Abstract
Objective:
Banning flavors in select tobacco products, while allowing in others, may shift consumer preferences towards products in which flavors are still allowed. This study examines flavor popularity and inconsistencies in flavor preference across non-cigarette tobacco products among US adults.
Methods:
Data from the Population Assessment of Tobacco and Health Study Wave 3 were used to assess the prevalence of flavor preference for users of non-cigarette tobacco products (N = 9,037), as well as flavor inconsistencies between products among polyusers (N = 3,183).
Results:
Most users of flavored tobacco products reported using one flavor category per product. Fruit and tobacco were among the most commonly used flavor categories of ENDS, hookah, traditional cigars, and cigarillo/filtered cigars. Menthol/mint was the most common flavor among snus/smokeless users. Polyusers of ENDS and traditional cigars had the largest inconsistency, where about 68–76% used different flavors across products. Conversely, polyusers of traditional cigars and cigarillos/filtered cigars had the lowest inconsistency (25–28%).
Conclusions:
Flavor preferences differed according to product suggesting that consumers are not likely to switch across products to maintain a flavor preference. Future research should assess flavor preferences prospectively to better understand potential benefits of flavor bans.
Keywords: flavors, electronic nicotine delivery systems (ENDS), cigars, hookah, smokeless
Characterizing flavors, excluding tobacco and menthol, were banned in cigarettes by the United States Food and Drug Administration (US FDA) following the Family Smoking Prevention and Tobacco Control Act of 2009.1 Although the FDA now has the authority to ban characterizing flavors in non-cigarette tobacco products marketed in the US as per the Deeming Rule of May 2016,2 this policy was not immediately extended to currently marketed other non-cigarette tobacco products. However, some states (eg, New Jersey, New York, and Rhode Island) and localities (eg, Chicago, and Santa Clara County) did ban characterizing flavors in electronic nicotine delivery systems (ENDS).3–8 Furthermore, following the spike in cases of lung injury and deaths associated with the use of ENDS,9 several states and localities have issued emergency rules banning the sale of flavored ENDS.10 Recently, the FDA prioritized the enforcement of the sale of flavored cartridge-based ENDS, except tobacco or menthol, while leaving other ENDS and flavored tobacco products alone to ensure that manufacturers are taking the proper precautions to minimize youth access.11
Flavors are added to tobacco products in part to mask the harsh taste of tobacco or nicotine.12–17 This facilitates consumer initiation and continuation of tobacco use. 12–17 It has been reported that flavored tobacco products are viewed as more favorable than unflavored products, as they increase satisfaction, create a better feel and taste, and allow consumers to customize their experience.18–20 Previous studies have shown that young adult ENDS users (generally 18–30 years of age) are more attracted to sweet flavors (eg, fruit and candy).21–26 Similar patterns can be seen among adult vapers, though more bitter flavors (eg, menthol/mint27 and tobacco12–17) are also common among adults,28,29 especially smokers.26 ENDS, however, are not the only tobacco products that are available in flavors. ENDS, as well as smokeless tobacco, hookah, and cigarillos/cigars are available in flavors. In 2013–2014, more than 50% of adults reported trying flavored hookah or snus before the age of 18 years.30 First time use of a flavored cigar, especially cigarillos and filtered cigars, was also prevalent among the youth and young adult population.30,31 Furthermore, about 60% of current cigarillo and filtered cigar users reported using a flavored product.32 It has been shown that sweeter flavors, such as fruit, candy/other sweets, chocolate or alcohol-flavors, are popular among young adult hookah and cigar users,33,34 while mint flavored snus is preferred by combustible cigarette smokers.35
Public health officials continue to gather data on the use of flavored tobacco products to determine if the flavor ban should be extended beyond that of flavored cartridge-based ENDS. However, the ban on flavored cartridge-based ENDS or the implementation of any extension to this ban will likely alter the tobacco market share. As of 2018, about 49.1 million or 19.7% of US adults reported currently using any tobacco products.36 Cigarettes were the most prevalent tobacco product used with 13.7% of US adults using cigarettes followed by cigars (3.9%), ENDS (3.2%), smokeless tobacco (2.4%), and the use of regular pipe, water pipe or hookah (1.0%).36 Although any form of flavor ban is likely implemented to reduce appeal and, therefore, overall prevalence of use, the ban on flavored cartridge-based ENDS may not result in a change in ENDS use, but rather a shift in the type of ENDS device used (eg, open, modifiable ENDS devices). In the event of a more intense ban on all flavored ENDS, the market share of tobacco use may shift to other products that are still available in flavors (eg, cigars or smokeless tobacco).
