2016). Concept flavors may also be attractive to those who smoke WT because they are novel and mysterious, with ambiguous flavors. Explicit flavors often used fruit descriptors, yet concept flavors used location/place, mythical, and sensation/emotion descriptors. Although tobacco products with flavor names have been able to circumvent and local flavor prohibitions, the proposed product standard for characterizing flavors in cigar products does not rely on flavor names. As described in the Proposed Rule, the determination of whether cigars contain a characterizing flavor will include: the presence and amount of artificial and natural flavor compounds, constituents, additives, or ingredients, the experience of using the product, including taste, aroma, and cooling sensation, and flavor representation (F. a. D. A. U.S. Department of Health and Human Services, Center for Tobacco Products, 2022). Although this rule has yet to be finalized, it is expected that it will prevent cigars from being sold in any flavoring other than tobacco, whether the name is an explicit or concept flavor.

Mint/menthol was the second most common flavor descriptor (12.5%) and 84.8% of brands had one or more mint/menthol flavor. Menthol is an organic compound that has pharmacological effects, including analgesic and cooling sensations (Krishnan-Sarin et al., 2017). The tobacco industry has long been aware that menthol masks the throat irritation caused by inhaling smoke (Villanti, Collins, Niaura, Gagosian, & Abrams, 2017). Similarly, mint flavoring also produces a cooling sensation and is a familiar flavor used in many consumer products such as toothpaste and gum. In addition to menthol and mint, there are other cooling agents that are added to tobacco that do not have a minty taste or smell. This allows a cooling sensation to be added to other, non-mint, flavors. The use of cool/ice flavor descriptors has been documented in e-cigarettes (Leventhal, Dai, Barrington-Trimis, & Sussman, 2021). To our knowledge, this is the first study to assess cool/ice in WT flavors, finding 157 (5.3%) flavors and over half the brands (59.1%) using this descriptor. These cooling agents may not be considered characterizing flavors, therefore, targeted regulatory actions may be needed.

One hundred sixty-one flavors were coded as alcohol (5.5%), and 59.1% of brands had at least one alcohol flavor. Using alcohol-flavors in tobacco products is common and may be particularly appealing to youth. One study found that youth who preferred e-cigarettes in alcohol flavors had higher rates of binge drinking (Jackson et al., 2020). Because WT use and alcohol are often paired in bar settings, alcoholic flavors may contribute to the co-use of WT and alcohol (Soule, Barnett, & Curbow, 2012).

Over 250 (8.8%) flavor names were coded as candy or baked desserts/sweets. Candy flavors were offered by 63.6% of brands and baked goods/sweets by 45.5% of brands. Data from the National Youth Tobacco Survey 2021 show that among those who use disposable e-cigarettes and tank systems, ‘candy, desserts, and other sweets’ was the second most commonly used flavor type (behind fruit); while among those who use pods, ‘candy, dessert, and other sweets’ ranked fourth (Park-Lee et al., 2021). Similar to fruit flavors, sweet flavors have long been used in tobacco products to mask harshness and increase appeal. However, data on the role of these flavor types for WT initiation and continued use are needed.

Despite guidance in the FCTC to restrict or prohibit flavors as a means to reduce product appeal, global adoption of such policies is limited. As of 2019, only 11 countries and the European Union have enacted restrictions on the sale of flavored tobacco (Erinoso et al., 2020). Of those, three countries (USA, Moldova, and Turkey) and the European Union only restrict flavors in cigarettes and roll-your-own products. Six countries (Brazil, Ethiopia, Mauritania, Nigeria, Senegal, and Uganda) restrict flavors from products made or derived from the tobacco leaf. One country, Singapore, prohibits fruit flavors only in WT products. Given that the FCTC has 168 Signatories, there is much progress to be made regarding flavor restrictions, especially for WT, which is rarely the focus of such policies.

Limitations.

Although we believe our process was exhaustive in identifying available WT products, we may have missed WT brands or flavors. Our search may have been influenced by Google’s algorithms that utilize information from previous searches on each computer to generate results. However, at the time of the study there was no publicly available database of WT brands or flavors. This study was limited to WT brands sold online in the USA and may not be representative of the global market. Our study coded the flavor names from the text flavor descriptors only and did not include imagery on the packaging that may provide consumers with information about flavor. Finally, we collected data on available brands in 2020; thus more brands and flavors could have entered the USA market since then. Continued surveillance of the WT market is needed.

Conclusion.

Results from this study show that WT is available for online sale in the USA in over 1,800 unique flavors across 66 brands, including flavors known to be attractive to youth. Like other tobacco products, fruit and mint/menthol were the most commonly used flavor descriptors. In addition, over a quarter of the flavors were coded as concept flavors, suggesting the industry may try to circumvent USA, state and local regulations that restrict explicit flavors. The role of flavors in encouraging youth cigarette smoking led to the federal ban of characterizing flavors, other than menthol, in cigarettes. If the FDA goes forward with action announced in April 2022 to prohibit menthol in cigarettes and ban all explicit flavors, including menthol, in cigar products (USA Department of Health and Human Services, Food and Drug Administaion, Center for Tobacco Products, 2022), WT would become the only combustible tobacco product on the USA market that would still be available with explicit flavors. Given the health harms associated with WT use (Montazeri et al., 2017; Waziry et al., 2017), and the widespread use of flavored WT among youth and young adults (Villanti, Johnson, et al., 2017), the FDA should consider including WT in any regulatory action that would remove flavors from combustible tobacco products.

Data Availability:

Data are available upon reasonable request with a request to the corresponding author via email.