Abstract
This study examines the recent changes in self-reported flavored tobacco product use among youth tobacco users between 2014 and 2017.
Although characterizing flavors other than menthol in cigarettes is prohibited in the United States,1 flavored noncigarette tobacco products are widely available, and flavoring has become 1 of the leading reasons for current tobacco use among youths.2 In 2018, the US Food and Drug Administration issued an advance notice of proposed rulemaking on regulation of flavors in tobacco products.3 This study examined the changes in self-reported flavored tobacco product (FTP) use among youth tobacco users between 2014 and 2017.
Methods
The National Youth Tobacco Survey is a cross-sectional and school-based annual survey of middle school and high school students in the United States. The survey was conducted using a stratified, 3-stage cluster sampling procedure. The overall response rates for participating schools and students were 73.3%, 63.4%, 71.6%, and 68.1% for the 2014, 2015, 2016, and 2017 National Youth Tobacco Survey, respectively.4 The University of Nebraska Medical Center institutional review board determined that this study was exempted given the use of deidentified data. For this reason, informed consent was not obtained.
Current use of any tobacco was defined by use of any tobacco products at least 1 day in the last 30 days. Students who reported using menthol cigarettes or any flavored noncigarette tobacco product(s) were categorized as FTP users.
Weighted estimates and 95% confidence intervals of FTP use among current tobacco users were calculated using survey weights and stratum to account for the complex survey design. Changes in prevalence of FTP use and product-specific flavor use patterns (eg, electronic cigarettes, cigars, and hookah) were calculated across years. Logistic regression was conducted to examine the trends and factors associated with the FTP use. Statistical analyses were performed using SAS, version 9.4 (SAS Institute Inc), and a 2-sided P value of less than .05 was considered statistically significant.
Results
The analysis included 78 265 participants from the combined 2014 to 2017 National Youth Tobacco Survey (girls, 49.2%; high school, 55.9%; non-Hispanic white, 57.0%; non-Hispanic black, 13.9%; and Hispanic, 23.9%). The prevalence of current use of any tobacco products decreased from 17.3% in 2014 to 13.6% in 2017.
Among current tobacco users, the prevalence of FTP use decreased significantly from 2014 (69.4%; 95% CI, 66.5%-72.3%) to 2016 (57.7%; 95% CI, 54.6%-60.7%) and rebounded from 2016 to 2017 (63.6%; 95% CI, 60.6%-66.5%) (Table). Product-specific flavor use exhibited different temporal patterns, with no change for menthol cigarette use, a decreasing and then increasing trend in flavored electronic cigarette use, and a decreasing and then leveling off trend in other flavored tobacco (cigar, hookah, and smokeless tobacco) use. In the multivariable analysis, the odds of FTP use among current tobacco users were higher in 2014, 2015, and 2017 than they were in 2016 (not shown in Table). Girls (vs boys), high school (vs middle school) students, non-Hispanic white individuals (vs nonwhite individuals), and dual/poly-tobacco (vs single-tobacco) users were more likely to report FTP use.
Table. Changes in Flavored Tobacco Use Among Current Tobacco Users, NYTS 2014-2017.