The availability of flavored tobacco products is known to be a top reason for using non-cigarette tobacco products.31,37,38 The flavor additives used in various tobacco products could differ in quality; hookah tobacco may be flavored with natural additives, such as fruit and honey, while e-liquid may be artificially flavored. The quality of flavor additives in various tobacco products could alter the sensory perception among consumers, and therefore, alter flavor preference between tobacco products. In the event of a partial flavor ban, such as the ban of flavored cartridge-based ENDS, the observation of shifts in the tobacco market is likely. Although we would expect a reduction in the prevalence of use,39,40 the use of other tobacco products that are still available in flavors could also be expected,39,41–43 which would continue to pose a risk to the public health.44 Therefore, understanding consistencies in flavor preference across products may portend switching to another product with a comparable flavor rather than remaining loyal to the current product. To our knowledge, the flavor preference across various tobacco products and among polytobacco users has not been assessed beyond flavor use among cigarette and ENDS users.45 Using data from Wave 3 (W3) of the Population Assessment of Tobacco and Health (PATH) Study, the purpose of this study was to 1.) examine the popularity of flavors among exclusive and polytobacco users of various type of flavored tobacco products, and 2.) analyze inconsistencies in flavor preference among polytobacco users of different types of flavored tobacco products in the US.
METHODS
Study Design and Population
The PATH Study is a nationally representative, longitudinal cohort study of tobacco use and its health effects among non-institutionalized adults and youth in the US, through the National Institute of Health and the US FDA. Data from W3 of the PATH Study were collected between October 19, 2015 and October 23, 2016 among 28,148 adult and 13,651 youth respondents. More information about the PATH Study design and methods can be found elsewhere.46 This analysis provides W3 cross-sectional estimates from 9,037 adult flavored tobacco users. Analyses were done to assess the popularity of flavors of various non-cigarette tobacco products, as well as inconsistencies in preferred flavor across various non-cigarette tobacco products, among adult users of multiple flavored tobacco products.
Flavored Tobacco Product Use
Adult participants were asked to report on their tobacco product use. Products of interest included ENDS, traditional cigars, cigarillos, filtered cigars, hookah, snus, and smokeless tobacco. Variables were derived by Westat for use of each tobacco product, which included current established users (have ever used the product fairly regularly and currently use them every day or some days), current experimental users (never used the product fairly regularly, and currently use them every day or somedays), non-current 30-day users (former experimental, new former, or still former established users in W3 who have used the product in the past 30 days), and new former established users (former established user; were current established or current experimental users in W2, have ever used the product fairly regularly, and did not use them in the past 12 months or currently use them not at all). Cigarettes were excluded from the analysis of flavor inconsistencies since they are not marketed in flavors other than menthol.
All participants who reported current, established or experimental use, were former established users, or non-current 30-day users (as defined by Westat) of ENDS, traditional cigars, cigarillos, filtered cigars, hookah, snus, or smokeless tobacco were asked to report on the regular flavor of their tobacco product(s). Participants who reported ENDS use could choose from tobacco, menthol/mint, clove/spice, fruit, chocolate, an alcoholic drink, a non-alcoholic drink, candy/desserts/other sweets, or some other flavor. Participants who reported using traditional cigars, cigarillos, filtered cigars, or hookah could choose from menthol/mint, clove/spice, fruit, chocolate, an alcoholic drink, candy/other sweets, or some other flavor. Finally, those who reported using snus or smokeless tobacco could choose menthol/mint, wintergreen/spearmint/frost, clove/spice, fruit, chocolate, alcoholic drinks, candy/other sweets, or some other flavor. Tobacco flavor was only explicitly offered as a flavor option among those who used an ENDS as the other tobacco products are by default tobacco flavored. Therefore, if users of traditional cigars, cigarillos, filtered cigars, hookah, snus or smokeless answered no to, “[Is/Was] [your regular brand/the last brand] you [use/used] flavored to taste like menthol, mint, clove, spice, fruit, chocolate, alcoholic drinks, candy or other sweets?” then they were assumed to use tobacco flavor. For the purpose of this analysis, menthol/mint and wintergreen/spearmint/frost were combined (menthol/mint from here on), as well as an alcoholic drink and a non-alcoholic drink (beverage from here on), to allow for common flavor categories across products.
