INTRODUCTION
Prevalence of use of e-cigarettes among youth1 and adults2 in the U.S. continues to rise, and flavored tobacco product use is associated with initiation and subsequent use of tobacco products.3 However, little data exist on whether flavored e-cigarettes are associated with cigarette-cessation behaviors,4 including attempting to quit cigarette smoking and quit success among those who attempt to quit,5 though Buu et al.6 found that, among exclusive cigarette smokers, using flavored e-cigarettes 1 year later was associated with lower quantity of cigarette smoking. This study uses U.S. nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study to report on e-cigarette flavor use among adult past 30–day dual users of e-cigarettes and cigarettes, and to longitudinally evaluate the relationship between flavor use and attempting to quit cigarette smoking approximately 1 year later.
METHODS
Participants
The PATH Study is an ongoing, nationally representative, cohort study of adults and youth in the U.S. Data were collected October 2015–October 2016 (Wave 3) and December 2016–January 2018 (Wave 4) using audio computer-assisted self-interviews administered in English or Spanish. The PATH Study was conducted by Westat and approved by the Westat IRB. Respondents aged ≥18 years provided informed consent. Details on the PATH Study design are published elsewhere7 and access to the data is available at https://doi.org/10.3886/Series606.8 The authors analyzed restricted use data from adults who smoked cigarettes and used e-cigarettes (dual users) at least once in the past 30 days in 2015–2016 and had follow-up data in 2016–2017 (n=1,529; interview interval, approximately 1 year).
Measures
In 2015–2016, regular/last e-cigarette flavor use was categorized into: (1) only tobacco; (2) only menthol/mint; (3) only non-tobacco, non-menthol/minta; and (4) any combination of tobacco, menthol/mint, or other flavor. In 2016–2017, attempting to quit cigarette smoking was defined as having tried to quit completely in the past 12 months or currently not smoking cigarettes at all. Further details on these and other measures are provided in Table 1.
Table 1.
E-cigarette Flavor Use and Attempting to Quit Cigarette Smoking Among U.S. Adult Dual Users
| Attempted to quit cigarette smoking completely in the past 12 months, assessed in 2016/2017e |
|||
|---|---|---|---|
| Adult dual usersa in 2015/2016 | % (95% CI) | AORf (95% CI) | p-value |
| E-cigarette flavor useb | |||
| Only tobacco flavor (n=337, 25% of dual users) | 42.6 (37.0, 48.4) | ref | |
| Only menthol/mint flavor (n=246, 16% of dual users) | 41.3 (34.8, 48.1) | 0.9 (0.6, 1.4) | 0.784 |
| Only non-tobacco, non-menthol/mint flavor(s)c (n=784, 49% of dual users) | 45.8 (41.2, 50.4) | 1.0 (0.7, 1.4) | 0.872 |
| Any combination of tobacco, menthol/mint, or other flavor(s)d (n=162, 10% of dual users) | 49.2 (39.8, 58.6) | 1.3 (0.8, 2.0) | 0.297 |
| Overall (n=1,529) | 44.6 (41.8, 47.4) | – | – |
Notes: %, AOR, and 95% CIs are weighted; sample sizes are unweighted; average interview interval between 2015/2016 and 2016/2017 was 1 year.
Dual users were defined as those who smoked a cigarette and used an e-cigarette product (including e-cigarettes, vape pens, personal vaporizers and mods, e-cigars, e-pipes, e-hookahs and hookah pens) at least once in the past 30 days, and smoked at least 100 cigarettes in lifetime.