| Characteristic | Weighted % (95% CI) | |||||||
|---|---|---|---|---|---|---|---|---|
| Flavored Tobacco Use Among Current Tobacco Usersa | Change Across Years | |||||||
| 2014 (n = 3822) | 2015 (n = 3072) | 2016 (n = 2814) | 2017 (n = 2501) | 2016 vs 2014 | P Valueb | 2017 vs 2016 | P Valuec | |
| Overall | 69.4 (66.5 to 72.3) | 61.7 (59.1 to 64.3) | 57.7 (54.6 to 60.7) | 63.6 (60.6 to 66.5) | −11.7 (−16.0 to −7.5) | <.001d | 5.9 (1.7 to 10.1) | .007d |
| Product-specific flavor use | ||||||||
| Cigarettese | 53.6 (47.9 to 59.2) | 51.7 (45.6 to 57.7) | 47.8 (41.1 to 54.5) | 48.6 (43.5 to 53.8) | −5.8 (−14.9 to 3.4) | .21 | 0.9 (−7.8 to 9.5) | .84 |
| E-cigarettesf | 63.3 (59.8 to 66.8) | 41.9 (37.8 to 46.1) | 51.4 (47.8 to 55.1) | 58.7 (54.3 to 63.2) | −11.9 (−17.0 to −6.8)f | <.001d | 7.3 (1.5 to 13.1) | .01d |
| Cigarsg | 63.5 (59.3 to 67.6) | 61.1 (56.8 to 65.4) | 51.3 (47.2 to 55.5) | 49.0 (43.7 to 54.2) | −12.1 (−17.9 to −6.3) | <.001d | −2.4 (−9.2 to 4.4) | .49 |
| Hookahh | 60.6 (56.8 to 64.4) | 70.5 (65.6 to 75.5) | 37.4 (31.8 to 43.0) | 30.6 (24.5 to 36.6) | −23.2 (−30.0 to −16.4) | <.001d | −6.8 (−15.1 to 1.5) | .11 |
| Smokelessi | 63.5 (58.9 to 68.2) | 47.2 (42.1 to 52.3) | 46.8 (42.1 to 51.4) | 44.5 (38.3 to 50.7) | −16.8 (−23.6 to −10.0) | <.001d | −2.3 (−10.1 to 5.6) | .57 |
| Sex | ||||||||
| Male | 68.9 (65.6 to 72.2) | 60.5 (57.4 to 63.7) | 56.1 (52.5 to 59.6) | 63.6 (59.1 to 68.0) | −12.8 (−17.8 to −7.9) | <.001d | 7.5 (1.9 to 13.2) | .01d |
| Female | 70.0 (66.4 to 73.6) | 63.8 (59.9 to 67.7) | 60.1 (55.8 to 64.3) | 63.7 (59.8 to 67.7) | −10.0 (−15.4 to −4.5) | <.001d | 3.7 (−2.1 to 9.5) | .21 |
| Grade | ||||||||
| Middle school | 55.5 (47.1 to 63.9) | 51.7 (46.6 to 56.8) | 47.7 (43.0 to 52.5) | 54.6 (49.1 to 60.1) | −7.8 (−17.4 to 1.8) | .12 | 6.9 (−0.3 to 14.1) | .06 |
| High school | 72.8 (70.3 to 75.2) | 64.1 (61.4 to 66.8) | 60.3 (57.1 to 63.6) | 65.4 (62.0 to 68.9) | −12.4 (−16.5 to −8.4) | <.001d | 5.1 (0.4 to 9.8) | .03d |
| Race/ethnicity | ||||||||
| non-Hispanic white | 74.6 (71.7 to 77.5) | 65.8 (61.9 to 69.6) | 61.2 (57.6 to 64.9) | 68.3 (64.2 to 72.4) | −13.4 (−18.0 to −8.7) | <.001d | 7.1 (1.6 to 12.6) | .01d |
| non-Hispanic black | 54.0 (47.7 to 60.3) | 59.0 (53.4 to 64.7) | 46.8 (41.3 to 52.3) | 47.8 (41.2 to 54.5) | −7.2 (−15.5 to 1.1) | .14 | 1.0 (−7.8 to 9.8) | .82 |
| Hispanic | 66.0 (61.2 to 70.7) | 57.6 (54.0 to 61.2) | 54.9 (49.9 to 59.8) | 61.9 (57.3 to 66.4) | −11.1 (−18.0 to −4.2) | .002d | 7.0 (0.1 to 13.9) | .045d |
| Others | 64.9 (57.5 to 72.3) | 47.8 (40.7 to 55) | 52.8 (42.3 to 63.3) | 44.1 (29.4 to 58.8) | −12.1 (−24.8 to 0.7) | .07d | −8.8 (−26.1 to 8.6) | .34 |
| No. of tobacco products currently used | ||||||||
| 1 | 52.7 (48.9 to 56.4) | 42.0 (38.7 to 45.3) | 42.3 (38.5 to 46.1) | 51.4 (46.8 to 56.0) | −10.4 (−15.8 to −5.0) | <.001d | 9.2 (3.1 to 15.2) | .003d |
| 2 | 80.4 (77.2 to 83.6) | 74.6 (71.2 to 78.0) | 63.0 (56.9 to 69.0) | 68.9 (62.5 to 75.2) | −17.4 (−24.3 to −10.5) | <.001d | 5.9 (−3.0 to 14.8) | .19 |
| ≥3 | 92.4 (90.5 to 94.3) | 88.1 (84.1 to 92.1) | 84.2 (80.9 to 87.6) | 84.3 (79.9 to 88.7) | −8.2 (−12.0 to −4.4) | <.001d | 0.1 (−5.3 to 5.4) | .98 |
Abbreviations: e-cigarette, electronic cigarette; NYTS, National Youth Tobacco Survey.