Statistical Analysis
The prevalence of reported flavor categories were assessed according to tobacco products among users of one or more flavored tobacco products. A stratified analysis was also conducted according to age (young adults versus older adults) among those using one or more flavored tobacco products.47 The probability of reporting a flavor category for a particular product among all adult users of flavored tobacco products was assessed using generalized estimating equations (GEE) to account for polyuse. Models used a logit link function and an unstructured correlation matrix. Models were adjusted for sex, age race/ethnicity, and cigarette smoking and smoking of regular or menthol cigarettes. Adjusted odds ratios (aORs) and 95% confidence intervals (95%CI) are reported. We also assessed prevalence in flavor preference inconsistencies among adult polytobacco users. An inconsistency in flavor preference was identified when a polytobacco user reported a different flavor(s) for each of their reported tobacco products. Therefore, the prevalence in flavor preference inconsistencies represents the number of participants that reported use of a specific flavor for one of the products in the comparison, but not the other. For this, each flavor category was evaluated individually. Analyses were conducted using Stata 16 software (StataCorp LLC, College Station, TX, USA) with W3 replicate weights and balanced repeated replication methods with Fay’s adjustment of 0.3.
RESULTS
Demographic and Smoking Behavior Characteristics
A total of 9,037 adults used one or more flavored non-cigarette tobacco products. The highest percentages of tobacco users were 35–54 years of age (31.9%), male (67.5%), and Non-Hispanic White (77.5%). Just over half were current combustible cigarette smokers (54.9%) and used non-mentholated cigarettes (60.2%). When examining tobacco products that are available in characterizing flavors (ENDS, traditional cigars, cigarillos/filtered cigars, hookah, and snus/smokeless tobacco), most users reported using only one product (68.9%; see Table 1). ENDS only use was the most popular product (27.0%), followed by snus/smokeless only (13.2%). Traditional cigars and cigarillos/filtered cigars were the most popular products used in combination (5.4%), followed by ENDS and hookah (4.3%; see Figure 1 and Supplemental Table 1).
Table 1:
Demographic and Smoking Behavior Characteristics of Adult Users of Flavored Tobacco Products (N = 9,037) – The Population Assessment of Tobacco and Health Wave 3
| Characteristics | Tobacco Users |
|
|---|---|---|
| N | % | |
| Age, N(%) | ||
| 18–24 years old | 3208 | 23.2 |
| 25–34 years old | 2211 | 25.4 |
| 35–54 years old | 2354 | 31.9 |
| 55 years and older | 1264 | 19.5 |
| Sex, N(%) | ||
| Male | 5608 | 67.5 |
| Female | 3425 | 32.5 |
| Race/Ethnicity, N(%) | ||
| Non-Hispanic White | 6495 | 77.5 |
| Non-Hispanic Black | 1333 | 13.5 |
| Other | 997 | 9.1 |
| Cigarette Smoking Status, N(%) | ||
| Never | 2494 | 26.8 |
| Former | 1826 | 26.7 |
| Current | 4187 | 46.5 |
| Current Smoker Mentholation Status, N(%) | ||
| Non-Menthol | 2275 | 60.2 |
| Menthol | 1670 | 39.9 |
| Number of Tobacco Products Used, N(%) | ||
| 1 product | 5854 | 68.9 |
| 2 products | 2166 | 21.8 |
| 3 products | 730 | 6.7 |
| 4 products | 249 | 2.2 |
| 5 products | 38 | 0.4 |
| Type of Tobacco Products, N(%) | ||
| Used ENDS | 4676 | 62.2 |
| Used traditional cigars | 2169 | 43.3 |
| Used cigarillos/filtered cigars | 2875 | 57.5 |
| Used hookah | 1961 | 25.7 |
| Used snus/smokeless tobacco | 1881 | 29.5 |
Figure 1: Flavored Tobacco Products Used among Adult Tobacco Users (N = 9,037) - The Population Assessment of Tobacco and Health Wave 3.
NOTE: Only products that are available in characterizing flavors were analyzed; cigarettes were excluded from this analysis; the “other combinations” category prevalence ranged from 0.1% to 2.2%.