Respondents who had used an e-cigarette product in the past 30 days were asked: What flavor is [your regular brand/the brand you last used]*? Choose all that apply. Response options: tobacco-flavored; menthol or mint; clove or spice; fruit; chocolate; an alcoholic drink (such as wine, cognac, margarita or other cocktails); a non-alcoholic drink (such as coffee, soda, energy drinks, or other beverages); candy, desserts, or other sweets; some other flavor. E-cigarette flavor(s) used were categorized into 4 mutually exclusive groups: (1) tobacco-flavor only, (2) menthol/mint-flavor only, (3) non-tobacco, non-menthol/mint flavor(s) only, and (4) any combination of tobacco, menthol/mint, other flavor(s). *Those who reported having a regular brand were asked about flavor of regular brand; those who did not have a regular brand were asked about flavor of brand last used.
Only non-tobacco, non-menthol/mint flavor includes clove or spice; fruit; chocolate; an alcoholic drink (such as wine, cognac, margarita or other cocktails); a non-alcoholic drink (such as coffee, soda, energy drinks, or other beverages); candy, desserts, or other sweets; some other flavor. The majority (89%) of those who use only non-tobacco, non-menthol/mint flavor use fruit and/or candy, desserts, other sweets. Among those who used only fruit and/or candy, desserts, other sweets, prevalence of making a quit attempt was 46.7% (95% CI: 41.6, 51.9) and logistic regression analysis comparing this group to the only tobacco flavor group yielded AOR=1.0 (95% CI=0.7, 1.4).
Any combination of tobacco flavor, menthol/mint flavor, or other flavor(s) has the following distribution: 47% only menthol/mint flavor+non-tobacco flavor(s), 28% only tobacco flavor+non-menthol/mint flavor(s), 12% only tobacco flavor+menthol/mint flavor, 13% tobacco flavor+menthol/mint flavor+other flavor(s). The prevalence of making a quit attempt among those who used only menthol/mint flavor+non-tobacco flavor(s) was 43.7% (95% CI: 30.7, 57.6) and the prevalence of making a quit attempt among the rest of the combination group was 54.1% (95% CI: 42.0, 65.6).
At follow-up in 2016/2017, respondents were asked whether they now smoke cigarettes every day, some days, or not at all. Those who were dual users in 2015/2016 and reported smoking cigarettes not at all in 2016/2017 were not asked about having made a cigarette quit attempt in 2016/2017 but were coded as having attempted to quit cigarette smoking completely in the past 12 months since they were no longer smoking cigarettes at all. Those who were dual users in 2015/2016 and reported smoking cigarettes every day or some days in 2016/2017 were asked: In the past 12 months, have you tried to quit [cigarettes/tobacco] completely? Those who ever used at least one other non-e-cigarette tobacco product fairly regularly and currently use it every day or some days were asked in reference to trying to quit tobacco rather than in reference to trying to quit cigarettes. All those who responded yes to having tried to quit cigarettes/tobacco completely were coded as having attempted to quit cigarette smoking completely in the past 12 months.
Adjusted for age group (18–24, 25–39, 40–54, ≥55 years); sex (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic other (includes two or more races), Hispanic, not reported); sexual orientation (heterosexual, other/not reported); frequency of cigarette smoking (nondaily, daily); frequency of e-cigarette use (nondaily, daily); e-cigarette device type (disposable (i.e., not rechargeable), closed (i.e., rechargeable and uses cartridges), open (i.e., rechargeable, does not use cartridges, and refillable), not reported). All covariates assessed in 2015/2016.
Statistical Analysis
Among adult dual users, prevalence of e-cigarette flavor use was determined in 2015–2016, and rates of attempting to quit cigarette smoking in the past 12 months were determined in 2016–2017 for each e-cigarette flavor use category. Logistic regression analysis was used to evaluate the association between flavor use and attempting to quit, adjusting for demographics, cigarette smoking frequency, e-cigarette use frequency, and e-cigarette device type. Analyses were weighted to produce nationally representative estimates and CIs were computed using the balanced repeated replication method9 with Fay’s adjustment set to 0.30.10 Stata, version 15 was used. Analyses were conducted in 2019–2020.
