E-cigarettes were initially intended as a smoking cessation tool, yet vaping has skyrocketed among kids to the point that the US Food and Drug Administration (FDA) and the US Surgeon General both recently declared youth e-cigarette use an epidemic. Adolescent and young-adult e-cigarette users are attracted to vaping because of appealing marketing, and report tempting e-juice flavors as a leading reason for use. They are more interested in experimenting with fruit-, candy-, or menthol-flavored e-cigarettes than with tobacco-flavored e-cigarettes, perceiving sweet flavors as less harmful than tobacco flavors.

The FDA recently requested information on the role flavors may play in both attracting youth to tobacco products and also transitioning traditional smokers to e-cigarettes. A new Dartmouth study, led by Samir Soneji, PhD, aims to address some of the current research gaps by providing information on flavor types. Objectives of the study included assessing the categories of e-cigarette flavors (including fruit, candy, mint/menthol, and tobacco) used by adolescent, young adult, and older adult e-cigarette users; comparing across these groups the availability of appealing flavors as a reason for e-cigarette use; and correlating the use of flavor types with the simultaneous use of multiple flavor types.

Four main findings emerged from this nationally representative study. "The availability of appealing e-cigarette flavors was a more salient reason for vaping among adolescents and young adults than among older adults," says Soneji. "We found that adolescent and young adult vapers were not only more likely than older adult vapers to use fruit- and candy-flavored e-cigarettes, but were more likely to concurrently use multiple flavor types. We also found that current cigarette smokers who tried to quit smoking in the past year were more likely than non-cigarette smokers to use tobacco-flavored e-cigarettes." The team's study, "Use of Flavored E-Cigarettes Among Adolescents, Young Adults, and Adults: Findings From the Population Assessment for Tobacco and Health Study" is newly published in Public Health Reports.

Studies increasingly show that fruit and sweet e-cigarette flavors may be particularly toxic because of the chemicals included in these flavors. Common components of fruit- and sweet-flavored e-cigarettes may have negative impacts on lung function and may contribute to respiratory cell inflammation, respiratory disease, and irritation when inhaled. In addition to the potential harms from e-cigarette flavorings, nicotine intake levels from e-cigarettes may be similar to levels from combustible cigarettes, further contributing to nicotine addiction and increasing the risk of cigarette smoking initiation. "We are looking to determine if adolescents who vape sweet-flavored e-cigarettes are more likely to initiate cigarette smoking than their counterparts who vape tobacco-flavored e-cigarettes," says Soneji. "On the other hand, we'll determine if adult cigarette smokers who vape tobacco-flavored e-cigarettes are more likely to quit cigarette smoking than their counterparts who vape sweet flavored e-cigarettes."

The rapid rise in youth e-cigarette use has erased recent declines in youth cigarette smoking. E-cigarette use has the potential to create a new generation of nicotine-addicted adults. By providing information on flavor types, Soneji's study could help the FDA and other regulatory agencies in refining effective e-cigarette regulation. "Stricter regulation or banning of flavored e-cigarettes, such as fruit and candy, can achieve the dual goal of reducing youth vaping while not burdening older adult cigarette smokers who use e-cigarettes to help quit," he says.