Flavor Use among All Adult Flavored Tobacco Users
Of the 9,037 adults who used one or more flavored non-cigarette tobacco products, 9,033 users provided flavor-related data. Most users of a flavored tobacco products reported only using one flavor category (ENDS: 79.9%; Traditional cigars: 95.6%; Cigarillos/filtered cigars: 87.8%; Hookah: 66.7%; Snus/smokeless: 96.0%). When examining those who only use one flavor category, tobacco and fruit were among the most common flavors reported alone. For users of traditional cigars (79.9%) and cigarillos/filtered cigars (59.3%), tobacco flavor was the most common, while fruit was the most common flavor category among users of ENDS (31.8%) and hookah (44.2%). Menthol/mint was the most common flavor reported alone by snus/smokeless users (53.2%). Menthol/mint was also among the top 3 flavors used alone for all of the other flavored tobacco products. When looking at users who reported 2 or more flavor categories, fruit was the most popular flavor category used in combination with other flavor categories for all tobacco products (ENDS: 79.7%; Traditional cigars: 68.0%; Cigarillos/filtered cigars: 61.8%; Hookah: 93.4%), except for snus/smokeless where menthol/mint was the most common (90.6%) flavor used in combination with other flavors. Candy/other sweets and menthol/mint were also commonly reported flavor combinations (see Table 2).
Table 2:
Flavor Category Use According to Flavored Tobacco Product among Adult Exclusive and Polytobacco Users (N = 9,033) – The Population Assessment of Tobacco and Health Wave 3
| Used ENDS | Used traditional cigars | Used cigarillos/ filtered cigars | Used hookah | Used snus/ smokeless tobacco | |
|---|---|---|---|---|---|
| N = 4,676 | N = 2,169 | N = 2,871 | N = 1,955 | N = 1,878 | |
| Number of flavor categories used, N(%) | |||||
| One flavor | 3667 (79.9) | 2047 (95.6) | 2499 (87.8) | 1316 (66.7) | 1793 (96.0) |
| 2 or more flavors | 1009 (20.1) | 122 (4.4) | 372 (12.2) | 639 (33.3) | 85 (4.0) |
| Flavor categories used alone, N(%) | |||||
| Tobacco | 801 (25.2) | 1578 (79.9) | 1417 (59.3) | 486 (36.3) | 734 (43.1) |
| Fruit | 1273 (31.8) | 143 (5.5) | 372 (13.1) | 580 (44.2) | 24 (1.3) |
| Menthol/mint | 651 (18.3) | 76 (3.4) | 206 (8.4) | 105 (8.9) | 995 (53.2) |
| Candy/other sweets | 663 (17.0) | 63 (2.7) | 118 (4.5) | 85 (5.9) | 5 (0.2) |
| Beverage | 121 (3.3) | 66 (2.6) | 172 (5.7) | 14 (0.9) | 5 (0.4) |
| Some other flavor | 87 (2.5) | 62 (3.2) | 89 (3.8) | 24 (2.3) | 23 (1.2) |
| Chocolate | 44 (1.2) | 35 (1.6) | 35 (1.3) | 14 (0.8) | 3 (0.4) |
| Clove/spice | 27 (0.7) | 24 (1.1) | 90 (3.9) | 8 (0.6) | 4 (0.2) |
| Flavor categories used in combination, N(%) | |||||
| Included tobacco | 212 (22.9) | ||||
| Included fruit | 819 (79.7) | 86 (68.0) | 239 (61.8) | 595 (93.4) | 55 (65.4) |
| Included menthol/mint | 341 (35.5) | 40 (32.7) | 154 (44.6) | 334 (55.5) | 77 (90.6) |
| Included candy/other sweets | 718 (69.9) | 59 (48.3) | 178 (46.2) | 391 (55.4) | 16 (19.2) |
| Included beverage | 213 (19.9) | 40 (34.3) | 133 (37.2) | 154 (21.5) | 10 (13.4) |
| Included some other flavor | 31 (2.7) | 31 (26.8) | 84 (21.2) | 79 (11.6) | 21 (23.0) |
| Included chocolate | 143 (14.7) | 45 (35.7) | 87 (25.9) | 94 (15.5) | 7 (8.4) |
| Included clove/spice | 56 (4.9) | 24 (20.7) | 80 (23.6) | 72 (11.5) | 1 (0.9) |
NOTE: Product categories are not mutually exclusive as both exclusive and polytobacco users are included. Tobacco flavor is only asked for those who reported ENDS use since the other tobacco products are by default tobacco flavored. It was assumed that those who responded that their product was not flavored are using a tobacco-flavored product. Therefore, only consumers of ENDS can use tobacco flavor in combination with another flavor (indicated by the greyed cells).