RESULTS
Findings reflect the behavior of 8.1 million (95% CI=7.6, 8.6 million) adult dual users in the U.S. Approximately half (4.0 million, 95% CI=3.6, 4.4 million) used only non-tobacco, non-menthoFmint flavor e-cigarettes (Table 1). There were no statistically significant differences in rates of attempting to quit cigarette smoking as a function of e-cigarette flavor use.
DISCUSSION
E-cigarette flavor use among adult dual users in the U.S. does not appear to be associated with attempting to quit cigarette smoking, though use of non-tobacco, non-menthol/mint flavor e-cigarettes, particularly fruit/candy/desserts/other sweets flavors, is most prevalent among adult dual users. Study limitations include not assessing flavor use at the time of the quit attempt. Future research can examine stability of e-cigarette flavor use, and whether flavor use is associated with cigarette quit success among quit attempters.
ACKNOWLEDGMENTS
This manuscript is supported with Federal funds from the National Institute on Drug Abuse (NIDA), NIH, and the Center for Tobacco Products, U.S. Food and Drug Administration (FDA), HHS, under contract to Westat (Contract No. HHSN271201100027C and HHSN271201600001C) and through an interagency agreement between the FDA Center for Tobacco Products and the Centers for Disease Control and Prevention.
Staff from NIDA and FDA contributed to the design and conduct of the study; interpretation of the data; preparation, review, and approval of the manuscript; and the decision to submit the manuscript for publication. NIDA and FDA were not directly involved in the collection of study data.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of HHS or any of its affiliated institutions or agencies.
Dr. Goniewicz receives fees for serving on an advisory board from Johnson & Johnson and grant support from Pfizer outside of the submitted work. Dr. Fong has served as an expert witness on behalf of governments in litigation involving the tobacco industry; no other disclosures were reported. No other financial disclosures were reported by the authors of this paper.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
For category (3), the subset of those who used only fruit or candy, desserts, other sweets was also considered.
REFERENCES
- 1.Cullen KA, Gentzke AS, Sawdey MD, et al. E-cigarette use among youth in the United States. JAMA. 2019;322(21):2095–2103. 10.1001/jama.2019.18387. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Creamer MR, Wang TW, Babb S, et al. Tobacco product use and cessation indicators among adults - United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68(45):1013–1019. 10.15585/mmwr.mm6845a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Villanti AC, Johnson AL, Glasser AM, et al. Association of flavored tobacco use with tobacco initiation and subsequent use among US youth and adults, 2013–2015. JAMA Netw Open. 2019;2(10):e1913804 10.1001/jamanetworkopen.2019.13804. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.National Academies of Sciences Engineering and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018. 10.17226/24952. [DOI] [PubMed] [Google Scholar]
- 5.Kasza KA, Edwards KC, Tang Z, et al. Correlates of tobacco product cessation among youth and adults in the United States: findings from the PATH Study Waves 1–3 (2013–2016). Tob Control. 2020;29(suppl 3):s203–s215. 10.1136/tobaccocontrol-2019-055255. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Buu A, Hu Y-H, Piper ME, et al. The association between e-cigarette use characteristics and combustible cigarette consumption and dependence symptoms: results from a national longitudinal study. Addict Behav. 2018;84:69–74. 10.1016/j.addbeh.2018.03.035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hyland A, Ambrose BK, Conway KP, et al. Design and methods of the Population Assessment of Tobacco and Health (PATH) Study. Tob Control. 2017;26(4):371–378. 10.1136/tobaccocontrol-2016-052934. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.PATH Study series page. National Addiction & HIV Data Archive Program. 10.3886/Series606. [DOI]
- 9.McCarthy PJ. Pseudoreplication: further evaluation and applications of the balanced half-sample technique. Vital Health Stat 2. 1969;(31):l–24. [PubMed] [Google Scholar]
- 10.Judkins DR. Fay’s method for variance estimation. J Off Stat. 1990;6(3):223–229. [Google Scholar]