Students who reported using menthol cigarettes or any flavored noncigarette tobacco product(s) were categorized as flavored tobacco users.
Logistic regression was performed to detect a linear trend from 2014 to 2016.
Logistic regression was performed to detect the difference from 2016 to 2017.
Indicates a statistically significant difference (P < .05).
The proportion of current cigarette smokers reported using menthol cigarettes in the past 30 days.
The proportion of current e-cigarette users reported using flavored e-cigarettes in the past 30 days. Flavored e-cigarette use significantly decreased from 2014 to 2015 (difference, −21.4%; 95% CI, −26.7% to −16.0%; P < .001) and significantly increased from 2015 to 2017 (difference, 16.8%; 95% CI, 10.6%-20.0%; P < .001).
The proportion of current cigar (ie, cigars, cigarillos, or little cigars) users reported using flavored cigars in the past 30 days.
The proportion of current hookah users reported using flavored hookahs in the past 30 days.
The proportion of current smokeless tobacco (ie, chewing tobacco, snuff, or dip) users reported using flavored smokeless tobacco in the past 30 days.
Discussion
This study found a significant decrease in FTP use from 2014 to 2016 among current youth tobacco users. The decrease could be owing to multiple factors, such as public education campaigns, changes in labeling on noncigarette tobacco products, and strategies to reduce youth access to flavored tobacco products.5,6 However, the decreasing trend did not continue, and FTP use rebounded significantly from 2016 to 2017. Further analyses of product-specific flavor use indicate that the rebound was largely owing to an increase of flavor use in electronic cigarettes. As flavor use in other tobacco products decreased or leveled off, flavored electronic cigarette use continued to increase from 2015 to 2017. Continuous surveillance of FTP use and efforts to decrease FTP use among youth are warranted.
The main limitations of the study are that FTP use is self-reported and it is subject to recall bias. The ambiguous labeling of characterizing flavor in some noncigarette tobacco products might introduce additional bias on reporting FTP use.6
References
- 1.Gostin LO. FDA regulation of tobacco: politics, law, and the public’s health. JAMA. 2009;302(13):1459-1460. [DOI] [PubMed] [Google Scholar]
- 2.Ambrose BK, Day HR, Rostron B, et al. . Flavored tobacco product use among US youth aged 12-17 years, 2013-2014. JAMA. 2015;314(17):1871-1873. doi: 10.1001/jama.2015.13802 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.US Food and Drug Administration Regulation of flavors in tobacco products, advance notice of proposed rulemaking (ANPRM). https://www.federalregister.gov/documents/2018/03/21/2018-05655/regulation-of-flavors-in-tobacco-products. Published March 21, 2018. Accessed September 10, 2018.
- 4.The Centers for Disease Control and Prevention Smoking and tobacco use: National Youth Tobacco Survey (NYTS). https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm. Accessed September 2, 2018.
- 5.Campaign for Tobacco-Free Kids Flavored tobacco products attract kids. https://www.tobaccofreekids.org/assets/factsheets/0383.pdf. Published August 21, 2018. Accessed September 10, 2018.
- 6.Viola AS, Giovenco DP, Miller Lo EJ, Delnevo CD. A cigar by any other name would taste as sweet. Tob Control. 2016;25(5):605-606. doi: 10.1136/tobaccocontrol-2015-052518 [DOI] [PMC free article] [PubMed] [Google Scholar]