Significant differences in prevalence of regular flavor categories reported according to tobacco product among adults using one or more flavored tobacco products were seen when stratified by age. Tobacco flavor was significantly more prevalent among older adults (≥25 years of age; 32–78%) compared to young adults (18–24 years; 8–70%) for all tobacco products except for hookah (26.6% versus 21.9%, respectively). On the other hand, fruit flavors were significantly more prevalent among young adults (13–64%) compared to older adults (7–58%) for all tobacco products except for snus/smokeless (4.0% versus 4.2%, respectively). Menthol/mint flavor was significantly more prevalent among older adults compared to young adults when looking at ENDS (23.7% versus 17.0%, respectively) and cigarillos/filtered cigars (14.8% versus 9.7%). Conversely, menthol/mint was significantly more prevalent among young adults (72.5%) compared to older adults (54.2%) who were snus/smokeless tobacco users (see Supplemental Table 2).
When comparing traditional cigars to ENDS, users of traditional cigars had significantly greater odds of reporting use of some other flavor (aOR: 1.77; 95%CI: 1.25, 2.50). However, users of traditional cigars had significantly lower odds of reporting use of a fruit (aOR: 0.17; 95%CI: 0.14, 0.21), menthol/mint (aOR: 0.21; 95%CI: 0.16, 0.26), or candy/other sweets (aOR: 0.18, 95%CI: 0.14, 0.23) flavor when compared to ENDS users. Similarly, users of cigarillos/filtered cigars had significantly greater odds of reporting use of a beverage flavor (aOR: 1.36; 95%CI: 1.10, 1.69), some other flavor (aOR: 2.21; 95%CI: 1.65, 2.96), and clove/spice (aOR: 3.99; 95%CI: 2.78, 5.74) compared to ENDS users. On the other hand, users of cigarillos/filtered cigars had significantly lower odds of reporting using a fruit flavor (aOR: 0.34; 95%CI: 0.30, 0.39), menthol/mint (aOR: 0.38; 95%CI: 0.32, 0.46), a candy/other sweets flavor (aOR: 0.24; 95%CI: 0.20, 0.30) compared to ENDS users. Users of hookah had significantly higher odds of reporting use of a fruit flavor (aOR: 1.70; 95%CI: 1.49, 1.94), some other flavor (aOR: 2.01; 95%CI: 1.42, 2.84), a chocolate flavor (aOR: 1.37; 95%CI: 1.02, 1.85), and clove/spice (aOR: 2.64; 95%CI: 1.72, 4.05) compared to ENDS users. Conversely, users of hookah had significantly lower odds of reporting using a candy/ other sweets flavor (aOR: 0.59; 95%CI: 0.51, 0.69) compared to ENDS users. Finally, users of snus/smokeless tobacco had a lower odds of reporting use of a fruit flavor (aOR: 0.07; 95%CI: 0.05, 0.09), a menthol/mint flavor (aOR: 0.26; 95%CI: 0.20, 0.35), a candy/other sweets flavor (aOR: 0.02; 95%CI: 0.01, 0.04), a beverage flavor (aOR: 0.13; 95%CI: 0.07, 0.26), a chocolate flavor (aOR: 0.21; 95%CI: 0.08, 0.56), and clove/spice (aOR: 0.25; 95%CI: 0.08, 0.81; see Table 3).
