Flavors Are a Major Driver of the Youth E-Cigarette Epidemic

Considerable declines in cigarette smoking have occurred among US high school students over the past two decades: smoking declined from 30% in 2000 to 6% in 2019.¹ However, e-cigarette use has increased substantially over the past decade, with current use among high school students increasing from about 1% in 2011 to nearly 28% in 2019.¹ This increase was of greater magnitude in recent years, which coincided with the growing popularity of cartridge-based e-cigarettes known as “pod mods,” including those made by Juul, the market leader since 2017.² These newer products use nicotine salts, which allow higher levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine used in earlier e-cigarettes. Nicotine is an addictive drug that can harm adolescent brain development and prime the brain for addiction to other drugs.³

The increase in youth e-cigarette use has been driven by multiple factors, including advertising, high nicotine content, and the availability of flavors that appeal to youths.³ Youths report that flavors are a primary reason they use e-cigarettes, and most youth e-cigarette users first initiate use with flavored products.⁴ Among youth e-cigarette users in 2019, 70% reported using flavored varieties, making e-cigarettes the most common flavored tobacco product used among youths.¹

Under authority from the 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA), the Food and Drug Administration issued a policy in January 2020 that prioritized enforcement against certain unauthorized cartridge-based e-cigarette flavors that appeal to youths, including fruit and mint. The policy was informed by available data, including from (1) a study of high school students that found the most commonly reported flavors used by current exclusive e-cigarette users were fruit (66%) and menthol or mint (57%),⁵ and (2) a study that assessed mint and menthol separately that found that among current Juul users in 8th, 10th, and 12th grades, the self-reported use of mint-, mango-, and other fruit–flavored e-cigarettes was greater than the use of tobacco- or menthol-flavored e-cigarettes.⁶ The FSPTCA does not preempt states and localities from adopting more restrictive regulations than the federal standard in some instances. Accordingly, several communities have restricted flavored e-cigarette sales, including menthol; additionally, Massachusetts and New Jersey have enacted legislation prohibiting all flavored e-cigarette sales, and beginning in late 2019, seven other states issued executive or emergency actions to temporarily prohibit flavored e-cigarette sales, some of which were overturned after legal challenges (www.tobaccofreekids.org/assets/factsheets/0398.pdf).

Evaluation of these policies is critical to ascertain their impact on youth e-cigarette use. Such studies will also be important to identify any potential unintended consequences, including transitions to other tobacco products, e-cigarette types, or flavors excluded from some policies. In addition to annual self-reported surveys of youths, subannual assessments—including retail sales data from commercial databases and self-reported data from existing or newly developed Web panels—can quickly inform policy refinements that may be warranted to best protect public health.

We are at the precipice of a critical period in the history of tobacco control. Cigarette smoking has declined, but this progress has been offset by increased youth e-cigarette use.¹ The situation has been compounded by the recent outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI), which has mostly affected young adults and is strongly linked to vitamin E acetate in tetrahydrocannabinol-containing products from informal sources.⁷ Although both the EVALI and youths’ use epidemics have warranted urgent public health action, efforts to address each must focus on their drivers.⁷ To effectively combat the youth e-cigarette epidemic, efforts at the national, state, and local levels are critical to make flavored e-cigarettes less acceptable, accessible, and appealing to youths.³ It is important that such efforts are part of a comprehensive approach alongside other evidence-based population-level strategies.³