Use of Flavored Tobacco Products Are on the Rise in Youth

Hongying (Daisy) Dai, PhD

The rate of US adolescents using flavored tobacco products (FTPs) rose to 63.6% in 2017, ending a steady decline in use, which had fallen to 57.7% the year prior. As youth FTP users begin to increase again, investigators and health officials are left wondering why, a number of sources are pointing fingers at a lack of legislation and e-cigarettes, which offer users the luxury of added taste.

“Flavoring has become one of the leading reasons for current tobacco use among youth,” Hongying (Daisy) Dai, PhD, told MD Magazine®. “The 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA) banned cigarettes with characterizing flavors (eg, candy, fruit, and clove) except menthol. However, there are no restrictions on the marketing and sales of flavored non-cigarette tobacco products.”

In her data analysis from The National Youth Tobacco Survey, a cross-sectional and school-based annual survey of middle school and high school students in the United States, Dai and her team assessed youth tobacco use in more than 78,000 students in the years 2014-2017 through a three-stage cluster sampling procedure.

Current tobacco use was defined as the use of products at least 1 day in the last 30 days. Self-reported FTP users were recorded as students who used menthol cigarettes or any flavored noncigarette tobacco products.

Survey weights and stratum were used to calculate weighted estimates (95% confidence intervals [CI] of FTP use among current tobacco users). Trends and factors associated with the FTP use were assessed via logistic regression. Changes in product-specific flavor use patterns (eg, electronic cigarettes, cigars, and hookah) and prevalence of FTP use were calculated across years. SAS, version 9.4 (SAS Institute Inc), and a statistically significant two-sided P value <.05 were used to perform statistical analyses.

From the 78,265 participants, 49.2% were girls; 55.9% were high school students. In comparing participating ethnicities and races, 57% were white; 13.9% were black; and 23.9% were Hispanic. From 2014 to 2017, the prevalence of current use of any tobacco products decreased from 17.3% to 13.6%.

Dai noted that females (vs males), high school (vs school) students, whites (vs non-whites), and dual/poly tobacco (vs single) users were more likely to report flavored tobacco use.

“This study shows that the rebound was largely due to an increase of flavor use in e-cigarettes,” Dai said. “Current e-cigarette users reported the largest proportion of flavored e-cigarette use in 2017 (58.7%), followed by current cigar users (49.0%), cigarette smokers (menthol, 48.6%), smokeless tobacco users (44.5%), and hookah users (30.6%). As flavor use in other tobacco products decreased or leveled off, flavored e-cigarette use continued to increase from 2015 to 2017.”

Dai added that the widespread availability of flavors only adds to the problem: she had learned from a separate study that more than 460 brands and 7,700 flavors of e-cigarettes are on the market, including candy crush, gummy bears, and bubble gum. She warned that flavored tobacco products could serve as “starter kits” for smoking, since adolescents often experiment with smoking while pursuing novelty and their own curiosities.

Institutions, such as the American Medical Association (AMA) and US Food and Drug Administration (FDA) have presented legislation in a response to the growing abundance of unrestricted FTPs on the market.

The AMA spoke on the importance of strengthening policies pertaining to e-cigarette use with the release of a new policy in 2015. It emphasizes the importance of setting the minimum legal purchase age for e-cigarettes and their liquid nicotine refills at 21 years old; requiring liquid nicotine to be packaged in child-resistant containers; and urging strict enforcement of laws prohibiting the sale of tobacco products to minors.

After delays in regulatory action, the AMA and other organizations filed a lawsuit against the FDA in October 2018, stating that every day the federal organization delays regulating e-cigarettes, flavored cigars and other tobacco products “aimed at attracting new nicotine users, particularly teens and children—the public’s health is at risk.”

In November 2018, FDA Commissioner Scott Gottlieb, MD, called for and proposed new legislation that would prevent kids from having access to flavored tobacco products, especially those used in electronic nicotine delivery systems (ENDS) products.

He asked the FDA’s Center for Tobacco Products (CTP) to revisit the compliance policy as it applies to deemed ENDS products that are flavored, including all flavors other than tobacco, mint, and menthol. He stated that they should be sold in age-restricted, in-person locations, and under heightened practices if sold online (for age verification).

“The actions #FDA announced today are a response to our deep concern over the epidemic growth in kids’ use of e-cigarettes,” Gottlieb tweeted. “The data released by the #CDC shows a trend in use that simply cannot stand. We must reverse this trajectory of youth use and addiction … ”

Dai, who suspects previously limited law on FTPs encouraged their prevalence among adolescents, anticipates the proposed FDA restrictions will have a positive impact on reducing youth access to products including JUUL, and therefore decrease use as well.

That said, she conceded that a majority of young tobacco users get their products through social access, such as through friends or family members, or by giving someone else money to buy for them. She reiterated that additional tobacco control strategies, such as raising the minimum age of purchase for tobacco products to 21 years and restricting the promotion and advertising of tobacco products, are needed to further reduce youth tobacco use.

From FDA’s statements, the AMA policies, and Dai’s analysis, it is clear the issue of youth who use flavored tobacco products is multidimensional and requires help from every angle—ranging from legislation to personal intervention.