Table 3:
Flavor Use According to Tobacco Product among Adult Polytobacco Users (N = 9,033) - The Population Assessment of Tobacco and Health Wave 3
| Traditional Cigar vs. ENDS |
Cigarillos/Filter cigars vs. ENDS |
Hookah vs. ENDS |
Smokeless vs. ENDS |
|||||
|---|---|---|---|---|---|---|---|---|
| Crude OR (95%CI) |
Adjusted ORa (95%CI) |
Crude OR (95%CI) |
Adjusted ORa (95%CI) |
Crude OR (95%CI) |
Adjusted ORa (95%CI) |
Crude OR (95%CI) |
Adjusted ORa (95%CI) |
|
| Fruit |
0.15 (0.12, 0.17) |
0.17 (0.14, 0.21) |
0.31 (0.28, 0.35) |
0.34 (0.30, 0.39) |
2.02 (1.79, 2.28) |
1.70 (1.49, 1.94) |
0.06 (0.04, 0.07) |
0.07 (0.05, 0.09) |
| Mint/Mentholb |
0.23 (0.19, 0.28) |
0.21 (0.16, 0.26) |
0.43 (0.36, 0.50) |
0.38 (0.32, 0.46) |
1.14 (0.99, 1.32) |
1.16 (0.98, 1.37) |
0.21 (0.16, 0.27) |
0.26 (0.20, 0.35) |
| Candy/sweets |
0.15 (0.12, 0.18) |
0.18 (0.14, 0.23) |
0.23 (0.19, 0.28) |
0.24 (0.20, 0.30) |
0.72 (0.63, 0.83) |
0.59 (0.51, 0.69) |
0.02 (0.01, 0.04) |
0.02 (0.01, 0.04) |
| Beverage |
0.72 (0.56, 0.92) |
0.84 (0.64, 1.09) |
1.21 (0.99, 1.48) |
1.36 (1.10, 1.69) |
1.13 (0.89, 1.43) |
0.99 (0.77, 1.26) |
0.09 (0.05, 0.18) |
0.13 (0.07, 0.26) |
| Other flavor |
1.86 (1.35, 2.56) |
1.77 (1.25, 2.50) |
2.23 (1.68, 2.97) |
2.21 (1.65, 2.96) |
2.17 (1.59, 2.95) |
2.01 (1.42, 2.84) |
0.68 (0.43, 1.06) |
0.76 (0.47, 1.22) |
| Chocolate | 0.87 (0.65, 1.16) |
0.98 (0.71, 1.35) |
0.83 (0.60, 1.15) |
0.92 (0.66, 1.29) |
1.46 (1.09, 1.95) |
1.37 (1.02, 1.85) |
0.16 (0.07, 0.41) |
0.21 (0.08, 0.56) |
| Clove/Spice | 1.37 (0.89, 2.11) |
1.46 (0.91, 2.34) |
3.51 (2.55, 4.82) |
3.99 (2.78, 5.74) |
2.60 (1.79, 3.78) |
2.64 (1.72, 4.05) |
0.27 (0.10, 0.73) |
0.25 (0.08, 0.81) |
NOTE: Bolded point estimates indicates statistical significance at p < 0.05
Adjusted for age, sex, race/ethnicity, and cigarette smoking
The adjusted menthol model was adjusted for age, sex, race/ethnicity, cigarette smoking status/current menthol status
Flavor Inconsistency across Flavored Products among Polytobacco Users
There were 3,183 (31.1%) users who used 2 or more tobacco products that are marketed in characterizing flavors. There were 26 unique product combinations. When exploring the inconsistency between preferred flavor(s), those using traditional cigars and cigarillos/filtered cigars had the least amount (29%) of flavor inconsistency. Conversely, no user of combined ENDS, hookah and snus/smokeless used the same flavor(s). This was also true those using combined ENDS, traditional cigars, hookah and snus/smokeless. For the other 23 unique product combinations, 59.2–98% of users used a different flavor(s) when using various products (see Figure 2).
Figure 2: Flavor Category Combination Inconsistencies between Tobacco Product Combinations Used among Polytobacco Users (N = 3,183) – The Population Assessment of Tobacco and Health Wave 3.
NOTES: Abbreviations: E: ENDS, TC: Traditional cigars, LC: Cigarillos/Filtered cigars, H: Hookah, S: Snus/Smokeless, All Products: ENDS, Traditional cigars, Cigarillos/Filtered cigars, Hookah and Snus/Smokeless.
When examining across pairs of products for each flavor category, those who used ENDS and traditional cigars had the largest inconsistency in flavor category use. For each flavor category, 68.2–76.3% of users reported using a flavor category for one product but not the other. Users of traditional cigars and hookah showed a considerable amount of flavor inconsistency across products (56.0–64.1%). Similarly, users of traditional cigars and smokeless/snus had a considerable level of flavor inconsistency (50.8–63.1%). Users of cigarillos/filtered cigars and hookah, as well as users of cigarillos/filtered cigars and snus/smokeless tobacco, showed moderate level of flavor inconsistency for most flavor categories (with hookah: 34.2–43.2%; with snus/smokeless tobacco: 43.0–46.5%). The exceptions were the fruit category where there was a considerable amount of inconsistency (with hookah: 50.7%; with snus/smokeless tobacco: 56.0%), as well as menthol/mint for cigarillos/filtered cigars and snus/smokeless tobacco (67.8%). Hookah and snus/smokeless showed low to moderate levels of flavor inconsistency (27.3–39.7%), except for the fruit category (67.0%) and menthol/mint (68.8%). Users of ENDS and snus/smokeless tobacco showed moderate level of flavor inconsistency, except for fruit flavor where they showed considerable inconsistency (58.7%) and low levels of inconsistency for clove/spice (27.8%) across products. ENDS and hookah users showed low to moderate level of inconsistency in flavor use (25.6–47.4%). The lowest amount of inconsistency was seen for all flavor categories among users of traditional cigars and cigarillos/filtered cigars (25.1–28.1%; see Table 4).
Table 4:
Inconsistencies in Flavor Categories between Flavored Tobacco Products among Adult Polytobacco Users Only (N = 3,183) – The Population Assessment of Tobacco and Health Wave 3
| Flavor, N(%) | ENDS v. Traditional Cigars | ENDS v. Cigarillos/ Filtered cigars | ENDS v. Hookah | ENDS v. Smokeless | Traditional cigars v. Cigarillos/ Filtered cigars | Traditional cigars v. Hookah | Traditional Cigars v. Smokeless | Cigarillos/ Filtered cigars v. Hookah | Cigarillos/ Filtered cigars v. Smokeless | Hookah v. Smokeless |
|---|---|---|---|---|---|---|---|---|---|---|
| N = 677 | N = 1,101 | N = 955 | N = 548 | N = 1,021 | N = 374 | N = 393 | N = 531 | N = 420 | N = 210 | |
| Fruit | 508 (76.3) | 687 (62.8) | 448 (47.4) | 332 (58.7) | 304 (28.1) | 217 (64.1) | 227 (56.1) | 262 (50.7) | 235 (56.0) | 134 (67.0) |
| Mint/menthol | 484 (73.1) | 596 (55.0) | 388 (39.8) | 447 (80.4) | 281 (26.1) | 203 (57.6) | 258 (63.1) | 203 (40.0) | 285 (67.8) | 144 (68.8) |
| Candy/sweets | 495 (74.9) | 641 (58.8) | 449 (45.6) | 270 (47.8) | 293 (26.7) | 207 (60.2) | 214 (54.1) | 227 (43.2) | 183 (45.3) | 82 (39.7) |
| Beverage | 477 (70.6) | 603 (55.1) | 304 (31.4) | 172 (31.3) | 277 (25.5) | 201 (57.4) | 211 (52.6) | 213 (40.8) | 189 (46.5) | 59 (27.3) |
| Other flavor | 453 (69.2) | 51 (47.9) | 263 (26.4) | 165 (31.2) | 269 (25.3) | 195 (56.0) | 203 (50.8) | 183 (34.2) | 177 (44.0) | 59 (28.5) |
| Chocolate | 459 (69.2) | 403 (47.3) | 275 (27.5) | 163 (31.2) | 273 (25.1) | 204 (58.3) | 201 (51.6) | 179 (34.9) | 164 (43.0) | 56 (29.1) |
| Clove/Spice | 444 (68.2) | 521 (49.3) | 264 (25.6) | 148 (27.8) | 273 (25.2) | 197 (58.1) | 201 (51.4) | 201 (40.0) | 173 (44.6) | 61 (30.2) |
NOTE: The prevalence of inconsistencies represents the percent of consumers who report using the flavor category for one of the products but not the other. Five flavored tobacco product users were missing data for regular flavor.
DISCUSSION
Most adults who were a recent former user or are currently using flavored tobacco, alone or in combination, reported using only one tobacco product. ENDS was the most popular tobacco product to be used alone, and traditional cigars and cigarillos/filtered cigars was the most common product combination. In addition, most tobacco users reported using only one flavor category. Fruit and tobacco flavors were among the top individually reported flavor categories across all tobacco products, while fruit was the most popular flavor category to be reported in combination with other flavors. Finally, significant inconsistencies in flavor preference across products were found for polytobacco users in which adults who reported using 2 or more tobacco products appeared to report using a specific flavor for one tobacco product but not the other. Users of traditional cigars and cigarillos/filtered cigars had the lowest amount of inconsistency in flavor category preference, while moderate to high inconsistency was seen in most cases across other products of interest. However, there are some specific combinations where there is not a significant inconsistency in flavor preference across products (eg, candy/other sweets and menthol/mint for traditional cigars vs. ENDS).
About 31% of consumers reported using 2 or more non-cigarette tobacco products, which aligns with previous research.48 The availability of flavored tobacco products has been shown to be associated with dual or polytobacco use.30,37 Few flavor preferences were consistent across products. However, where they were consistent could suggest that users may maintain flavor loyalty if that flavor were to be eliminated in their current product. On the other hand, significant inconsistencies in flavor preference across products could suggest that users may maintain product loyalty. The inconsistencies in flavor preference may be due to the quality of flavor additives, or simply the amount of variability in available flavors. Both of these outcomes were observed with the US implementation of a ban on non-menthol flavors in cigarettes, in that the sale of other flavored tobacco products and the market share of menthol cigarettes increased following the ban.49,50
Although the PATH study has strong external validity, internal validity, and retention rates, there are some limitations to note. First, the PATH study has a large overall sample size, but this study had limited statistical power to assess certain flavors that are used by a relatively small percentage of the sample (eg, clove/spice), as well as certain covariates. Second, the flavor options provided are flavor categories. Therefore, we cannot distinguish if multiple specific flavors that fall under the same category (eg, strawberry and blueberry) were used. Third, the flavor category participants select for their flavor is based on personal perception (eg, apple pie may be listed as a candy/other sweets only, or as fruit and candy/other sweets). Fourth, studies have observed changes in flavor preferences.25,26 Future studies should identify a systematic method to identify flavor use, such as the e-liquid flavor wheel suggested by Krusemann, et al.,51 and follow flavor preferences over time to identify changes in preference. Finally, we cannot identify the flavor additives used to create a single flavor profile. The quality and type of additives used between tobacco products could differ greatly, which could impact flavor preference among various tobacco products. In the future, the association of cigarette use and preferred flavor of each non-cigarette tobacco product should be assessed further.
This analysis will inform future research, which should assess flavor preferences prospectively to better understand potential benefits of the current policy on flavored cartridge-based ENDS,11 as well as potential future flavor bans or policies, in order to better understand the pattern of switching between tobacco products, especially among those who have used or currently use multiple tobacco products. Previous studies have indicated that a partial ban on flavored ENDS would reduce the use of ENDS,39,40 but the use of other tobacco products that are still available in flavors would also be expected.39,41–43 Our finding of significant differences in flavor preference according to product suggest that there is an association of particular flavorings to particular tobacco products. Therefore, with the enforcement of the sale of flavored cartridge-based ENDS that are appealing to children,11 consumers of non-cigarette tobacco products may not be likely to switch across products in order to maintain use of a particular flavor category given the currently available flavors. For example, the JUUL flavor ban may have resulted in the switching to disposable ENDS that do have flavors. However, more than 30% of participants have used 2 or more flavored tobacco products fairly regularly at some point in their lifetime. Therefore, these participants may be more inclined to continue or switch products to maintain their nicotine addiction. In addition, a longitudinal study25 that examined changes in flavor use in response to hypothetical flavor bans found that about 50% of the participants would “find a way” to buy their preferred flavor or aftermarket flavor additives.25 This continued use of tobacco products would still pose a risk to public health,44 and future policies should then be implemented. Although our data do not suggest that users will switch non-cigarette tobacco products to maintain flavor preference, past research has indicated that use of other products is likely, as well as consumers finding a way to maintain the use of their flavor.
Supplementary Material
Acknowledgments
Funding/Support
This work was supported by the US Food and Drug Administration and National Cancer Institute (U54CA238110) and by the University of Rochester CTSA award number TL1 TR002000 from the National Center for Advancing Translational Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the US Food and Drug Association.
Human Subjects Statement
The Population Assessment of Tobacco and Health Study was approved by the Westat Institutional Review Board.
Conflict of Interest Statement
MLG receives fees for serving on an advisory board from Johnson & Johnson and grant support from Pfizer. All other authors did not have any conflicts to report.
Contributor Information
Liane M. Schneller, Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY.
Dongmei Li, Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY.
Zahíra Quiñones Tavárez, Translational Biomedical Science, University of Rochester Medical Center, Rochester, NY.
Maciej L. Goniewicz, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
Amanda J. Quisenberry, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
Zidian Xie, Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY.
Irfan Rahman, Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY.
Scott McIntosh, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY.
Richard J. O’Connor, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
Deborah J. Ossip, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY.
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